Case-Based Questions for Teaching Emergency Medicine Pharmacotherapy

**Background:** Pharmacotherapy is a critical component of daily emergency medicine (EM) practice, with an estimated 368.5 million drugs dispensed in U.S. emergency departments annually, covering 81.1% of patient visits. Despite this, many EM residency programs lack a formal, dedicated pharmacotherapy curriculum, often teaching this content informally during clinical shifts or embedded within other lectures. The American Board of Emergency Medicine (ABEM) and the Accreditation Council for Graduate Medical Education (ACGME) have established milestones for competency-based assessment, including the pharmacotherapy milestone (PC5). At the University of Pittsburgh, the Clinical Competence Committee had limited objective evidence to assess this milestone, relying on anecdote and general gestalt. This innovation aimed to address this deficiency by creating a dedicated, longitudinal pharmacotherapy curriculum integrated into the existing 18-month didactic cycle.

**Methods:** The curriculum was designed for EM residents of all postgraduate years (PGY-1 to PGY-3) and rotating medical students. It consisted of monthly case-based question sets (approximately 10 questions per block) aligned with the organ-system-based educational blocks (e.g., cardiology, ENT/ophthalmology, gastroenterology, hematology/oncology, infectious disease, musculoskeletal, pulmonary/critical care, trauma). Questions were written by resident physicians using textbooks and online resources, then reviewed and edited by attending physicians and an EM pharmacist. During conference, residents had 10–15 minutes to complete a paper copy of the questions, followed by a large-group discussion led by the question author and faculty, spending 1–2 minutes per question. Residents unable to attend received an electronic version and, upon completion, an answer key with explanations. The curriculum was implemented at the University of Pittsburgh EM residency program. Initial data covered a 4-month pilot period. Survey questionnaires using a 7-point Likert scale (1 = strongly agree, 7 = strongly disagree) were administered pre- and post-intervention to assess self-assessed knowledge and satisfaction. The primary outcome was resident agreement with the statement, “I am confident in overall knowledge of EM pharmacotherapy.” Secondary outcomes included readiness for independent practice, knowledge appropriate for training level, board exam preparedness, and satisfaction. Statistical analysis used the Wilcoxon signed-rank test on paired data from 30 residents who completed both surveys (14 PGY-1, 16 PGY-2; 24 male, 6 female).

**Key Results:** The primary outcome showed significant improvement: the mean score for “I am confident in my overall knowledge of EM pharmacotherapy” improved from 3.7 pre-intervention to 2.6 post-intervention (p = 0.00008). Confidence in applying knowledge to clinical practice improved from 3.2 to 2.3 (p = 0.0004). Self-assessed knowledge appropriate for training level improved from 3.0 to 2.3 (p = 0.010). The largest improvement was in readiness for independent practice, from 4.3 to 3.0 (p = 0.0003). Satisfaction with the curriculum improved from 3.8 to 3.2 (p = 0.022). Self-assessed knowledge improvement (post-only) scored 2.2 (SD 0.92), and perceived efficacy of the cases scored 2.3 (SD 1.1). Self-assessed preparation for the in-service exam showed a trend from 3.2 to 2.7 but did not reach statistical significance (p = 0.057). Open-ended feedback led to expanded explanations for incorrect answers.

**Clinical Implications:** This study demonstrates that a dedicated, case-based pharmacotherapy curriculum integrated into existing conference time can significantly improve residents' self-assessed confidence and knowledge in EM pharmacotherapy. The curriculum is easy to implement, requires minimal additional time (15–20 minutes per session plus 30 minutes administrative time for scoring), and is generalizable to other programs. It provides the Clinical Competence Committee with objective data for assessing the pharmacotherapy milestone (PC5). The authors note that the improvement in independent practice readiness may be partially confounded by the passage of time, but the targeted intervention likely contributed substantially. Future directions include expanding the question bank to avoid repetition in the 18-month cycle and potentially correlating quiz performance with in-service examination scores.