The ABCs of OTCs: A Video-Based Curriculum Regarding Over-the-Counter Pediatric Products

OPEN ACCESSJune 6, 2023The ABCs of OTCs: A Video-Based Curriculum Regarding Over-the-Counter Pediatric Products Alanna Higgins Joyce, MD, MPH, MST, Kristin Van Genderen, MD, Shelly Vaziri Flais, MD, Meg Keeley, MD, Nathan Gollehon, MD, MHPTT, Michael S. Ryan, MD, MEHP Alanna Higgins Joyce, MD, MPH, MST https://orcid.org/0000-0003-1593-2241 Pediatric Clerkship Director and Associate Professor, Department of Pediatrics, Northwestern University Feinberg School of Medicine E-mail Address: [email protected] Google Scholar More articles by this author , Kristin Van Genderen, MD https://orcid.org/0000-0002-5291-343X Pediatric Hospitalist and Assistant Professor, Department of Pediatrics, Northwestern University Feinberg School of Medicine Google Scholar More articles by this author , Shelly Vaziri Flais, MD General Pediatrician and Clinical Assistant Professor, Department of Pediatrics, Northwestern University Feinberg School of Medicine Google Scholar More articles by this author , Meg Keeley, MD https://orcid.org/0000-0001-8602-2638 Senior Associate Dean for Education and Professor, Department of Pediatrics, University of Virginia School of Medicine Google Scholar More articles by this author , Nathan Gollehon, MD, MHPTT https://orcid.org/0000-0002-3448-9284 Vice Chair for Education and Associate Professor, Department of Pediatrics, University of Nebraska Medical Center Google Scholar More articles by this author , Michael S. Ryan, MD, MEHP https://orcid.org/0000-0003-3266-9289 Associate Dean for Assessment, Evaluation, Research and Innovation and Professor, Department of Pediatrics, University of Virginia School of Medicine Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.11315 SectionsAboutPDF ToolsDownload Citations ShareFacebookTwitterEmail Abstract Introduction: Over-the-counter (OTC) products are widely used by families with young children. To educate future pediatricians on OTC product counseling and support the health and safety of children under their care, modern, accessible, and engaging curricula are needed. Methods: We developed an OTC product curriculum consisting of seven videos and one facilitated group discussion using a flipped classroom pedagogy to educate students on counseling parents about OTC product use. Fourth-year medical students pursuing pediatric training from four institutions participated in the curriculum during their end-of-year transition-to-residency course. We measured effectiveness via a pre/post comparison using a student self-assessment with multiple-choice questions. A simulated parent call OSCE provided participants with an opportunity to apply their knowledge and receive directed formative feedback. Data were analyzed using descriptive and inferential statistics. Results: A total of 41 students participated in the curriculum and completed all assessments. The majority (93%) watched all the videos. All participants (100%) agreed the videos were useful. Knowledge improved significantly (pretest mean score = 70%, posttest mean score = 87%, p < .001). No significant differences were found when comparing institution, gender, prior experience, or electives. Discussion: We developed a feasible and effective video-based curriculum to teach OTC product guidance. Given the importance of discussing OTC medications with families and the need for convenient educational tools, this curriculum may have widespread application to medical students during clinical rotations as well as pediatric and family medicine trainees. Educational Objectives By the end of this activity, learners will be able to: 1.List five to seven of the most commonly used over-the-counter products (OTC) in the pediatric population.2.Discuss common uses of five to seven of the most commonly used OTC products in the pediatric population.3.Provide anticipatory guidance to a patient and/or family regarding OTC products.4.Triage common pediatric questions surrounding OTC products in a simulated parent phone call. Introduction Americans spend more than 30 billion dollars on over-the-counter (OTC) medications per year, and 50% of children receive one or more OTC products each week.1–3 Caregiver misunderstanding of children's OTC medications is common, and labels may contain misleading language and graphics resulting in inadvertent harm including overdose and death.4,5 Children's products are often sold in liquid formulations