Sources and References

Online resources — Access Pharmacy (McGraw-Hill); Health Canada drug product database; Canadian Pharmacists Association resources; FDA drug information portal

Chapter 1: The Pharmacy Profession and the Canadian Healthcare System

Overview of Pharmacy as a Discipline

Pharmacy occupies a singular position among the health professions. It is, at its core, the discipline that connects the chemistry of medicines to the biology of patients, and it does so through a clinical and scientific lens that has evolved dramatically over the past century. Where pharmacists once operated primarily as compounders and dispensers of remedies, they now serve as medication management specialists embedded throughout the entire continuum of care — from the community drugstore where a patient first describes a symptom, to the hospital intensive care unit where a clinical pharmacist adjusts vancomycin dosing in real time based on serum trough concentrations. Understanding the profession means appreciating both its scientific foundations and its social mandate.

Canada’s healthcare system is structured around the principles articulated in the Canada Health Act of 1984: public administration, comprehensiveness, universality, portability, and accessibility. Physician and hospital services are provincially funded through single-payer mechanisms, but pharmacy services exist in a more complex funding landscape. Outpatient prescription drugs are not uniformly covered under provincial plans, and coverage varies significantly from province to province, with Ontario’s OHIP+ program covering those under 25 and those receiving social assistance, while Alberta and British Columbia maintain their own formulary and co-payment structures. This heterogeneity in funding directly shapes how pharmacists practise and how patients access the medications they need.

The Canadian healthcare team encompasses physicians, nurse practitioners, nurses, pharmacists, physiotherapists, occupational therapists, dietitians, social workers, and many other regulated and unregulated practitioners. Pharmacists interact with virtually every member of this team in some capacity. In a community setting, the pharmacist may consult with a family physician about a potential drug interaction flagged during dispensing; in hospital, the clinical pharmacist attends rounds alongside the medical team and contributes therapeutic recommendations; in a long-term care facility, the consultant pharmacist performs comprehensive medication reviews for residents whose polypharmacy burden may exceed a dozen concurrent medications.

Practice Settings and Pharmacy-Adjacent Professions

The diversity of pharmacy practice settings reflects the breadth of situations in which drug therapy is used. Community pharmacy remains the most publicly visible setting, accounting for the majority of pharmacy graduates’ first jobs. Community pharmacists are the most accessible healthcare providers in Canada — most are available without appointments, in locations that span urban and rural environments — and they handle tens of millions of prescription transactions annually. Their work extends well beyond counting tablets: medication reconciliation, adherence counselling, immunization delivery, blood pressure monitoring, and minor ailment prescribing increasingly characterize the contemporary community pharmacist’s day.

Hospital pharmacy encompasses both the technical operations of a large inpatient dispensing service and the highly specialized clinical work of pharmacists assigned to patient care units. Hospital pharmacists are particularly active in therapeutic drug monitoring, antibiotic stewardship, formulary management, and parenteral nutrition support. In teaching hospitals, pharmacy residents and clinical specialists may hold prescribing authority under collaborative practice agreements or as part of expanded scope legislation.

Beyond direct patient care settings, pharmacists find careers in the pharmaceutical industry, in federal and provincial regulatory agencies, in academia, and in policy organizations. Industry roles span medical affairs, pharmacovigilance, clinical research, health economics, regulatory affairs, and marketing. Regulatory pharmacists employed by Health Canada evaluate new drug submissions, post-market safety signals, and drug advertising materials. Academic pharmacists divide their time among teaching, research, and sometimes clinical practice.

Pharmacy-adjacent professions deserve attention as well. Pharmacy technicians are regulated in most Canadian provinces and take on the technical and operational functions of a pharmacy under pharmacist supervision, freeing pharmacists to focus on clinical activities. Pharmaceutical scientists — researchers working in medicinal chemistry, pharmacology, pharmaceutics, and related disciplines — generate the knowledge base that underpins drug development and formulation. Toxicologists, epidemiologists, and health economists all contribute to the broader ecosystem of understanding drug benefits and harms at population scale.

Chapter 2: Principles of Basic Pharmacology

The Drug-Body Relationship: Pharmacokinetics

Every drug that enters the body undergoes a series of processes that collectively determine the time course of drug concentrations in blood and tissue. These processes — absorption, distribution, metabolism, and excretion — are grouped under the term pharmacokinetics, a word derived from the Greek for “drug movement.” Understanding pharmacokinetics allows the clinician to predict how quickly a drug will begin to work, how long its effects will last, what happens in patients with organ dysfunction, and how drugs might interact with one another.

