September 25, 2014

Consumerism and Entitlement: What is Education Worth?

by Gina Stassinos, Pharm.D., Clinical Toxicology Fellow, Maryland Poison Center and University of Maryland School of Pharmacy

Recently, I took advantage of Maryland’s tax free week and bought myself a few clothes. I wasn’t entirely sure of a few purchases.  So I asked about the return policy. Indeed, I later discovered that some things didn’t fit me well.  Economic exchanges can be a risk, especially large economic exchanges. What if that product being purchased was an education? A professor at a graduation ceremony once told the class that, unlike other things that can be lost, an education can’t be taken away from you. An education may be the single best investment anyone can make.  But I’ve heard some graduates say they would not make the same decision to pursue pharmacy as a career path or enroll in a specific program or school if they could do it over. Indeed, this question was included on the Pharmacy Alumni Survey distributed by the American Association of Colleges of Pharmacy and the Accreditation Council for Pharmacy Education.

It is difficult to believe that the value of an education could be in disputed. Like the dress sitting in my closet, some people haven’t gotten much use out of their degree.  Some degrees are tied to a specific set of skills that have perceived value in the marketplace. But if the necessary skill set changes or demand shifts, the anticipated return on investment will be diminished or lost. There are also people who enroll in a specific school only to find the culture isn’t a good fit for them.  Lastly, educational value can be viewed from a quality standpoint. Teachers and schools today are ranked and evaluated based on numerous parameters.

These “value” propositions often espouse an ideology that view students as consumers — consumers entitled to a quality produce at a reasonable (competitive) price.  Students (the consumers) are not accountable for the quality of the product.  Rather, an education is something to be purchased and it is a means to employment. Academic entitlement is a term used to describe the tendency of students to expect academic success without taking personal responsibility for achieving the success. Entitled behaviors include being overly critical of instructors, contesting grades, demanding accommodations, and arriving late to class.1  A number of causes have been identified.  The millennial generation has been described as coddled narcissists.  There has been a rise in the number of market-driven degree programs and for-profit educational institutions.  Moreover, consumerism — societal trends to acquire ever increasing amounts of goods and services as well as to protect consumers against useless, inferior, or dangerous products — has become pervasive.2 Several negative consequences of academic entitlement and student consumerism have been described. The rigorousness of instruction and school-wide morale are reduced when professors must cater to student desires and are pressured to make the “numbers look good” by inflating grades.  When the student is a consumer, teachers and schools are more apt to tolerate unprofessional behaviors.  In the end, more graduates may be unemployable because they lack the knowledge, skills, and attitudes needed.

Are students today really entitled narcissists? Academic entitlement is certainly not new.  It has been described as early as 1986.3  A study conducted at Roseman University of Health Sciences attempted to develop an objective and measurable way to identify individuals who are “academically entitled.”  They found that only 10% of their graduating students (14 out of 141) were “academically entitled” based on the criteria they developed.2  In the end, the authors concluded that there is a lack of empirical data about whether academic entitlement is a growing problem.

Let’s look at student consumerism using a different variable – the cost of education. A study comparing national data regarding pharmacy and other health care professions found that pharmacy students’ total debt increased 23% over the last 5 years compared to 4.7% for dental and 8.5% for medical students. It also found that the return on investment expressed as a ratio of average salary to indebtedness was now below 1.0 and the number of pharmacy positions in the United States is no longer increasing.4 The authors concluded that institutions were shifting are greater cost burden to students. It could be that students are painfully aware of their degree of indebtedness and as cost increases so do their expectations.

What is the solution to student consumerism and risky educational investments? Many have proposed to decrease tuition, increase government regulation, or decrease the number of graduates.  In reality, controlling the ebb and flow of an economy isn’t easy.  Centrally controlled economies (think the old Soviet Union and Eastern Block countries!) don’t have a particularly good track record.  Most agree that an undue cost burden should not be placed on students as this fuels consumerism. Some experts believe that academic entitlement in health professional education can be combatted by rightfully acknowledging that the patient is the consumer (not the student).5

Instructors should be prepared to face entitled students by increasing their awareness of the issues and cautiously considering student demands, and designing assessments that reinforce student accountability.1  
All consumers, whether they are buying a dress or paying for tuition, should accept that there is risk in their decisions. It is common practice to assign value to intangible assets, like a college degree, more can be done to measure the quality appropriately.6  More objective data is needed to differentiate reasonable student requests from entitled ones. Student requests may be reasonable when they are based on four fundamental rights: 1) opportunities to learn, 2) to learn from faculty members dedicated to the best teaching practices, 3) to learn within a curriculum designed to prepare them for the profession, and 4) to have access to resources necessary to succeed.7 Clothing stores may go out of business and clothes will get used and thrown away, but education lasts a lifetime.  There will always be patients needing high quality providers. The focus should not be on whether the purchase should occur or if it fits just right, but on how we can enhance its value and take pride in our profession.