in varying concentrations. Dosing instruments such as syringes or cups come in many styles, have units that may not match product labels, and are not always included in product packaging.3,6–8 Vulnerable populations with low health literacy are especially at risk for errors,3,9 and significant numbers of children have experienced an adverse drug event from medication use.10 As a result, the Accreditation Council for Pharmacy Education recently established the importance of proficiency in pediatric pharmaceuticals.11 Despite the critical need for education on OTC counseling, there are substantial gaps in medical education, clearly highlighted by a case control study in which 89% of medical students failed to identify a significant overdose of acetaminophen in a simulated pediatric outpatient visit.12,13 An older study detailed a shopping trip for pediatric residents, but its focus was primarily on cost and availability of products rather than application in the patient care setting.14 A more recent publication focused on pharmacy students teaching medical students prescription-writing skills and hosting a case-based discussion of nonprescription medication; however, no content was devoted to other products such as suction devices, formulas, supplements, or topical products.15 During our literature search, we did not identify any teaching tools directed at counseling about the myriad of OTC products families with children commonly encounter. Modern and accessible teaching tools to educate future pediatricians on OTC products are needed to support the health and safety of children under their care. We developed and implemented an OTC curriculum across four institutions for fourth-year medical students entering the field of pediatrics using adult learning principles. Kolb's experiential learning theory served as a conceptual framework for the educational strategies,16 and Kirkpatrick's evaluation model of reaction, learning, and behavior guided our evaluation.17 We aligned our design with prior successful educational interventions in telephone triage18,19 and OSCEs for medical students.20 Methods Curriculum Development We developed a video-based curriculum that used a flipped classroom technique to deliver and apply content to graduating fourth-year medical students across four diverse institutions in the context of preexisting transition-to-residency courses. Two authors, a general pediatrician with expertise in outpatient pediatrics (Shelly Vaziri Flais) and a clerkship director with expertise in educational delivery (Alanna Higgins Joyce), developed videos that covered seven core topic areas related to OTC products. Topics were chosen based on prior didactic sessions given by Shelly Vaziri Flais, an American Academy of Pediatrics parenting book author and spokesperson. The strategy for curriculum delivery was designed to avoid cognitive overload21 via three spaced learning opportunities (Figure). Students first completed a self-guided review of online videos (Appendices A–G) with pre/post testing (Appendix H), subsequently attended a facilitated small-group discussion (Appendix I), and finally participated in a simulated phone call with a parent (Appendix J). Figure. Over-the-counter products spaced learning opportunities. Setting and Participants We developed the curriculum for graduating fourth-year medical students entering pediatric training. The curriculum was integrated into required transition-to-residency courses for all fourth-year medical students who matched in pediatrics at four institutions—the University of Virginia, Virginia Commonwealth University, University of Nebraska Medical Center, and Northwestern University—in the spring of 2021. Written informed consent was obtained from those willing to allow their evaluation data to be used for analysis. Participants created unique identifiers for response tracking while preserving anonymity. Institutional review board approval was received from each of the four participating institutions. Resident and Faculty Participation Contributing authors at each institution identified a facilitator at each site to host the small-group discussions with students after they had watched the videos. Resident physicians were recruited to participate in the parent phone-call OSCE and score the rubrics. For each of these roles, participants received 30–60 minutes of orientation to review the existing curricular materials, including the case vignette, scoring