Design of a foundational sciences curriculum: Applying the ICAP framework to pharmacology education in integrated medical curricula

Abstract Expectations for physicians are rapidly changing, as is the environment in which they will practice. In response, preclerkship medical education curricula are adapting to meet these demands, often by reducing the time for foundational sciences. This descriptive study compares preclerkship pharmacology education curricular practices from seven allopathic medical schools across the United States. We compare factors and practices that affect how pharmacology is integrated into the undergraduate medical education curriculum, including teaching techniques, resources, time allocated to pharmacology teaching, and assessment strategies. We use data from seven medical schools in the United States, along with results from a literature survey, to inform the strengths and weaknesses of various approaches and to raise important questions that can guide future research regarding integration of foundational sciences in medical school and health professions’ curricula. In this comparative study, we found that there is significant heterogeneity in the number of hours dedicated to pharmacology in the preclerkship curriculum, whereas there was concordance in the use of active learning pedagogies for content delivery. Applying the ICAP (Interactive, Constructive, Active, Passive) Framework for cognitive engagement, our data showed that pharmacology was presented using more highly engaging pedagogies during sessions that are integrated with other foundational sciences. These findings can serve as a model that can be applied beyond pharmacology to other foundational sciences such as genetics, pathology, microbiology, biochemistry, etc.


| INTRODUC TI ON
Institutional emphasis on accreditation standards, coupled with evidence from educational and cognitive psychology literature, is driving dramatic changes to undergraduate medical education (UME) curricula across the United States and worldwide. 1, 2 The last decade has seen shifts in medical education designed to prepare future physicians as life-long learners who will deliver cost-effective care in teams, using electronically available facts to improve the healthcare system. 3 For years, disciplines such as pharmacology had their own discipline-specific course in the UME curriculum. Now, however, basic science disciplines are integrated into organsystem blocks of instruction as longitudinal threads within the preclerkship curriculum. [4][5][6][7][8] This restructuring has occurred along with curricular changes aimed at providing earlier exposure to patient care, integration of health systems sciences, incorporation of more team-based learning activities, adoption of competency-based assessment practices and a greater emphasis on use of new technologies. While many courses are highly integrated, integration at the individual session level is variable, and there is a paucity of data available.
Medical education pedagogies are increasingly guided by findings from experimental studies on student learning from the medical education and psychology literature. [9][10][11][12] Didactic content delivery occurs in ways that use technology to enable asynchronous content delivery and allow the learner to control pace, timing, and learning sequence. Sessions are intentionally built around cognitive theories and, as such, many sessions include active learning strategies such as team-based learning (TBL), problem-based learning (PBL), case-based learning (CBL), and simulations, which provide opportunities for students to apply what they have learned. 7 The ICAP framework for cognitive engagement can be used to categorize educational pedagogies as Interactive, Constructive, Active, or Passive. 13 In modern medical curricula, these pedagogies co-exist, permitting a variety of individual learning styles among a singular student body. 14,15 Problematically, there is little guidance for faculty on which approaches are best suited for specific types of activities that have varying degrees of integration with other foundational and clinical sciences.

Despite many published examples of both integrated curricula
and educational strategies, there is a dichotomy in the existing literature. Existing studies tend to either describe the entire curriculum broadly (AAMC Curriculum Survey, https://www.aamc.org/ data-repor ts/curri culum -repor ts/repor t/curri culum -reports), or they describe singular, narrowly focused interventions. This can make it difficult for content-expert instructors, who are responsible for weaving content throughout the curriculum, to determine pedagogies suitable for the desired level of cognitive engagement at the session level. There is a paucity of data describing pharmacology content integration throughout the UME curriculum.
Thus, when taken together, with the prominent role pharmacology knowledge plays in clinical clerkships, there is a clear need to understand how to optimally deliver pharmacology content to medical students that leads to durable long-term retention and recall. 16 Our multi-institutional collaborative comprised faculty from seven allopathic medical schools in the United States and was aimed at identifying elements of curricular integration that contribute to effective pharmacology education within the preclerkship curriculum. In this descriptive study, we detail trends observed at our own institutions for pharmacology instruction in the preclerkship medical curriculum and contextualize those trends in the literature that currently exists for this type of collaborative work. We apply the ICAP framework to the most-commonly utilized pharmacology pedagogies and compare the level of cognitive engagement required from students in dedicated pharmacology sessions versus integrated sessions that include pharmacology. This descriptive work will be useful for other pharmacology content experts as they engage in curriculum design and reform, and it may serve as a model for other foundational science content experts to develop similar collaboratives and studies.