  1. Cain J, Romanelli F, Smith KM. Academic Entitlement in Pharmacy Education. Am J Pharm Educ 2012; 76: Article 189.
  2. Jeffres M, Barclay SM, Stolte SK. Academic Entitlement and Academic Performance in Graduating Pharmacy Students. Am J Pharm Educ 2014; 78: Article 116.
  3. Dubovsky SL. Coping with entitlement in medical education. N Engl J Med. 1986;315:1672–1674
  4. Cain J, Campbell T, Cogndon HB, et al. Pharmacy Student Debt and Return on Investment of a Pharmacy Education. Am J Pharm Educ 2014; 78: Article 5.
  5. Holdford DA. Is a Pharmacy Student the Consumer or the Product? Am J Pharm Educ 2014; 78: Article 3. 
  6. Cain J, Noel Z, Smith KM, Romanelli F. Four Rights of the Pharmacy Educational Consumer. Am J Pharm Educ 2014; 78: Article 115.
  7. Fazlagic A. Measuring the intellectual capital of a university. Paper presented at: Conference on trends in the management of human resources in higher education; 2005 Aug 25-26; Paris, France.

September 16, 2014

Relationships Matter: Lessons for Teachers, Managers, and Clinicians

by Joey Mattingly, PharmD, MBA, Assistant Professor, University of Maryland School of Pharmacy

Teacher quality is often cited as one of the most important variables in student achievement and this quality varies significantly.1,2  Are we stuck with a predetermined stratification of teacher talent, or is it possible to dig deeper and identify ways to improve organizational environments to achieve gains in teacher quality?  This post attempts to break down an important variable in education, the teacher-student relationship, and identify strategies for individuals and institutions to create environments that improve this exchange.

Figure 1
From a process analysis perspective, learning is an exchange between teacher and student(s) that takes place through a dyadic relationship (See Figure 1).  Since the student (member) essentially reports to the teacher (leader), this dynamic reflects organization reporting structures described in business literature.  The Vertical Dyad Linkage (VDL) and Leader-Member Exchange (LMX) theories were created to examine the impact of these relationships on important business outcomes such as efficiency, profitability, employee turnover, and job satisfaction.3,4  In the clinical setting, we see research on the patient-doctor relationship (PDR) model and impact on healthcare outcomes and patient satisfaction.5,6  While all of these theoretical models are being studied by researchers in various fields, there are a few common threads that we can all learn from (See Figure 2). 

Figure 2
John Maxwell simplified the importance of empathy in his book The 21 Irrefutable Laws of Leadership through a quote he often shared with his employees, “People don’t care how much you know until they know how much you care.”7  A physician may be brilliant and considered a leader by peers, but a patient’s decision to continue the patient-doctor relationship is significantly influenced by whether or not the patient perceives that the physician actually cares.8  An educator who displays empathy toward students is able to build a positive classroom climate, stimulate growth, and cultivate more productive learners.9 

Multiple studies have demonstrated the importance of respect and the relationship between teacher-student.10-12  Teachers that respect their students, managers that respect their employees, and healthcare professionals that respect their patients are able to build stronger relationships.  Listening is a great way to demonstrate respect.  Students’ perceptions of their professor’s respectfulness are also associated with stronger student self-confidence and motivation.12

Top-down accessibility and availability has been cited as an important variable in the dyadic relationship.  One of the components of the VDL and LMX theories within management is the “high quality” and “low quality” relationships that develop between supervisor and subordinate(s).  Dansereau, Graen, and Haga described this phenomenon as employees being divided into the “in group” or the “out group” in terms of relationship quality.  They found that leaders devoted more time, attention, and support to subordinates within the “in group” even though employees in the “out group” needed more support.3  Building strong relationships with students, employees, or patients requires time and making oneself available.

A Leader’s Dilemma
While evidence supports the need for leaders to incorporate empathy, respect, and accessibility into interactions with subordinates, profit- and efficiency-maximizing strategies are often not conducive to relationships building.  An organization wishing to gain economies of scale through growth will increase the number of members reporting to each leader in the organization.  Similarly, a teacher may see class size grow from year to year or a physician may be required to see more patients in order to increase revenues (aka “Do more with less”).

On the flip side, a 1:1 student-teacher ratio would not be practical (and too costly) to implement in most cases even though it would definitely allow the teacher to focus all efforts on one subordinate.  So what is the answer?  Is there a magic number of subordinates that would allow teacher, manager, and physician to build strong relationships with the members they serve? 