rubric, and discussion guide. We did not provide any additional training materials. Subsequently, residents and faculty were easily able to lead the group or host the phone call and score the rubric. Pretest Participants received a link to the video presentations (Appendices A–G) and a pretest (Appendix H), which they were instructed to complete before viewing the videos. The pretest was hosted by Qualtrics (Qualtrics International Inc.) and included basic demographic variables and an objective knowledge-based assessment related to the definition of fever, the use of antipyretics, cough and cold medications, applications of topical products, formula content, and colic remedies. The questions were multiple choice and true/false. Online Videos After completing the pretest, students were instructed to independently watch the videos (Appendices A–G), which outlined typical uses, indications, and precautions for various OTC products using unbranded examples. The videos were 5–9 minutes each and collectively totaled 45 minutes. Segments included antipyretics, cough/cold medications, infant formulas, vitamins/supplements, topical skin care, colic remedies, and solid food products. The Northwestern University Feinberg School of Medicine Instructional Design and Development Center produced all the videos, which were hosted on Vimeo with graphics licensed from iStock (Getty Images). After viewing the videos, students completed a posttest, the same knowledge-based objective assessment as the pretest, on Qualtrics. Skip logic embedded in the survey added additional questions related to the value and effectiveness of the videos. Small-Group Discussion Within 1 week of watching the videos, students attended a facilitated group discussion hosted by a pediatric educator (a faculty member or local general pediatrician) at their institution. This took place in a classroom sized for eight to 25 people or was delivered virtually using a videoconferencing platform. We provided the facilitator with a copy of the discussion guide (Appendix I) with specific learning points to cover in 30–50 minutes. We also provided faculty development to the facilitators to ensure standardization of the content. Exercise After the small-group session, students applied knowledge through an OSCE caregiver phone-call exercise. The purpose of the OSCE was to provide students with the opportunity to practice and receive feedback on skills developed during the workshop. Residents at each institution were recruited and trained to play the role of a parent requesting advice about their 18-month-old child with an upper respiratory tract infection. Over hospital phones, residents relayed a clinical vignette (Appendix J) with scripted questions covering medication use, fever triage, and supportive care for their child. During the course of the call, the resident scored the student's responses to questions on a structured rubric (Appendix J) in real time and provided brief directed feedback. Evaluation Tools We utilized a pre/post survey (Appendix H) to assess knowledge acquisition. To ensure relevance of content, the pre/post video survey was distributed to five expert community pediatricians for feedback prior to implementation. The survey was then pilot tested with a cohort of early pediatric interns from Northwestern University to establish benchmark performance of similar peers. In addition, we used the previously described OSCE to provide formative feedback to the learners regarding their performance applying the knowledge and skills developed in the session. At two of the project sites, two residents independently evaluated several of the OSCE encounters in real time to establish interrater reliability for the structured scoring rubric. Analysis All data were aggregated centrally at Northwestern University using Qualtrics. Demographic data, reactions, and performance were summarized using percent and frequencies for categorical variables and mean and standard deviation for continuous variables. Inferential statistics (unpaired t test and analysis of variance) were used to compare pre- and posttest performance and to examine the association between covariates and dependent variables. Statistical significance for all analysis was set at p < .05. All analyses were performed using IBM SPSS Statistics version 28.0. Results A total of 41 students (a range of eight to 16 per site) participated in the curriculum and completed all assessments. The majority were