This idea came to me while relaxing in the Mallorcan sun a couple of summers ago. Amazing what we can come up with when the day job is put to one side! It has now been through a series of improving iterations and represents a novel approach to teaching pharmacology.
Lecture-based delivery can result in a lack of student engagement and foster short-term memory of that presented. Alternatively, actively involving students in their learning nurtures a more effective retention and application of knowledge. This session forms part of 'Cardiovascular Medicine: An Evidence-based Approach', a final year module for BSc Medical Pharmacology and Intercalated BSc students at Cardiff University. It aims to immerse them in the topic and facilitate active deep learning by encouraging critique and original thought around a controversial subject area in a novel and enjoyable way.
Disclaimer
This is a mock trial and procedures have been altered and may be very different to those actually used in law.
Argument
Cholesterol-lowering 'statins' are in the dock accused of 'doing more harm than good'.
Background
Statins constitute one of the most commonly prescribed medicines today. If you don’t take one yet, it probably won’t be too long before you do! UK National Institute for Health and Care Excellence guidelines now recommend statin therapy for anyone with a 10% risk of developing cardiovascular disease within the next 10 years.
However, this extended use comes with significant controversy surrounding the increased incidence of reported (and often debilitating) side effects. Hence the question whether they are doing more harm than good.
Wider pedagogy
While this collaborative approach to teaching lends itself very well to an in-depth study of the clinical implications of increased drug therapy, in reality it could easily be adapted to other controversial, debatable subject areas or academic disciplines.
The flip
One week before the session, guidance on the trial process is uploaded to the University’s Virtual Learning Environment (VLE) along with a specific set of learning outcomes. Notably the brief informs the students that they have to get together in teams to plan their legal case. The class of 32 students is split in to four legal teams (two defence and two prosecution) for Trials A and B (two consecutive 80 minute sessions). Both are 'trials by judge' (me!) and no jury used (potential to do this for bigger classes perhaps).
At the same time a number of peer-reviewed papers, that illustrate both sides of the statin argument, are uploaded to the VLE. All 'evidence' is thus available to both defence and prosecution teams. Giving the students time to cover background material in this way, and become conversant with it, before the related teaching session is what appeals. It puts ownership of the scholarship in their hands, with the educational focus being on peer-to-peer collaborative and cooperative learning.
Building the case
Using the papers and articles uploaded to the VLE (or the much wider literature available through PubMed), the defence and prosecution teams then formulate their case before coming to the formal session. The prosecution team chooses three people to act as witnesses – for example, individuals who can variously; highlight the debilitating side effects on their quality of life, observe lots of patients presenting with side effects and question the cost-benefit of increased prescribing, focus on details such as the reported association of increased type two diabetes with statin treatment and so on.
The defence team also chooses three people to act as witnesses – for example, individuals who variously; highlight the benefit of statins with regard to cardiovascular disease prevention, describe that statins are now off patent and potentially present a very cost-effective treatment option, detail the effect of lowering plasma cholesterol on the progression of atherosclerotic vascular disease and so on. The barristers (different people to those who made the opening statements) then ask the witnesses a maximum of three questions each to build the case. The team should construct the questions in the week before the case in conjunction with the witness.
The area of expertise of each witness is communicated to the opposition before the trial, thereby making it easier for the respective teams to build their cases and formulate cross examinations.
The prosecution teams are told that they must show enough evidence to make the judge feel really sure that the defendants (statins) are guilty. If the Judge is not sure, then they must give a 'not guilty' verdict. Under the principle that statins are 'innocent until proven guilty', the defence teams are told they do not have to prove the accused is innocent. Rather they should present information that puts the accused in the best light while casting doubt on the prosecution's potential arguments.
The Trial
Opening statements
The prosecution and then the defense make opening statements to the Judge. These statements provide an outline of the case that each side expects to present.
Each team chooses one or two members to act as presenting barristers but the whole team must make a contribution to putting the case together. The case may be delivered by giving a speech or using Powerpoint slides. Either way this should last no longer than 10 minutes for each team.
Prosecution case-in-chief
The prosecution presents its main case through direct examination of prosecution witnesses. The barristers (different team members to those who made the opening statements) ask the witnesses a maximum of three (previously constructed) questions each to build the case.
Cross-examination
While the prosecution barrister is questioning each witness, members of the defence team come up with three response questions for their barrister to present. These questions may also include examples that have been previously constructed given the knowledge of the witness’s area of expertise. Again, this barrister can be anyone from the defence team. Both legal teams are encouraged to raise objections (supported by good reason) to lines of questioning, and depending on their reason, the judge will sustain or over-rule (and explain why).
Prosecution rests
Defence case-in-chief
The defence presents its main case through direct examination of defence witnesses. The barristers (different team members to those who made the opening statements) ask the witnesses a maximum of three (previously constructed) questions each to build the case.
Cross-examination
While the defence barrister is questioning each witness, members of the prosecution team come up with three response questions for their barrister to present. These questions may also include examples that have been previously constructed given the knowledge of the witness’s area of expertise. Again this barrister can be anyone from the prosecution team. Objections are encouraged as above.
Defence rests
Closing arguments
Each legal team chooses one or two people to present their closing arguments, but all must make a contribution to putting it together. This may be delivered by giving a speech or using Powerpoint slides. In both cases it should last no longer than 10 minutes. While these can be prepared in advance, a short break is allowed to add anything that has come to light during the trial.
Prosecution closing argument
The prosecution makes its closing argument, summarising the evidence as the prosecution sees it and explaining why the judge should render a guilty verdict.
Defence closing argument
The defence makes its closing argument summarising the evidence as the defence sees it and explaining why the judge should render a 'not guilty' verdict.
The Verdict
As the trial proceeds, the judge makes an evaluation of how well each legal team presented and questioned their witnesses and also how effective each cross-examination was. The verdict is then based on which team performed best overall, the judge being careful to explain why that decision has been reached.
Reflection
Student feedback on this teaching session is very positive.
Enjoyed the interactive style and innovative way of teaching
I loved this module!! I found the exam hard but it was really good overall and engaging
Engagement is well-evidenced by the depth of passionately-presented and argued cases. While raising objections adds humour, it also forces the opposition to think on their feet in rewording or asking different questions. Importantly, a working knowledge of a complex subject developed in just one week is palpable.
Both trials are video-captured, and the subsequent recoding made available on the VLE. This is important since issues raised in one trial (the importance of the nocebo effect for instance) may not be raised in the other.
Getting the witnesses to deliver their oath or affirmation whilst holding a copy of a very well-known pharmacology textbook again adds homour. Moreover, restricting the witnesses and questions to three per team is essential in maintaining session momentum and participant interest. Importantly, both these actions help to foster a very positive learning environment, informality being the key to enjoyment and success.
The competitive element really enthuses the students who become vehemently attached to their arguments. Therefore, it is vital that the judge carefully evaluates the functioning and efficacy of each team before fully explaining the verdict.
End of module exam
While any exam questions are importantly aligned to the learning outcomes, it is essential to move away from a binary (right or wrong) approach. More specifically they are designed to empower expression of individual opinions, systematically supported by evidence from the published literature. Previous answers have included significant levels of detail and the depth of working knowledge very obvious. This confirms the aim of achieving active deep learning and fully supports the use of this methodology.
Take home message
Without doubt, this is one of the most rewarding teaching sessions I have ever been involved in! I would be very interested to hear about the experience of others trying this out and I am happy to help if required.
Comments
If you are a British Pharmacological Society member, please
sign in to post comments.