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Steven M. Lazar, MD Chief Resident Neurodevelopmental Disabilities & Child Neurology Baylor College of Medicine

Jon A. Cokley, PharmD, BCPPS Clinical Pharmacy Specialist – Pediatric Neurology Department of Pharmacy | Texas Children's Hospital Neurology Instructor Department of Pediatrics | Baylor College of Medicine

Best practices in neurocritical care emphasize a multidisciplinary approach (Moheet et al., 2018). While various medical training pathways have been created, refined, and implemented within pediatric neurocritical care, emphasis on cross-disciplinary care continues to grow (M. Scher, 2008, 2022). Within the Texas Children’s Hospital Neurocritical Care Service, a clinical pharmacist with specialized expertise in pediatrics and neurology has been incorporated into daily patient care discussions. This addition has improved the delivery of patient centered care to complex critically ill patients, while enhancing symbiotic learning for medical and pharmacy trainees and faculty alike. Given the enthusiasm for continual learning of pharmacologic concepts, an elective experience in clinical neuropharmacology was created to help foster deeper education for neurology residents.

Traditionally, multidisciplinary and medical education has followed the apprenticeship model in which an expert guides a novice through direct instruction and modeling. The expert increases the learner’s responsibility through a practice termed legitimate peripheral participation where they are expected to model and learn from experts (Cruess et al., 2018; Lave & Wenger, 1991). As the learner gains skills and knowledge, they take on more responsibility with appropriately increasing autonomy. To better understand how learning occurs in this setting, the model of situated learning has been applied in which a learner participates in a real-world environment amongst peers, advanced learners, and experts within a community of practice (O’Brien & Battista, 2020).  In our setting, the child neurology or neurodevelopmental disabilities resident starts by observing and learning the basics of the clinical pharmacist’s role within a pediatric neurology division. Foundational neuropharmacology knowledge is reinforced through rigorous review of pharmacokinetic, pharmacodynamic, and pharmacogenetic considerations of medical therapy in patients across outpatient, acute care, and intensive care settings. Learners take ownership of the concepts they learn in patient care, providing didactic teaching to a multidisciplinary audience.  By the end of the experience, learners are expected to demonstrate mastery of these neuropharmacology principles by independently completing clinical neuropharmacology consultations. Figure 1 provides the theoretical models of legitimate peripheral participation and situated learning adapted to this curriculum.

Figure 1: Legitimate Peripheral Participation and Situated Learning in the Neurocritical Care Unit

Adapted from Mina Herrera, “Situated Learning” in Theoretical Models for Teaching and Research. WSU Open Text. (Mina Herrera; Licensed under Creative Commons Attribution-NonCommercial 4.0 International License; https://creativecommons.org/licenses/by-nc/4.0/)

Within the multidisciplinary community of practice in the neurocritical care unit, quality improvement, departmental, and institutional initiatives are crucial to legitimate participation in pharmacologic care. Through this rotation, the learner engages in institutional initiatives related to pharmacologic processes and systemic quality improvement. Not only is the learner brought in to observe these discussions, but they are also in a unique position to bring a clinical resident’s perspective to the feasibilities of institutional changes and the potential impact on clinical practice. Examples include practical considerations such as the computerized physician order entry design of weight-based dosing for anti-seizure medications. Learners are in the unique position to combine neuropharmacology considerations with the nuances of practical user-end implementation in a way that will be conducive to more accurate and appropriate dosing for patients with epilepsy. Similarly, learners involved with pediatric stroke initiatives have learned the clinical considerations of patient management, while also actively participating in the redesign and optimization of standard operating procedures to reduce time to treatment for patients presenting with acute ischemic stroke.  Through progressive and increasing involvement and responsibility, this opportunity has allowed child neurology trainees and pharmacists alike to enhance their knowledge and skills related to clinical neuropharmacology through legitimate participation in both clinical and administrative settings

With the understanding that active, work-based learning, as seen in clinical rotations, does not occur in a silo, the relative expertise of faculty and trainees within pediatric neurology and clinical pharmacy forms a symbiotic system of learning and community of practice. Within the rotation, the pediatric neurology trainee’s clinical experience is leveraged to teach clinical pharmacy learners the nuances of neurologic care through patient case discussions and dedicated didactics within the context of patient care. The goal of this learning reciprocity is to simultaneously guide learners in their respective fields to higher levels of clinical knowledge and skill through interdisciplinary learning with the ultimate goal of strengthening pharmacist and physician knowledge alike. In this fashion, the resident learners are tasked with teaching nuances of care, such as the implication of pathogenic SCN1A and SCN8A variants on the role of sodium channel blockade in epilepsy patients.