female (68%), reported prior experience caring for children (61%), and had no prior elective or specific training in nutrition (90%). Most students reported watching all the videos (93%). All students (100%) agreed (10%) or strongly agreed (90%) that the videos were useful. Participants viewed the content favorably in terms of relevance (98% stated agreement), learning level (88%), quality (88%), and duration (93%). Mean performance on the knowledge-based assessment improved significantly on the posttest (pretest M = 70%, posttest M = 87%, p < .001; Table 1), with positive gains on many individual questions (Table 2). OSCE performance revealed participants’ strengths in management and return to clinic precautions, with weaknesses in triage and supportive care. Interrater reliability for resident OSCE graders was shown to be consistent across sites. There were no significant differences in performance when stratified by institution, gender, prior caregiver experience with children, or elective experience. Table 1. Student Performance on Pre/Post Test and OSCETable 1. Student Performance on Pre/Post Test and OSCE Table 2. Pre/Post Test Descriptive StatisticsTable 2. Pre/Post Test Descriptive Statistics Discussion We developed an effective, convenient, and practical video-based curriculum to teach learners about OTC guidance. Nearly all participants used the videos, perceived them to be effective, and completed them in their entirety. The content was delivered across four diverse institutions, was integrated into an existing transition-to-residency course commonly used across US medical schools,22,23 and required relatively minimal faculty development or resources. Learners demonstrated significant knowledge acquisition related to OTC guidance based on improvement in multiple-choice question scores. Our project expanded upon existing pharmacy literature reporting pharmacy knowledge gains in a small group of medical students after in-person faculty teaching.11 Our video-based curriculum offers flexible delivery, reduces resource requirements, and can be used in situations where in-person learning is not feasible.24 Unique to our curriculum was a brief OSCE requiring students to navigate fever, cough and cold medication, and triage for dehydration or severe illness. The OSCE format allowed us to capture the nuanced nature of an after-hours phone call integrating triage for an ill child with the use of OTC products. While it would have been helpful to assess students on their baseline clinical abilities concerning OTC product counseling prior to participation in the curriculum, our OSCE's labor- and time-intensive nature was a barrier to our sites conducting a pretest OSCE. Nevertheless, the OSCE allowed students to obtain brief formative feedback. We ascertained that, like other learners in OSCE assessments,25 students in our project struggled most with appropriate patient triage, highlighting an important area for future learning.15 Students likely showed gaps in triage skills because, although triage was addressed in the facilitated discussion and videos, the focus of the material remained on OTC products and guidance and instruction on their use. A next step may be to expand participation to other medical trainees and health professions. OTC product knowledge is applicable to many groups, including pediatric interns, clerkship medical students, physician assistant students, and nurse practitioner students. Interdisciplinary workshops with pharmacy students have been shown to improve knowledge and confidence in pediatric prescribing.26 Our curriculum could expand on this by covering counseling for office visits, after-hours phone calls, or discharge guidance. Collaborative interprofessional application of our session may improve identified areas of weakness across all levels. Our curriculum has several limitations. It is targeted to transition-to-residency courses for fourth-year medical students. Thus, while any institution with a similar program can implement our work, it may not be appropriate for other learner groups. Our learners were all fourth-year medical students matched in pediatrics who likely were more invested in this topic area than the average medical student. This may have affected our high metrics for video completion and favorable reviews of the content. Due to the COVID-19 pandemic, our learners had less exposure to common colds/coughs than during a typical pediatric respiratory season. As