| Literature survey for preclerkship pharmacology curricula
We conducted a PubMed search in 2020 with the assistance of the  Board of Medical Examiners). In addition, pharmacology-specific curricular elements were captured, including teaching hours and pedagogies, discipline-specific assessment requirements, resources available (i.e., textbooks, commercially available programs), etc. We also collected information (hours and pedagogies) on sessions that were dedicated exclusively to pharmacology and sessions where pharmacology was integrated with other disciplines.

| Comparative curriculum inventory
We defined pedagogies so that data were represented consistently across the schools. For example, when we discussed Team-Based Learning (TBL) as a pedagogy, we agreed to only count TBL sessions that mostly follow the trademarked TBL ® process with individual readiness assurance tests (iRAT), group readiness assurance tests (gRAT), and application exercises that follow the 4S model. 17

| Application of cognitive engagement framework
To determine whether levels of cognitive engagement varied between integrated sessions or sessions dedicated to pharmacology, we assigned each pedagogy to a cognitive engagement category of interactive, constructive, active, or passive, based on the ICAP framework. 13 We calculated a "score" for each category (interactive, constructive, active, or passive) by tallying the number of pedagogies that are used in our curricula for each category ( Figure 1 and Table 2). We further parsed the scores by whether the pedagogy was used in integrated pharmacology sessions or sessions dedicated exclusively to pharmacology.

| Identification of key questions for pharmacology curricular designers
To identify the key questions for our descriptive study, we searched for detailed descriptions of incorporation of pharmacology within integrated preclerkship curricula across medical schools. We conducted a survey of the literature looking for works describing entire pharmacology curricula in preclerkship medical programs. There were only two dozen of such works, but many of these papers described approaches to clinical therapeutics or pharmacogenomics rather than basic pharmacology. There were five studies describing detailed curricular pharmacology trends in Australia, the UK, Mexico, and Europe. [18][19][20][21][22] In reviewing these works, we noted differences among countries in overall curricular representation of pharmacology and clinical therapeutics. We observed that there were few details about the pedagogies used for teaching pharmacology, F I G U R E 1 Distribution of reported pharmacology pedagogies according to the ICAP framework (I = Interactive, C = Constructive, A = Active, P = Passive 13 ). Categorizing the pedagogical methods reported by the different institutions in this study based on the ICAP framework yields a model for evaluating the level of active and interactive learning used in dedicated and integrated pharmacology sessions

BOX 1 Key questions for pharmacology curricular designers
• How much pharmacology representation is required in an integrated curriculum, and how is this distributed between sessions dedicated solely to pharmacology versus sessions where pharmacology is integrated with other disciplines?
• What pedagogies are best suited for pharmacology instruction in medical curricula? Does this vary at the session level depending on whether the session is dedicated to pharmacology or integrated with other disciplines?
• How can pharmacology-specific content be effectively assessed across an integrated curriculum?
• What resources should be provided to students, includ- Type of curriculum Number of faculty teaching >10 h of pharmacology  context to deliver pharmacology content. This is not surprising, given the trend toward increased curricular integration of basic and clinical sciences, and the fact that pharmacology naturally fits into case-centric active learning exercises. We also discovered many commonalities in pharmacology texts and recommended question banks (Table 1).
Although each school follows an integrated curriculum map, we found that each school also had some pharmacology sessions that were integrated with other disciplines (integrated), and other pharmacology sessions that were dedicated entirely to pharmacol- Another prominent difference among our institutions is how pharmacology content is represented on assessments, and how pharmacology performance on assessments is tracked. The  percentage of pharmacology questions on summative exams in organ system courses ranged from 8% to 25%, which is somewhat consistent with the representation of pharmacology in national

