Handwriting vs. Typing Notes: What is Their Impact on Learning?

by Olivia Redmann, PharmD, PGY-1 Community-Based Pharmacy Resident, The University of Mississippi School of Pharmacy

In an age dominated by technology, handwriting notes may seem antiquated. With laptops, tablets, and smartphones at our fingertips, the convenience of typing notes during lectures has quickly become the norm. In my own experience, I find handwriting notes better for learning. I had a chemistry teacher in high school who taught lectures by handwriting notes with the students in real-time and projecting her notes on a screen for us to follow along as we wrote our own notes. She explained that she wrote her college thesis by hand and found that taking a more creative and hands-on approach to note-taking was beneficial in learning and processing the information. This experience changed my note-taking and studying habits. I found that taking a more “hands-on” and creative approach to note-taking allowed for better reading comprehension and improved my test scores. But is my personal experience supported by the data?  That’s what led me to dive deeper into the topic of handwriting vs. typing notes.  I wanted to know what impact each note-taking strategy has on students’ ability to learn and digest information.

One of the primary benefits of handwriting notes is its positive impact on memory retention. Multiple studies have shown that the physical act of writing engages the brain in a way that typing does not. A study published in the Frontiers in Behavioral Neuroscience used three groups of participants to perform a schedule-recording task using either a paper notebook, an electronic tablet, or a smartphone, followed by a retrieval task. The study demonstrated that “brain activations related to memory, visual imagery, and language during the retrieval of specific information, as well as the deeper encoding of that information, were stronger in participants using a paper notebook than in those using electronic devices.”¹ The investigators concluded that the use of a paper notebook and handwriting can affect higher-order brain functions, which could have important implications for learning. In contrast, typing notes often encourages a more passive approach to information processing. The ease of copying (and pasting) notes word-for-word from a screen can lead to shallow understanding and limited retention. Handwriting forces us to synthesize and paraphrase information, promoting a deeper understanding of the material. This led me to believe that active engagement with the material has the potential to significantly improve our ability not only to remember but also to apply what we have learned.

Using a computer or smartphone to take notes can lead to distractions. The allure of social media and countless other digital temptations are just the click away. Handwriting notes demands a higher level of concentration and attention, it does not generate the distractions that come with digital devices. When we write by hand, we are less likely to veer off course and more likely to stay fully engaged with the material in the present moment.² Additionally, the tactile feedback of pen and paper provides a sensory experience that is different in key ways (pun intended) compared to typing. This sensory connection can lead to a more profound sense of connection with the content, helping learners stay present and attentive throughout an entire lecture or class period.³

Typing notes on a device can encourage the unproductive habit of multitasking. It’s just too easy to switch between a note-taking app and other applications. This constant task-switching can hinder deeper learning and comprehension. In contrast, handwriting notes on paper eliminates the temptation to check emails, browse the internet, or engage in unrelated tasks. The absence of digital distractions during note-taking allows for sustained focus on the subject matter at hand. This undivided attention fosters a more immersive learning experience, enabling students to absorb information more effectively.

Another infamous study done by Mueller and Oppenheimer took a different approach to understanding why typing notes is detrimental to one’s learning. One of the key arguments against typing notes is that electronic devices present numerous distractions to students. But perhaps it’s the way that students take notes when they type isn’t as effective from a learning perspective. In their study, Mueller and Oppenheimer allowed participants to use their normal note-taking strategy in the classroom.  What they were interested in was seeing how the information was actually recorded. Mueller and Oppenheimer found that laptop note-takers had a tendency to transcribe lectures verbatim rather than processing information and reframing it in their own words. This may be another explanation for why typing notes is detrimental to learning.⁴

For me, handwriting notes offer a level of customization and creativity that typing cannot match. With a pen and paper, I can easily create diagrams, charts, or sketches to illustrate complex concepts. I have the opportunity to use different colors, underline, highlight, or circle key points to make them stand out. These visual aids not only enhance comprehension but also make the notes more visually memorable. Thus, the act of physically writing on paper (and perhaps using a stylus on a tablet device) allows for greater personalization of notes. In addition, notes in the margins and annotations all add a unique layer of engagement with the material that most digital note apps can match. This personal touch makes notes more meaningful and easier to revisit when it comes time to study before the exam. Lastly, handwriting notes may offer long-term learning benefits. When we write by hand, we create a tangible record of our thoughts and ideas.