Several physicochemical properties govern oral absorption. Lipophilicity — quantified by the octanol-water partition coefficient log P — correlates broadly with a drug’s ability to passively cross lipid bilayer membranes, though highly lipophilic drugs often suffer from poor aqueous solubility and consequently erratic absorption. The Henderson-Hasselbalch equation predicts the ionization state of weakly acidic or basic drugs at a given pH: at physiologic intestinal pH of approximately 6.5 to 7.4, weakly basic drugs are substantially unionized and thus more freely absorbed than at the acidic pH of the stomach. Exceptions abound — some drugs exploit active transporters, others undergo paracellular absorption, and the enterocyte expresses efflux transporters such as P-glycoprotein that actively pump certain substrates back into the intestinal lumen.

Once absorbed, a drug distributes throughout the body’s fluid compartments and tissues. The volume of distribution (\(V_d\)) is a proportionality constant relating the total amount of drug in the body to the plasma concentration:

A large volume of distribution indicates extensive tissue binding or partitioning, meaning the drug has left the plasma and is sequestered in peripheral compartments. Highly lipophilic drugs such as amiodarone may have volumes of distribution exceeding several hundred litres in a 70-kilogram person — far larger than the actual volume of the human body — because the drug concentrates avidly in adipose tissue and other lipid-rich compartments. Conversely, large polar molecules that remain confined primarily to plasma may have a volume of distribution approximating the plasma volume of roughly 3 to 5 litres.

Protein binding is an important determinant of distribution. Albumin is the dominant drug-binding protein in plasma, with affinity for acidic drugs; alpha-1-acid glycoprotein preferentially binds basic drugs. Only the unbound fraction of drug is pharmacologically active and available for distribution, metabolism, and excretion. In patients with hypoalbuminaemia — as seen in liver disease, severe malnutrition, or nephrotic syndrome — the free fraction of highly bound drugs increases, potentially producing elevated pharmacologic effects at standard doses.

Drug metabolism, or biotransformation, refers to the enzymatic conversion of a drug to one or more metabolites. The primary site of metabolism is the liver, though the intestinal wall, kidneys, lungs, and plasma also contribute to varying degrees. Hepatic metabolism occurs in two broad phases. Phase I reactions introduce or unmask functional groups — hydroxyl, carboxyl, amino, or sulfhydryl — typically through the cytochrome P450 (CYP) family of enzymes. Phase II reactions conjugate the drug or its Phase I metabolite to endogenous molecules such as glucuronate, sulfate, acetate, or glutathione, generally producing more polar, readily excreted products. Phase I reactions do not invariably reduce pharmacologic activity; indeed, some prodrugs such as codeine require Phase I metabolism to generate their active form — in codeine’s case, O-demethylation by CYP2D6 yields morphine.

Excretion is the irreversible removal of drug from the body. Renal excretion is the predominant route for most drugs and involves glomerular filtration of unbound drug, passive tubular reabsorption of lipophilic molecules, and active tubular secretion mediated by transporters such as OAT, OCT, and MDR1. Biliary excretion contributes significantly for drugs with large molecular weights or anionic character. The clearance (CL) of a drug quantitatively describes the volume of plasma from which the drug is completely removed per unit time:

Hepatic clearance is further described by the hepatic extraction ratio — the fraction of drug removed during a single pass through the liver — which determines whether hepatic blood flow or intrinsic metabolic capacity is the rate-limiting determinant of elimination.

The half-life (\(t_{1/2}\)) of a drug is the time required for the plasma concentration to decline by 50%. For a drug exhibiting first-order kinetics (the most common scenario), half-life is related to clearance and volume of distribution by:

Clinically, half-life governs the time to reach steady state during repeated dosing (approximately four to five half-lives) and the duration of drug effect after discontinuation.

Pharmacodynamics: How Drugs Produce Effects

Whereas pharmacokinetics describes what the body does to a drug, pharmacodynamics describes what the drug does to the body. Most drugs exert their effects by binding to specific molecular targets — receptors, enzymes, ion channels, or transporters — and either activating or inhibiting their function.