USMLE
Step 1 exams (16%-23%) (https://www.usmle.org/step-1/#conte nt-outlines). Our data agrees with previously published work that pharmacology representation on assessments can have a powerful effect on student perceptions and behavior regarding studying and valuing pharmacology. 23 Tracking pharmacology performance across assessments differs dramatically among our institutions. Among our working group of seven medical schools, 57% track pharmacology performance across foundational science exams longitudinally, but longitudinal pharmacology competency is only required at 29% of our schools and recommended at an additional 14%.
Another interesting finding that represents a large change in pharmacology education, is that over 85% of the faculty authoring this perspective had primary appointments as educators. 24 This

| Integrated sessions have higher levels of cognitive engagement
Integrated curricula contextualize learning in such a way that students are more engaged with foundational science content and learners' cognitive outcomes are improved, but it is unclear whether this trend persists down to integration at the session level. 5,26 Because we identified an even split between sessions dedicated entirely to pharmacology (dedicated) and sessions where pharmacology is integrated with other disciplines (integrated), we wanted to determine whether more cognitively engaging pedagogies were used in our integrated pharmacology sessions as compared to our dedicated pharmacology sessions.
To that end, we applied the ICAP Framework to our described pedagogies, assigning each pedagogy to a specific category of cognitive engagement: interactive, constructive, active, and passive ( To adapt our reported pedagogies to the ICAP framework, we tallied the number of times that each specific category of cognitive engagement was represented in the teaching pedagogies listed for dedicated or integrated pharmacology sessions to create a "score" for each category of cognitive engagement. We found that dedicated pharmacology sessions are higher in passive and active pedagogies, where integrated sessions are higher in interactive and constructive pedagogies (Figure 1).

| DISCUSS ION
Herein we have described our efforts to identify trends in curricu-

| Theme 1: The value of dedicated pharmacology educators
One of the findings in our analysis was the proportion of faculty In all of our schools, students rated their perception of pharmacology preparation for clinical clerkships as good to excellent, with percentages well above the national average on the AAMC Graduation Questionnaire (GQ, Table 1). The GQ data presented reflect years from 2018 to 2020 in which the curriculum survey data described are applicable and available. We attribute this data, in large part, to the commitment of our medical schools to employing basic science educators and giving them the protected time required to engage in scholarly teaching.
Since there is an increasing trend to condense preclerkship curriculum time to about 12-18 months, having designated foundational science educators ensures that the pharmacology discipline is not neglected within the curriculum, and that contact time with students is used in the most effective manner based on scholarly approaches to teaching. We have shown, using the ICAP framework, org/data-repor ts/curri culum -repor ts/repor t/curri culum -reports) to include data on teaching pedagogies, hours, and assessments at the discipline level, where it is most useful for subject matter experts who are doing the bulk of the pharmacology content creation, design, and teaching.

| Theme 2: The effect of integration on the preclerkship curriculum
All schools in this study utilize active learning formats to supplement/reduce the amount of didactic classroom time required in the integrated curriculum (Table 1) Time reduction in curriculum integration also forces pharmacology educators to make difficult decisions about selecting only minimal content beyond that which is deemed essential on USMLE Step 1, at the risk of losing the very structure of the discipline. In addition, they must contend with a continuously shifting landscape of drug approvals and withdrawals, student stress over cogni-