The Right Span
If we want to improve the quality of our teachers, managers, and physicians, then we need to consider ways to build an optimal span of control.  Dr. Harold Koontz identified several underlying factors for leaders to consider.13  For example, employees require different levels of training based on abilities and experiences.  A manager of a new location of a retail franchise with a high percentage of recently hired employees may be unable to adequately supervise 10 direct reports while a manager of a more established location with more experienced employees may be able to manage 15 people.  When applied to education, a professor leading an undergraduate course on basic microeconomic principles may have an easier time managing 100 students in a large lecture hall as compared to a professor managing a doctorate level course focused on an in-depth analysis of the Nash Equilibrium and other non-cooperative game strategies in economics.  A doctorate level student actually has more training to do the “job” of learning and one would expect a graduate school professor would be able to “manage” more students, but the complexity and intensity of training actually requires more instructional effort and thus limiting the professor’s span of control.  Understanding the variables that influence a leader’s span of control may help determine the right number of subordinates for each teacher, manager, or physician.

Reducing class size or number of patient visits may be difficult from a business perspective, but that doesn’t mean our hands are completely tied.  Knowing how Koontz’s factors influence a teacher’s span of control can help them improve educational outcomes, whether through advocating for appropriate class size changes or applying techniques to improve information exchange.  Improving the quality of communication and the clarity of plans helps simplify the instructions for each subordinate and reduces the amount of time the teacher needs to spend communicating.  Utilizing technology may also help leaders gain efficiencies to tackle their workload.

Identifying strategies to improve the different vertical relationships within organizations should be a top priority.  Developing stronger connections based on a foundation of empathy, respect, and accessibility could help schools, businesses, and health-systems reach desired outcomes. 

For more posts written by Dr. Joey Mattingly, please visit Leading Over The Counter, a blog dedicated to leadership and management topics for pharmacists and other health professionals.

  1. Riley RW. Our teachers should be excellent, and they should look like America. Education and Urban Society. 1998; 31:18-29.
  2. Slater H, Davies NM, Burgess S. Do teachers matter? Measuring the variation in teacher effectiveness in England. Oxford Bulletin of Economics and Statistics. 2012; 74:629-645.
  3. Dansereau F, Graen G, Haga WJ. A vertical dyad linkage approach to leadership within formal organizations: a longitudinal investigation of the role making process. Organizational Behavior and Human Performance. 1975;13:46-78.
  4. Thomas CH, Lankau ML. Preventing burnout: the effects of LMX and mentoring on socialization, role stress, and burnout. Human Resource Management. 2009;48:417-432.
  5. Mikesell L. Medicinal relationships: caring conversation. Medical Education. 2013; 47:443-452.
  6. Weng HC. Does the physician’s emotional intelligence matter? Impacts of the physician’s emotional intelligence on the trust, patient-physician relationship, and satisfaction. Health Care Manage Rev. 2008; 33:280-288.
  7. Maxwell J. The 21 Irrefutable Laws of Leadership. Nashville, TN: Thomas Nelson; 2007.
  8. DiMatteo RM, Prince IM, Taranta A. Patient’s perceptions of physicians’ behavior: determinants of patient commitment to the therapeutic relationship. J Community Health. 1979; 4:280-90.
  9. O’Brien LM. Caring in the ivory tower. Teaching in Higher Education. 2010; 15:109-15.
  10. Lammers WJ, Smith SM. Learning factors in the university classroom: faculty and student perspectives. Teaching of Psychology. 2008; 35:61-70.
  11. Micari M, Pazos P. Connecting to the professor: impact of the student-faculty relationship in a highly challenging course. College Teaching. 2012; 60:41-47.
  12. Komarraju M, Musulkin S, Bhattacharya G. Role of student-faculty interactions in developing college students’ academic self-concept, motivation, and achievement. J of College Student Development. 2010; 51:332-42.
  13. Koontz H. Making theory operational: the span of management. J of Management Studies. 1966; 3:229-43.