The addition of clinical pharmacist-led training at our institution has led to improved delivery of care and a broadened understanding of neuropharmacology for physician learners. Integration of specialized pharmacists in pediatric critical care have historically resulted in advances in care including reduced drug-drug reactions/interactions, decreased thromboembolic events, decreased ventilator days, improved morbidity/mortality and decreased length of ICU and hospital stay (Tripathi et al 2015). Since the inception of the learning experience in 2020, two to three neurology residents per academic year participate in advanced neuropharmacology training.

Involvement in this advanced neuropharmacology training experience has resulted in regional and international presentations, national panel discussions, and publications in peer-reviewed journals. Table 1 summarizes these scholarly activities.

Table 1: Presentations and Publications Resulting from the Advanced Neuropharmacology Training Experience

Future efforts include case reports on personalized treatment of severe autistic behavioral symptoms with memantine in a child with pathogenic GRIN2A variant and genetic and neuropharmacologic considerations in the management of intractable tuberous sclerosis. A future publication on how to establish and promote advanced neuropharmacology training opportunities at similar institutions is anticipated, with a goal of developing a novel pediatric neuropharmacology fellowship program. This advanced program will help ensure that future practitioners gain competency with neuropharmacology principles.

References

Cruess, R. L., Cruess, S. R., & Steinert, Y. (2018). Medicine as a Community of Practice: Implications for Medical Education. Academic Medicine, 93(2), 185–191. https://doi.org/10.1097/ACM.0000000000001826

Lave, J., & Wenger, E. (1991). Situated Learning: Legitimate Peripheral Participation. In Situated Learning. Cambridge University Press. https://doi.org/10.1017/CBO9780511815355

Mina Herrera, S. (n.d.). Situated Learning Theory. In J. Egber & M. Roe (Eds.), Theoretical Models for Teaching and Research. PressBooks - Open Text WSU. Retrieved April 11, 2022, from https://opentext.wsu.edu/theoreticalmodelsforteachingandresearch/chapter/situated-learning-theory/

Moheet, A. M., Livesay, S. L., Abdelhak, T., Bleck, T. P., Human, T., Karanjia, N., Lamer-Rosen, A., Medow, J., Nyquist, P. A., Rosengart, A., Smith, W., Torbey, M. T., & Chang, C. W. J. (2018). Standards for Neurologic Critical Care Units: A Statement for Healthcare Professionals from The Neurocritical Care Society. Neurocritical Care, 29(2), 145–160. https://doi.org/10.1007/S12028-018-0601-1/TABLES/3

O’Brien, B. C., & Battista, A. (2020). Situated learning theory in health professions education research: a scoping review. Advances in Health Sciences Education, 25(2), 483–509. https://doi.org/10.1007/S10459-019-09900-W/TABLES/5

Tripathi, S; Crabtree, H; Fryer, K; Graner, K; Arteaga, G. Impact of Clinical Pharmacist on the Pediatric Intensive Care Practice: An 11-Year Tertiary Center Experience. The Journal of Pediatric Pharmacology and Therapeutics (2015) 20 (4): 290–298. https://doi.org/10.5863/1551-6776-20.4.290

Scher, M. (2008). Proposed Cross-Disciplinary Training in Pediatric Neurointensive Care. Pediatric Neurology, 39(1), 1–5. https://doi.org/10.1016/J.PEDIATRNEUROL.2008.01.013

Scher, M. (2022). The first 1000 days influence life-course brain health: interdisciplinary fetal/neonatal neurology training. Pediatric Research 2022, 1–3. https://doi.org/10.1038/s41390-022-01936-w

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