An agonist binds to a receptor and activates it, mimicking or amplifying the effect of the endogenous ligand. A full agonist produces the maximal response the tissue is capable of generating (the intrinsic activity equals 1). A partial agonist binds the same site but produces a submaximal response even at saturating concentrations (intrinsic activity between 0 and 1). An antagonist binds to the receptor but produces no intrinsic response; instead, it prevents the agonist from binding, thereby inhibiting the physiologic or pharmacologic signal. A competitive antagonist competes reversibly at the same binding site as the agonist and can be overcome by increasing agonist concentration; a non-competitive antagonist either binds irreversibly at the orthosteric site or binds at an allosteric site, reducing the maximal response achievable by the agonist.

The quantitative relationship between drug concentration and effect is described by the dose-response curve, a sigmoid relationship characterized by two key parameters. The EC50 (or effective concentration 50) is the concentration producing 50% of maximal effect, reflecting the affinity and potency of the drug-receptor interaction. The maximal effect (\(E_{max}\)) reflects the drug’s intrinsic efficacy — the magnitude of response it is capable of eliciting. Understanding the shape and parameters of a dose-response curve allows prediction of therapeutic windows, comparison of drugs within a class, and rational interpretation of drug interactions.

Adverse Drug Reactions and Pharmacovigilance

Not all drug-body interactions are beneficial. Adverse drug reactions (ADRs) are defined by the World Health Organization as responses to a drug that are harmful and unintended, occurring at doses used in humans for prophylaxis, diagnosis, or therapy. The Rawlins and Thompson classification divides ADRs into Type A (augmented, dose-related, predictable from the drug’s pharmacology) and Type B (bizarre, dose-independent, idiosyncratic). Type A reactions account for the majority of ADRs and include, for example, bleeding with anticoagulants, hypoglycaemia with insulin, and bradycardia with beta-blockers. Type B reactions — such as anaphylaxis with penicillin or halothane hepatotoxicity — are not predictable from standard pharmacologic principles and occur in immunologically or metabolically susceptible individuals.

The Naranjo algorithm is a widely used probability scale for assessing causality in suspected ADRs, assigning numerical scores based on the temporal relationship between drug administration and reaction onset, the effect of dechallenge and rechallenge, alternative explanations, and laboratory confirmation. Pharmacovigilance — the systematic collection and analysis of post-marketing safety data — relies on voluntary adverse event reporting to systems such as Health Canada’s MedEffect Canada and the FDA’s MedWatch program, as well as on automated signal detection from electronic health records and insurance claims databases.

Chapter 3: Drug Discovery and Development

From Target to Molecule: The Early Drug Discovery Process

The journey from scientific hypothesis to marketed medicine is among the most complex and expensive endeavours in modern science. The full cycle — from initial target identification through regulatory approval — takes an average of twelve to fifteen years and costs, by industry estimates, between one and two billion US dollars per approved drug, a figure that accounts for the large number of candidate compounds that fail at various stages of development. Understanding this process reveals not only how medicines come to exist but also why they are priced as they are, why certain disease areas attract more development activity than others, and why apparent therapeutic gaps persist for conditions that are scientifically tractable but commercially unattractive.

Target identification and validation is the process of establishing that a specific molecular entity — a protein, a gene, a pathway — plays a causally important role in the pathophysiology of a disease and that modulating it pharmacologically would produce therapeutic benefit. Approaches include classical pharmacology (serendipitous observation of drug effects), genomics and proteomics (identifying disease-associated gene products), and phenotypic screening (identifying compounds that produce a desired cellular or organismal phenotype without presupposing a molecular target). The human genome project and subsequent advances in functional genomics have substantially expanded the universe of validated drug targets.

Once a hit compound is identified from HTS, the medicinal chemist undertakes hit-to-lead optimization. This iterative process involves synthesizing analogs of the hit to improve potency, selectivity, and druglikeness — properties captured roughly by Lipinski’s Rule of Five, which states that orally bioavailable drugs typically have molecular weight below 500 daltons, calculated log P below 5, fewer than 5 hydrogen bond donors, and fewer than 10 hydrogen bond acceptors. Lead compounds emerging from this optimization are evaluated in a battery of in vitro ADME (absorption, distribution, metabolism, excretion) assays and in vivo pharmacokinetic studies in animal models, establishing whether the compound has sufficient bioavailability and metabolic stability to sustain therapeutic concentrations.

