December 17, 2009

Experiential Learning: On-Call!

by John Hammer Pharm.D, MBA, PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

Aristotle once said, "For the things we have to learn before we can do them, we learn by doing them."  I believe this quote encompasses what is meant by experiential learning.  I think of experiential learning simply as learning by doing.

Experiential learning is what residency training is all about.  Residency training is about learning new concepts and building on knowledge previously obtained in pharmacy school through hands on learning.  It is true that students learn through their experiences as well, but it is to a lesser degree – perhaps due to less responsibility.

I feel that the amount of knowledge gained during residency training, whether we are talking about a pharmacy residency or a medical residency, is second to no other learning experience.  A residency teaches one how to act as an individual practitioner and through this we gain practical application of the theoretical knowledge learned in pharmacy school.  As residents we are frequently faced with issues that we have never seen or even read about before.

I believe that an on call program is a great hands-on experience to add to residency training.  When on call, the resident achieves another level of responsibility; acting as the clinical pharmacist that handles code coverage, pharmacokinetics, drug information questions, and whatever issues may arise during after hours.  For new residents, this responsibility may cause some anxiety – particularly given that you don’t know what may come your way - like a code.  But this is a good thing.  Residency training has a lot to do with going outside of you comfort zone in order to learn new things.  After experiencing something once you will be less uneasy and able to handle the situation better the next time.

I know this was true for me and many other residents at Johns Hopkins Hospital.  During the first code everything seemed to happen so quickly. There were a number of people packed tightly into a room, while someone was giving orders and others were running around quickly to perform important tasks.  I remember standing by the dispensing cabinet, trying to stay out of the way, when the physician asked me to prepare three drugs STAT [immediately] – drugs that I had only vague familiarity.  My hands were shaking as I pulled out my resources to verify the appropriateness of the doses and confirm how to prepare them.  I fumbled around with vials and syringes; which never seemed to be an issue for me in the past.  I triple checked my math and had someone else check the doses.  Even though I was nervous and fearful that I might do something wrong, the situation went well and the patient was fine.

I feel that it is experiences like this, where you are by yourself and forced to learn something new, under pressure, that make for the best learning experiences.  Experiences that take you outside your comfort zone occur all the time during residency training, but I feel that these experiences are more abundant while acting as the resident on call.

Experiential learning is the primary method for learning during a residency.  The variety of those experiences help to make one well rounded, and a residency on call program is useful in that it exposes one to a variety of unique experiences and responsibilities that one otherwise might not obtain.

[Editor’s Commentary:  Pharmacy residency on-call programs have existed for many years.  Perhaps the best known and oldest pharmacy residency on-call program was described in the American Journal of Health-System Pharmacy by Dr. Karen Smith and her colleagues at the University of Kentucky (AJHP 2003; 60: 2236-41).  Most residency on-call programs require the resident to troubleshoot drug-related problems that emerge during off hours (e.g. between 5pm and 7am).  This includes participation in hospital emergency care (aka "medical codes").  On-call programs require residents to act autonomously - to make decisions on their own - and in so doing, its intended to build self-directed learning skills.  For the new practitioner who is not yet accustomed to making decisions on his/her own or directing his/her own learning, this can (and should) produce some degree of anxiety.  By placing residents in situations of responsibility, residents develop a greater (and sometimes urgent) awareness of their gaps in knowledge and skills ... and this is an important step in the experiential learning process.  John describes this gap in his essay (vague familiarity with the three drugs used during the code) ... and, similar to the experiential learning model described by Kolb, he identified resources to help him fill that gap.  In this case, it was a drug information source available at the bedside.  Like the experiential learning model, he implemented strategies (obtained information, calculated doses, and had someone else double check him) and reflected on the success of those strategies (in this case, "the patient was fine.").  It is the last step, the thoughtful reflection about the experience, which is perhaps the most critical.  Without reflection, one is unlikely to learn from the experience or to actively identify gaps, seek resources, and implement new strategies in the future.  Life is FULL of experiences - but many (perhaps most) are not learning experiences.  As teachers, we must be mindful of the experiential learning process - and help our trainees learn from their experiences.  Perhaps the most important thing we can do is to set aside time for reflection (by the student or resident) and discussion (with us) at regular intervals.  It is often through a dialog with a skilled preceptor and experienced practitioner that the trainee will have those "ah ha" moments of understanding.  Reflection and discussion should occur as soon as possible after the experience - preferably within hours for major new experiences and less frequently (a few days) for experiences that have slightly new features (relative to the trainee's past experiences).  In addition to setting aside time for reflection, we should strive to prepare our trainees for major new experiences by helping them to identify gaps and assemble resources ahead of time.  The EXPERIENCE is solely the student's or resident's to have.  As much as we might like to take away their anxiety or to be at their side to take the weight of the responsibility, attempting to do so (all the time) is a disservice.  Indeed, it is the EXPERIENCE that sets the learning process in motion. - S.H.]

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