a result, their baseline familiarity with the material may have been limited, leading our data to show a more robust pre/post performance than if learners had had more clinical opportunities to engage with the material. There were multiple-choice questions for which we saw a decrease in performance. Question 6, relating to the number of upper respiratory infections children experience annually, was graded incorrectly (as 10–12 per year) compared with the accurate information presented in the videos (six to eight per year). This error has been corrected in the pre/post survey (Appendix H). We felt student answers to Question 1, related to the definition of fever, were affected by local practice variation during the pandemic. These concepts may warrant reinforcing in the facilitated group discussion. The OSCE was difficult to interpret due to the lack of a pretest and the lesser focus of videos on triage skills; however, we felt the opportunity to practice skills application and obtain feedback was valuable for the students. Finally, it may have been difficult for raters to score a student's answer while also playing the role of the parent. In the future, enlisting a separate grader may improve the accuracy of the OSCE assessment. OTC products are ubiquitous in the lives of families with young children, yet medical education devotes little time to teaching in this area. Given the feasibility and successful knowledge acquisition demonstrated by our curriculum, we aspire to share it widely with learners of varying levels and from diverse health professions to support the health and safety of children and families under their care. References1. Consumer Healthcare Products Association. Your Health at Hand: Perceptions of Over-the-Counter Medicine in the U.S. Consumer Healthcare Products Association; 2010. Accessed December 1, 2022. https://www.chpa.org/sites/default/files/media/docs/2021-05/CHPA-YHH-WOW-Final-Report-11232010.pdfGoogle Scholar2. OTC use statistics. Consumer Healthcare Products Association. Accessed December 1, 2022. https://www.chpa.org/about-consumer-healthcare/research-data/otc-use-statisticsGoogle Scholar3. Yin HS, Parker RM, Sanders LM, et al. Pictograms, units and dosing tools, and parent medication errors: a randomized study. Pediatrics. 2017;140(1):e20163237. https://doi.org/10.1542/peds.2016-3237Medline, Google Scholar4. Infant deaths associated with cough and cold medications—two states, 2005. MMWR Morb Mortal Wkly Rep. 2007;56(1):1–4.Medline, Google Scholar5. Lokker N, Sanders L, Perrin EM, et al. Parental misinterpretations of over-the-counter pediatric cough and cold medication labels. Pediatrics. 2009;123(6):1464–1471. https://doi.org/10.1542/peds.2008-0854Medline, Google Scholar6. Yin HS, Dreyer BP, Moreira HA, et al. Liquid medication dosing errors in children: role of provider counseling strategies. Acad Pediatr. 2014;14(3):262–270. https://doi.org/10.1016/j.acap.2014.01.003Medline, Google Scholar7. Berrier K. Medication errors in outpatient pediatrics. MCN Am J Matern Child Nurs. 2016;41(5):280–286. https://doi.org/10.1097/NMC.0000000000000261Medline, Google Scholar8. Wallace LS, Keenum AJ, DeVoe JE. Evaluation of consumer medical information and oral liquid measuring devices accompanying pediatric prescriptions. Acad Pediatr. 2010;10(4):224–227. https://doi.org/10.1016/j.acap.2010.04.001Medline, Google Scholar9. Krajnović D, Ubavić S, Bogavac-Stanojević N. Pharmacotherapy literacy and parental practice in use of over-the-counter pediatric medicines. Medicina (Kaunas). 2019;55(3):80. https://doi.org/10.3390/medicina55030080Medline, Google Scholar10. Kaushal R, Goldmann DA, Keohane CA, et al. Adverse drug events in pediatric outpatients. Ambul Pediatr. 2007;7(5):383–389. https://doi.org/10.1016/j.ambp.2007.05.005Medline, Google Scholar11. Cox CL, Todd TJ, Lubsch L, et al. Joint statement on pediatric education at schools of pharmacy. Am J Pharm Educ. 2020;84(8):ajpe7892. https://doi.org/10.5688/ajpe7892Medline, Google Scholar12. Henley E, Wenzel-Wamhoff J. Teaching medical students about over-the-counter medications. Med Educ. 2000;34(7):580–582. https://doi.org/10.1046/j.1365-2923.2000.00470.xMedline, Google Scholar13. Dudas RA, Barone MA. Can medical students identify a potentially serious acetaminophen dosing error in a simulated encounter? A case control study. BMC Med Educ. 2015;15:13. https://doi.org/10.1186/s12909-015-0288-3Medline, Google Scholar14. Moon RY, Gitterman B. Let's go shopping: a tool for pediatric resident education. Pediatrics. 