Preclinical Development and IND Applications

Before any new drug candidate may be tested in humans, the sponsoring organization must compile a substantial body of preclinical evidence demonstrating reasonable safety and scientific rationale for the proposed human studies. This evidence is submitted to the regulatory authority — Health Canada in Canada, the FDA in the United States — in the form of a Clinical Trial Application (CTA, Canada) or Investigational New Drug (IND) application. The preclinical package typically includes in vitro pharmacology and safety pharmacology data, acute and repeat-dose toxicology studies in at least two animal species (one rodent and one non-rodent), genotoxicity assays, and preliminary pharmacokinetic characterization.

Safety pharmacology studies specifically evaluate the drug’s effects on cardiovascular, central nervous system, and respiratory function — organ systems whose disruption poses the greatest immediate risk to clinical trial participants. The hERG (human ether-a-go-go-related gene) potassium channel assay is of particular importance: inhibition of this channel prolongs cardiac repolarization, manifesting as QT interval prolongation on the electrocardiogram and carrying risk of the potentially fatal arrhythmia torsades de pointes. Many otherwise promising compounds have been abandoned specifically because of hERG activity.

Clinical Development: Phases I Through IV

Clinical drug development is organized into four sequential phases, each with distinct objectives, populations, and regulatory significance.

Phase I trials are first-in-human studies conducted in a small number (typically 20 to 80) of healthy volunteers or, for drugs with significant toxicity such as oncology agents, in patients with the target disease who have exhausted other options. The primary objectives are to establish tolerability, characterize pharmacokinetics (including the relationship between dose, plasma concentration, and time), and identify the maximum tolerated dose (MTD). Phase I studies include single ascending dose (SAD) and multiple ascending dose (MAD) designs, as well as specific studies to characterize the drug’s behaviour in patients with hepatic or renal impairment and its interactions with commonly co-administered drugs.

Phase II trials move into the target patient population and pursue two related goals: confirming proof of concept (demonstrating that the drug produces the anticipated pharmacodynamic effect or early signs of clinical efficacy) and determining the optimal dose and dosing regimen for Phase III. Phase IIa studies are typically exploratory, whereas Phase IIb studies employ more rigorous designs aimed at selecting the dose(s) to advance. Sample sizes in Phase II range from a few dozen to a few hundred participants.

Phase III trials are the pivotal studies that form the primary evidence base for regulatory approval. They are large (typically hundreds to several thousand patients), randomized, double-blind, and controlled — usually against placebo but sometimes against an active comparator when placebo use is considered unethical. Phase III trials are designed to demonstrate efficacy on a clinically meaningful endpoint with statistical rigor (typically a two-sided alpha of 0.05 and power of 80% to 90%), and to characterize the adverse effect profile with sufficient precision to support labelling. Most sponsors conduct at least two adequate and well-controlled Phase III trials as FDA and Health Canada both require substantial evidence of efficacy from multiple independent studies.

Following successful Phase III trials, the sponsor submits a New Drug Submission (NDS, Canada) or New Drug Application (NDA, USA) to the regulatory authority. Health Canada evaluates the submission through its review divisions and, if the benefit-risk assessment is favourable, issues a Notice of Compliance (NOC) authorizing marketing of the drug in Canada, accompanied by an approved Product Monograph.

Phase IV refers to post-marketing surveillance and studies conducted after approval. Since clinical trials enroll selected populations under controlled conditions, important safety signals often emerge only when a drug is used widely in heterogeneous real-world patients over extended periods. Phase IV activities include ongoing spontaneous adverse event reporting, pharmacoepidemiological studies, and Risk Evaluation and Mitigation Strategies (REMS) required by regulators for drugs with serious or unusual risks. The tragic examples of thalidomide-induced phocomelia in the 1960s and rofecoxib-associated cardiovascular risk in the early 2000s illustrate the importance of rigorous post-marketing surveillance.

Regulatory Pathways and Health Canada’s Role

Health Canada is the federal department responsible for helping Canadians maintain and improve their health. Within Health Canada, the Health Products and Food Branch (HPFB) regulates drugs, biologics, natural health products, and medical devices. The Therapeutic Products Directorate (TPD) is specifically responsible for evaluating the safety, efficacy, and quality of prescription drugs and over-the-counter products. The regulatory framework governing drugs in Canada is established by the Food and Drugs Act and its accompanying regulations.