Grade Inflation: What Is It and What Can We Do?

by Brittany Lovko, Pharm.D., PGY1 Pharmacy Practice Resident, Suburban Hospital

Have you noticed that it’s getting easier to get an A in high school or college?  If you are student in (or recently graduated from) a rigorous curriculum like pharmacy, it may not have seemed so easy earning that “A”, but studies show it’s true. Grade inflation, first identified in the 1960s, is a growing problem in public and private institutions, including pharmacy schools.1 One study published in 2003 reviewed grade point averages at the University of Arkansas pharmacy school over a 20 year period and found a significant upward trend.  Grades increased by approximately 1% per year!1  From a teacher's perspective, this might be perceived as a positive sign. Shouldn't the goal be to educate students so that they’re all achieving the highest grade possible? Perhaps. But numerous studies have shown that student performance hasn’t really increased over the past 40 years based on indicators such as standardized test scores and scholastic aptitude tests.2

One might ask why grade inflation matters.  Grade inflation depreciates the value of an “A” and diminishes the meaning of a high grade point average.  How will students be able to set themselves apart if more (perhaps most) students graduate with a similarly elevated GPA? There is also some concern that grade inflation is leading to a culture of academic entitlement.3  Furthermore, graduates may have a false (inflated) sense of their knowledge and skills – and may not be able to delivery the standard of care expected in the health care today.3  So what can be done to curb this growing trend?

Normative vs. Criterion Grading4
There are two main types of grading systems – norm-referenced and criterion-referenced.  Normative grading is based on the direct comparison of a student to his/her peers. Thus, in a class of 20 students, you could decide that 5 would be assigned A's, 8 would be assigned B's, 5 would be assigned a C, and 2 students would get a D (or perhaps an F) based upon how each student's performance compared to the class average.  Normative grades are probably best suited for those courses that do not require absolute mastery of the subject matter.  Criterion-referenced grading, on the other hand, involves comparing the student's performance to a standard set by the teacher (or a standard established by some governing body).  This grading system is the most widely used.  We are all familiar with the percentage-based grading scheme where a score of 90% or above earns an “A”, an 80-89% earns a “B”, and so forth.  However, these cut points may or may not represent “mastery” of the material.  If criterion-based grading is to be used as recommended for courses that require mastery of the material, some experts recommend using a pass/fail system.4

Standardized Tests5
Another way to remedy grade inflation could be by using a well-accepted, national standard, as determined by standardized tests. The Pharmacy Curriculums Outcomes Assessment (PCOA) is a nationwide, standardized pharmacy assessment tool that can be used to measure academic progress of pharmacy students. This 220 question multiple choice test was created based upon the ACPE accreditation standards. The test is given annually to all professional students at participating institutions and the results are then reported both as a scale score and a national percentile rank.  The problem with this tool is that it still has not been widely implemented, in part due to the cost of administering the exam (which must be absorbed by the student or school).  If the PCOA were universally adopted, a new means to evaluate students could be established.   Colleges / schools of pharmacy could potentially move away from the traditional grading scheme and evaluate their pharmacy students in a more meaningful way. 

Numbers Instead of Letters4
Have you ever stopped to consider how arbitrary the traditional cut points are for each letter grade?  These cut points are not grounded in empirical data; rather, they are de facto “standards” merely because individual course instructors have repeatedly adopted them. Thus, letter grades can be misleading.  For example, two students who score only one percentage point apart in the course could end up with two different letter grades.  Some educators have recommended we stop converting these numbers into letter grades. Instead, we should report the class mean on a transcript next to the student's score to allow a more meaningful comparison.  Another normative approach would be to report each student’s class rank on his/her transcript. Both these methods would allow for students to be compared to each other.

Student Accountability for Learning3
For better or worse, the culture in which we live has put undue emphasis on the achievement of high letter grades. Thus, students will seek to achieve high grades and may pressure faculty members to reward them with high grades. This culture of academic entitlement refers to the growing anecdotal evidence that more and more students view their education as a commodity for purchase, meaning that they should be the ones in charge of dictating its path. This attitude can not only lead to grade inflation but also result in decreased faculty morale, disrespectful student behavior, and altered classroom practices. It is important that faculty members encourage students to take responsibility for their learning and professional development and not rely on educators to give them the grade they feel they “need” to succeed.

While grade inflation is certainly not an issue that can be fixed by a single teacher, or even by all teachers at a single institution, these principles are important to consider when choosing how to evaluate students.


  1. Granberry MC, Stiegler KA. Documentation and analysis of increased grade point averages at a college of pharmacy over 20 years. Am J Pharm Educ. 2003;67(3):Article 77.
  2. Rojstaczer S, Healy C. Where A is ordinary: the evolution of American college and university grading, 1940-2009. Teachers College Record. 2012;114(7):1-23.
  3. Cain J, Romanelli F, Smith KM. Academic entitlement in pharmacy education. Am J Pharm Educ. 2012;76(10):Article 189.
  4. Weil RR, Kroontje W. Grade inflation: causes and cures. J Agron Educ. 1977:29-34.
  5. Scott DM, Bennett LL, Ferrill MJ, Brown DL. Pharmacy curriculum outcomes assessment for individual student assessment and curricular evaluation. Am J Pharm Educ. 2010;74(10): Article 183.