2000;106(suppl 1):223–225. https://doi.org/10.1542/peds.106.S1.223Medline, Google Scholar15. Allen SM, Kachlic MD, Parent-Stevens L. Pharmacy students teaching prescription writing and nonprescription product selection to medical students. Am J Pharm Educ. 2020;84(3):6972. https://doi.org/10.5688/ajpe6972Medline, Google Scholar16. Kolb DA. Experiential Learning: Experience as the Source of Learning and Development. 2nd ed. Pearson Education; 2015.Google Scholar17. Smidt A, Balandin S, Sigafoos J, Reed VA. The Kirkpatrick model: a useful tool for evaluating training outcomes. J Intellect Dev Disabil. 2009;34(3):266–274. https://doi.org/10.1080/13668250903093125Medline, Google Scholar18. Blumberg JS, Barajaz M, Roberts D, Clary C, Kumar S. Call me maybe…: a simulation based curriculum for telephone triage education in a pediatric residency. Front Pediatr. 2020;8:283. https://doi.org/10.3389/fped.2020.00283Medline, Google Scholar19. Roth LT, Lane M, Friedman S. A curriculum to improve pediatric residents’ telephone triage skills. MedEdPORTAL. 2020;16:10993. https://doi.org/10.15766/mep_2374-8265.10993Medline, Google Scholar20. Laitman BM, Malbari A, Friedman S, Moerdler S, Kase S, Gibbs K. Preseason pediatrics: an interactive preclinical curriculum enhances knowledge and skills in medical students. Med Sci Educ. 2019;29(1):233–239. https://doi.org/10.1007/s40670-018-00676-zMedline, Google Scholar21. Leppink J, van den Heuvel A. The evolution of cognitive load theory and its application to medical education. Perspect Med Educ. 2015;4(3):119–127. https://doi.org/10.1007/S40037-015-0192-XMedline, Google Scholar22. Costich M, Finkel MA, Friedman S, Catallozzi M, Gordon RJ. Transition-to-residency: pilot innovative, online case-based curriculum for medical students preparing for pediatric internships. Med Educ Online. 2021;26(1):1892569. https://doi.org/10.1080/10872981.2021.1892569Medline, Google Scholar23. Teo AR, Harleman E, O'Sullivan PS, Maa J. The key role of a transition course in preparing medical students for internship. Acad Med. 2011;86(7):860–865. https://doi.org/10.1097/ACM.0b013e31821d6ae2Medline, Google Scholar24. Fitzgerald DA, Scott KM, Ryan MS. Blended and e-learning in pediatric education: harnessing lessons learned from the COVID-19 pandemic. Eur J Pediatr. 2022;181(2):447–452. https://doi.org/10.1007/s00431-021-04149-1Medline, Google Scholar25. Hastings JK, Flowers SK, Pace AC, Spadaro D. An objective standardized clinical examination (OSCE) in an advanced nonprescription medicines course. Am J Pharm Educ. 2010;74(6):98. https://doi.org/10.5688/aj740698Medline, Google Scholar26. Taylor D, Yuen S, Hunt L, Emond A. An interprofessional pediatric prescribing workshop. Am J Pharm Educ. 2012;76(6):111. https://doi.org/10.5688/ajpe766111Medline, Google ScholarPDF download Sign up for the latest publications from MedEdPORTAL Add your email below APPENDICESReferencesRelatedDetailsAppendices Fever.mp4 Fussy Infants and Probiotics.mp4 Infant Formulas.mp4 Solid Foods.mp4 Skin Care.mp4 Viral Upper Respiratory Infections.mp4 Vitamins and Supplements.mp4 Pre-Post Test.docx Facilitator Discussion Guide.docx Parent Call Rubric.docx All appendices are peer reviewed as integral parts of the Original Publication. Download CitationJoyce AH, Van Genderen K, Flais SV, Keeley M, Gollehon N, Ryan MS. The ABCs of OTCs: A Video-Based Curriculum Regarding Over-the-Counter Pediatric Products. MedEdPORTAL. 2023;19:11315. https://doi.org/10.15766/mep_2374-8265.11315 Copyright & Permissions© 2023 Higgins Joyce et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial license.KeywordsOver-the-Counter ProductsPharmacyClinical Skills Assessment/OSCEsPediatricsPrimary CareDisclosures None to report. Funding/Support None to report. Prior Presentations Higgins Joyce A, Van Genderen K, Flais SV, Keeley M, Gollehon N, Ryan MS. The ABCs of OTCs. Presented at: Council on Medical Student Education in Pediatrics (COMSEP) Annual Meeting; March 31, 2022; Cincinnati, OH. Higgins Joyce A, Van Genderen K, Flais SV, Keeley M, Gollehon N, Ryan MS. The ABCs of OTCs. Presented at: Pediatric Academic Societies (PAS) Annual Meeting; April 23, 2022; Denver, CO. Ethical Approval The Northwestern University, University of Nebraska Medical Center, University of Virginia, and Virginia Commonwealth University Institutional Review Boards approved this project. tabs.loading