The drug approval pathway in Canada has several specialized streams. The Priority Review designation is available for drugs that offer substantial improvement over existing therapies for a serious, life-threatening, or severely debilitating illness. Notice of Compliance with Conditions (NOC/c) is granted when the drug shows promising evidence of clinical effectiveness but requires further confirmatory studies. Extraordinary Use New Drug provisions expedite review for serious health threats. Once approved, drugs are assigned to schedules under provincial regulations that determine whether they require a prescription (Schedule I), are pharmacist-only sales (Schedule II), or are available without professional oversight (unscheduled).

Chapter 4: Clinical Research and Evidence-Based Pharmacy

Study Designs in Clinical Research

The evidence base that guides pharmacy practice is generated by clinical research studies that vary enormously in design, rigor, and applicability. The hierarchy of evidence — with systematic reviews of randomized controlled trials at the apex and expert opinion at the base — provides a useful framework for evaluating the strength of evidence underlying any clinical recommendation, but it is a simplification that requires contextual judgment.

The randomized controlled trial (RCT) is the design most capable of establishing causation because random allocation of participants to treatment and control groups eliminates systematic bias in the distribution of known and unknown confounders. Blinding — masking participants, investigators, outcome assessors, or all three — further prevents differential ascertainment of outcomes. The double-blind, placebo-controlled RCT remains the gold standard for efficacy evaluation in drug development, though practical and ethical constraints sometimes necessitate alternative designs.

Cohort studies follow a defined group of individuals over time, comparing outcomes between those exposed and unexposed to a drug or other factor. They are particularly suited to studying long-term effects or adverse drug reactions that are too rare to detect in RCTs, and they can capture real-world effectiveness in populations excluded from trials. Case-control studies identify individuals with the outcome of interest (cases) and match them to similar individuals without the outcome (controls), then look backward to compare the frequency of prior exposure. Case-control designs are efficient for studying rare outcomes but are vulnerable to recall bias and selection bias.

Systematic reviews and meta-analyses synthesize evidence across multiple primary studies using explicit, reproducible methods. A well-conducted systematic review with pooled quantitative meta-analysis can provide the most precise estimate of treatment effect available, but the quality of its conclusion is ultimately bounded by the quality of the included primary studies and the degree of clinical and statistical heterogeneity across them.

Measuring Drug Effects: Outcomes and Endpoints

The clinical significance of any drug depends not only on whether it produces measurable biological changes but on whether those changes translate into outcomes that patients and clinicians value. Surrogate endpoints — laboratory values or imaging findings that are correlated with clinical outcomes but are not themselves the outcomes of interest — are often used in trials because they are measurable earlier, more cheaply, and with greater precision than hard clinical events. However, surrogate endpoints can mislead: several drugs that improved glycated hemoglobin (HbA1c) in type 2 diabetes did not reduce cardiovascular mortality, and some antiarrhythmic drugs that effectively suppressed premature ventricular contractions actually increased mortality.

Patient-reported outcomes (PROs), including quality of life instruments, symptom scales, and functional assessments, have assumed increasing importance in drug evaluation as regulators and payers seek evidence that treatments make patients feel better or function better, not merely that they alter laboratory values. Health Canada’s guidance documents and the FDA’s PRO guidance specify methods for developing and validating PRO instruments for use in clinical trials.

Chapter 5: Pharmacy Practice and Patient-Centred Care

The Pharmacist’s Patient Care Process

Modern pharmacy practice is organized around a structured approach to patient care that parallels the clinical reasoning processes of other health professions. The Pharmacists’ Patient Care Process (PPCP), endorsed by pharmacy organizations in Canada and the United States, comprises five steps: Collect, Assess, Plan, Implement, and Follow-up. This framework ensures systematic identification of drug therapy problems, development of evidence-based care plans, and monitoring of outcomes.

Collecting information involves gathering a comprehensive medication history — including prescription drugs, over-the-counter products, natural health products, vitamins, and illicit substances — as well as relevant medical history, laboratory values, allergies, and patient preferences. A complete and accurate medication history is foundational to safe drug therapy and is one of the most important contributions a pharmacist makes in any care setting.

