September 14, 2010

Early Practice Experiences & Curricular Reform

by Liana Mark, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

Standard number 11 of the 2006 ACPE Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree states that “the pharmacy school must use and integrate teaching and learning methods that produce graduates who become competent pharmacists by fostering the development and maturation of critical thinking and problem skills.”  The Standards also go on to say that “the pharmacy school must enable students to transition from dependent to active, self-directed lifelong learners.”  This lofty goal is easier said than done, and I am not entirely convinced that the majority of pharmacy school curriculums enable students to achieve these objectives upon graduation.

My school of pharmacy implemented early (i.e. pre-P4) experiential learning into its curriculum after the 2006 Standards were published.  As such, I participated in both introductory and intermediate pharmacy practice experiences during the summers after my P1 and P2 years in addition to P4 advanced pharmacy practice rotations (APPEs).  During the school year, most learning was passive via didactic lectures and, in some cases, active through laboratory experiences and discussions.  Looking back, it seems as though I grew as a professional and as a learner at an exponential rate during my P4 APPEs, compared to the rather modest growth in the first few years of professional schooling.  My capacity to learn and apply resembles a J-curve, with a significant upswing towards the end of my student years.  However, now that I have the ability to look at pharmacy education from a bird’s eye view, I must say that I would have preferred my learning curve to resemble first-order kinetics during those years; with a steady, progressive increase that would have allowed me to build upon my prior knowledge and learn how to problem solve and critically think through problems early on, rather than just retaining factual knowledge and finally having a number of “a-ha!” moments at the end of my student career when everything suddenly fell into place.

So, the question is, how can first-order learning be promoted?  First, we must identify the barriers.  Passive learning techniques employed in the didactic portion of the Pharm.D. program provide limited opportunity for the development of problem solving and critical thinking skills.  This obstacle is mainly due to the factual nature and the sheer volume of information that pharmacy students must learn in order to create a substantial knowledge base.  A student can manage to pass via “cramming” and regurgitating the information on an exam, but this method of retention (because it is clearly not learning) benefits neither the learner nor his/her future patients.  Additionally, factual information, especially in the field of pharmacy, changes from year to year.  Taking this into account, treatment guidelines learned in the P1 year may not be applicable by the time the student reaches APPE rotations.  Thus, honing the skills of critical thinking and problem solving is absolutely necessary to prepare the student pharmacist for independent practice and satisfactory patient care.

Active learning is a more effective learning method for long term retention.  This method of learning includes discussion, practicing by doing, and teaching others.  Experiential learning is employed in many healthcare professions to prepare the student for independent practice, pharmacy included.  However, pharmacy experiential learning comes much later in the student pharmacist education as compared to other healthcare professions, and the experiential learning we do get early on is sparse and, in my experience, not fully maximized.  Students of dentistry, optometry, medicine, and physical therapy all have active, hands-on learning placed very early on in their curricula.  As such, by the time these students graduate, they have a strong fundamental, and, more importantly, applicable, knowledge base.  Individuals in these professions are well-equipped upon graduation to walk into a real-life setting, given that they have been in the setting as an apprentice for years.

A potential solution for student pharmacists is to incorporate weekly practice experience starting in the first few days of the Pharm.D. curriculum.  This integration would allow the student to apply facts learned in the classroom to a real situation, thus enabling him or her to critically think, problem solve, and retain the information in a different way than strictly classroom-based learning allows.  Weekly practice experiences may not be feasible due to course load.  Thus, another solution, which is employed at a number of pharmacy schools, is co-operative experiential learning, wherein the student pharmacist alternates classroom learning and experiential training from one semester to the next.  The experiential training, of course, must be coordinated with the classroom learning of the student.  My school’s current format that consists of IPPEs and APPEs could be maximized by ensuring that preceptors have a better understanding about their responsibility to the pharmacy student and to their profession.

It is clear that pharmacy education lags behind other professions in its active learning experiences.  Pharmacists need to be exposed to real-life situations earlier in their careers in order to meet the ACPE Standard that encourages the development of critical thinking and problem solving capabilities in the Pharm.D. curriculum.  Through active learning techniques, student pharmacists will be able to retain knowledge and create for themselves usable, applicable databases that will serve to improve their clinical abilities as practitioners and, additionally, encourage the pursuit of lifelong learning.

DiPiro JT. Making the most of pharmacy school. Am J Pharm Educ 2008; 72(1) Article 15.
DiPiro JT. Why do we still lecture?  Am J Pharm Educ 2009; 73(8) Article 137. 
[Editor's Commentary:  Is the typical pharmacy curriculum backward ... based on outdated, unproven notions about how people learn?  Should we provide students with experiences first and then talk about the theory and science that supports the practice of pharmacy afterward?  There are perhaps practical reasons why pharmacy schools (and most other professional schools) have elected to front load their curricula with didactic course work and save the practical experiences for the end. But most of the reasons have more to do with scheduling and resource allocation, not pedagogy or instructional design. Let's examine how one would go about teaching people to play a guitar (and to be good enough to make money playing it).  Now, learning how to play a guitar is complicated stuff.  To get really good at it you have to learn new terminology (e.g. adagio, allegro, forte), read (and perhaps even write) an entirely new form of communication (e.g. music notations), play different styles of music, and coordinate your actions with other people who are simultaneously playing their musical instruments or singing. If we approached learning how to play a guitar the same way we approach pharmacy education, we'd have the students sit through a series of didactic lectures about the guitar and its history, about guitar playing techniques, how to select a guitar, how to read music, and how to be a member of a band.  We'd probably have students watch an instructor (or better yet, a resident!) play a guitar in front of the class.  And then we'd have everyone watch videos of Eric Clapton and John Scofield playing guitars - and then debrief about it for 30 minutes.  In addition, we'd have the students participate in 3 or 4 "guitar labs" each semester where three or four students would use the school-provided XBox or PS3 and play "Guitar Hero" (or something like that) - and watch each other play - for a couple of hours.  And then, we'd have a one week observation (P1) and a one-month (P2 and P3) "guitar playing" rotation with a preceptor.  The student probably wouldn't be assigned his or her own guitar to play - but would rather "assist" the preceptor with some guitar playing activities (like, for example, handing the preceptor the right pick to use).  In the fourth year of our "guitar school,"  each of the students would be sent off into the field and would be asked to start playing guitars - 40 hours a week!  This would probably overwhelm our students, who haven't yet built the skills to play guitar very well on their own nor the stamina.  But, during the last year of the curriculum, most of our students would, indeed, get pretty good at it.  Most would become competent guitar players (good enough to be street musicians) and a few would become stars (acclaimed by their audience and peers as truly great musicians).  Many of our students would arrive at our fictitious guitar school with some guitar playing experience - and nearly all of them would be innately interested in guitar playing.  But we wouldn't let them touch a guitar until they've completed a least 16 credit hours of instruction about the latest statistics regarding guitar playing in the US, music theory, and (of course) the physics of sound.
Seems a bit absurd, doesn't it?  If you wanted to learn how to play guitar, the first thing you'd do is pick a guitar and try to make some sounds with it (not take a series of didactic lectures about it).  And a good teacher would encourage you to do so.  In fact, you probably wouldn't be allowed into "guitar school" unless you had access to a guitar and could get practice using it several hours a week.
I encourage you to read a provocative article by Wendy Duncan-Hewitt and Zubin Austin published in AJPE.  I think the traditional pharmacy curriculum is a relic of the past.  Its time to rethink and radically restructure things. -SH]

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