| Theme 3: Heterogeneity of pharmacology assessment
Our monthly discussions revealed that we used some common forms of summative assessments such as the NBME Comprehensive Basic Science Exam (CBSE) as well as USMLE Step 1 data to assess pharmacology-specific performance. All of our institutions had a pass/fail grading system for preclerkship exams and the percentage of pharmacology questions in foundational basic science courses ranged from 0% to 25% (Table 1), while those in organ-systems courses ranged from 8% to 25%. One of the topics that frequently arose in our discussions regarding assessments was whether students should be provided resources like drug lists during exams so that they focus less on memorization and more on higher order thinking according to Bloom's taxonomy (e.g., application and analysis). A counter argument is that there are certain drugs that clinical providers are expected to recall, and it is important for students have this knowledge base prior to entering the clerkship curriculum.
Unfortunately, we could not arrive at a consensus on this topic, reflective of the larger debate on this issue and indicating the need for more discussion from pharmacology educators at the international level.
Another issue impacting assessment is the increasing use of non-curricular third-party resources, which students often use to direct and focus their study for assessment. 30 As seen in Table 1, most schools provide students with access to electronic texts via subscription services. The non-curricular third-party resources that students frequently use are either purchased by the school or by individual students using discounts often provided to the school.
It causes student angst when there are discrepancies between internal assessments and non-curricular third-party resources. One avenue for intervention is to be more deliberate and effective in validating internal assessments, correlating them with performance on national board exams, and keeping students informed about these relationships. 6,[31][32][33] We anticipate that this tension will be resolved, in part, due to the impending changes in both the USMLE Step 1 and COMLEX grading to pass/fail.

| Theme 4: Debate about resources
A recent publication predicted that all students will use a common online curriculum as we reimagine medical education. 34 We do see a trend where students in our programs use very similar resources (e.g., First Aid, USMLE-Rx, Sketchy, Pathoma, UWorld) in preparation for national board exams, regardless of whether the school provides these or not. While these are valuable resources for board review, we would like to point out that some of these are discipline-specific resources lacking the integration and application that is the hallmark of enhanced cognitive engagement according to the ICAP framework.
In addition, there is often significant heterogeneity in the quality and focus of these resources. Too often, they focus on simple memorization and they often lack the context that can be provided within a structured curriculum. Therefore, these tools cannot replace the institution-specific integrated sessions where learners can apply multiple foundational sciences to a patient scenario in the presence of faculty available for questions and elaboration. This focus on application will become even more important in institutional settings given the recent move of the USMLE Step 1 to a pass/fail system.
The extent to which a student's national board exam performance is dependent on outside resources versus the institutions' own curriculum is unknown. It behooves us to study this in more detail as student utilization of outside resources increases. Also, the COVID-19 pandemic caused a rapid shift to remote online teaching, and the modalities used to deliver pharmacology may markedly change in the coming years. The corresponding impact of the COVID-19 pandemic on the utilization of outside resources also remains to be elucidated. Thus, the impact and student perception regarding outside resources versus institutional curriculum on student performance must be further investigated in the years ahead.

| CON CLUS IONS
Pharmacology, like many other foundational science disciplines, is increasingly being taught not as a stand-alone course, but rather as an integrated thread, focused on several core competencies. 29 Our data suggest that integration at the session level with multiple foundational science disciplines can enhance cognitive engagement.
Thus, this approach has many merits, however, we believe it also has the distinct disadvantage of fragmenting and diluting the flow and structure of topics in pharmacology. Having a better understanding of how to deliver topics most effectively in pharmacology to harmonize with other foundational science disciplines and retain a coherent structure and message is vitally important. Multi-institutional, data-driven analysis of teaching techniques best suited for specific pharmacology topics is needed. It is our hope that development of such evidence-based practices or guidelines could help pharmacology educators world-wide to improve students' knowledge acquisition, retention, and application in the clinical setting.

E THIC AL RE VIE W
Although no human subject data were used in creating this perspective, institutional approval and IRB review, when requested, was conducted at each institution.

ACK N OWLED G M ENTS
The authors thank Imelda Vetter, Health Science Librarian at Dell Medical School at the University of Texas at Austin for assistance in our literature search.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest but have made the following disclosures in the manuscript.

D I SCLOS U R E
MWL is the owner and creator of Pharmacology World™ Videos LLC and the creator of the Integrated Pharmacology Atlas™ medical education tool. KMQ and JBB are consultants with ScholarRx.
NZ is an item writer/reviewer for the NBOME (National Board of Osteopathic Medical Examiners).

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as all data created or analyzed in this study are detailed in the tables in the manuscript.