Assessing the collected information involves identifying actual or potential drug therapy problems. These may include unnecessary drug therapy, the need for additional drug therapy, selection of a suboptimal agent, dosage too low or too high, adverse drug reactions, or drug interactions. The pharmacist synthesizes this assessment to identify the most clinically important issues requiring immediate attention versus those that can be addressed over time.

Planning involves generating and selecting evidence-based therapeutic recommendations, specifying monitoring parameters and targets, and establishing goals of therapy in collaboration with the patient and other members of the healthcare team. The care plan must be individualized to the patient’s clinical characteristics, preferences, values, cultural context, and social circumstances.

Implementing the care plan may involve counselling the patient on their medications, collaborating with prescribers to recommend changes, administering treatments such as immunizations, and documenting clinical activities in the patient record. Effective communication — clear, jargon-free, and culturally sensitive — is central to implementation.

Follow-up is the often-neglected component that distinguishes comprehensive pharmaceutical care from mere dispensing. Monitoring whether therapeutic goals have been achieved, detecting and managing adverse effects, and adjusting the care plan in response to new information complete the cycle of care and demonstrate the pharmacist’s accountability for patient outcomes.

Medication Safety and the Systems Approach

Medication errors represent a significant and largely preventable source of patient harm. The landmark Institute of Medicine report “To Err is Human” (1999) estimated that medical errors, including medication errors, caused between 44,000 and 98,000 preventable deaths annually in US hospitals — a figure that galvanized the patient safety movement. Subsequent Canadian analyses similarly documented the prevalence and severity of medication-related adverse events in hospital settings.

Contemporary medication safety practice adopts a systems approach rather than a blame-oriented individual approach. This perspective, informed by James Reason’s Swiss Cheese Model, recognizes that errors are typically the product of system failures — gaps in workflow design, inadequate communication infrastructure, unclear labelling, distractions in the work environment — and that individual errors that cause harm do so because multiple defensive layers fail simultaneously. Effective safety interventions therefore target systems rather than punishing individuals.

Medication reconciliation is a formal process of obtaining and verifying a complete and accurate medication list at care transitions — admission, transfer, and discharge — and comparing it to medication orders at each transition to identify and resolve discrepancies. Discrepancies include omissions, duplications, incorrect doses, and addition of inappropriate new drugs. Evidence consistently demonstrates that medication reconciliation reduces adverse drug events at transitions of care, and pharmacist-led reconciliation programs are among the most thoroughly studied and effective implementations.

High-alert medications — drugs that bear heightened risk of significant patient harm when misused — receive special attention in safety programs. The Institute for Safe Medication Practices (ISMP) maintains a widely referenced list of high-alert medications that includes anticoagulants, concentrated electrolytes, insulin, concentrated opioids, and chemotherapy. Specific safety practices for these agents include independent double-checks, restricted storage, standardized concentrations, and bar-code medication administration systems.

Looking Forward: Technology, Personalized Medicine, and the Future Pharmacist

Pharmacy practice is undergoing a technological transformation that will reshape what pharmacists do and how they do it over the coming decades. Pharmacogenomics — the application of genomic knowledge to individualize drug selection and dosing — is moving from research to clinical routine. Clinical pharmacogenomic testing for variants in CYP2D6, CYP2C19, TPMT, DPYD, and other genes is now available in many centres, enabling prospective identification of patients at risk for drug toxicity or therapeutic failure before a prescription is written. The Clinical Pharmacogenomics Implementation Consortium (CPIC) provides regularly updated, peer-reviewed dosing guidelines for gene-drug pairs.

Artificial intelligence and machine learning are being applied to drug discovery, adverse event detection, clinical decision support, and pharmacy operations. Natural language processing enables automated extraction of adverse drug reaction reports from free-text clinical notes; machine learning models predict drug-drug interaction severity and hospital readmission risk. Robotics have been deployed in high-volume dispensing environments to reduce dispensing errors and free pharmacist time for clinical activities.

The expansion of telepharmacy and digital health tools has extended pharmaceutical care to patients in geographically remote or underserved communities. Asynchronous medication therapy management delivered through patient portals, remote monitoring of vital signs transmitted to pharmacist dashboards, and smartphone-based adherence support tools all represent emerging modes of practice that students entering the profession today must be prepared to engage with competently and critically.