In an increasingly digital world, the benefits of handwriting notes should not be underestimated. While typing offers convenience and speed, the cognitive and learning advantages of putting pen to paper—or stylus to tablet—are clear. Handwriting notes enhances memory retention, improves focus and attention, fosters creativity, and reduces the risk of distractions. The act of summarizing information during note-taking promotes deeper understanding, which can have a lasting impact on one’s knowledge retention. To truly harness the power of the written word in the digital age, we should consider embracing the time-tested practice of handwriting notes to enhance learning.

References:

1. Umejima K, Takuya I, Takahiro Yi, and Sakai KL. Paper Notebooks vs. Mobile Devices: Brain Activation Differences During Memory Retrieval. Frontiers in Behavioral Neuroscience 15 (2021). doi: 10.3389/fnbeh.2021.634158
2. Tamm S. Handwritten vs. Typed Notes: Which Is Really Better? E-Student (blog), March 24, 2021.
3. Ibañez F. Study Reveals the Advantages of Taking Notes by Hand. Observatory - Institute for the Future of Education (blog), June 7, 2021.
4. Mueller PA and Oppenheimer D. The Pen Is Mightier than the Keyboard: Advantages of Longhand over Laptop Note Taking. Psychological Science 2014; 25(6): 1159–68.

Interventions to Support Student Wellbeing to Improve Retention and Learning

by Alyssa Hooter, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Burnout, a term to describe a state of exhaustion from working excessively, was first used in 1974.¹ Burnout can also be used to describe the depleted mental state and mental exhaustion students develop toward their studies. This is often seen in students pursuing professional degrees in the health professions, including medicine, pharmacy, dentistry, and others.  Students need to recharge so that their long-term performance and success is not hindered. To combat student burnout, many institutions have implemented a variety of interventions to help students build up the stamina needed to pursue a career in healthcare.

Health professional students commonly experience burnout due to exhaustion and the gradual loss of excitement to pursue their career. Sometimes burnout can lead to physical manifestations, such as diseases like hypertension, and negative psychological states, like depression, and behavioral problems, like substance use or suicidal thoughts.¹ A meta-analysis of 39 learning burnout intervention studies, including 3,400 students, evaluated the effects of different interventions that were most effective in decreasing burnout.¹ The interventions were divided by type: individual, organizational, matching interventions, and learning engagement. The interventions most commonly studied were exercise (an individual intervention) and group counseling (an organizational intervention).

Physical activity has been shown to promote positive moods and decreases the risk of depression and reduces tension associate with prolonged learning activities.¹ Group counseling sessions involve providing students a safe group atmosphere and a process that facilitates respectful interactions between students.  Group counseling has been shown to improve students’ self-efficacy in learning behavior and the selection of positive coping strategies.

Healthcare workers are at particularly high risk for burnout, including medical students. Reducing the risk of student burnout can be done by individual faculty and the institution.  The American Medical Association (AMA) released an AMA STEPS Forward^TM initiative that describes the measures medical schools can take to promote well-being.² The first step is to recognize shared responsibility by assigning a faculty member with the obligation to oversee student well-being and evaluate resources to make school-level changes. Often, this person is deemed the Director of Student Well-Being.  The second step involves measuring student well-being regularly by using a standardized instrument to compare progress as the institution implements changes. Third, the AMA emphasizes the importance of optimizing the curriculum. Research has found that pass-fail grading is associated with a reduced risk of burnout. Even if pass-fail grading is not practical for every course, it can be beneficial in non-clinical courses. Moreover, changing to pass-fail has not had a detrimental impact on learning as measured by the United States Medical Licensing Examination Step tests. Fourth, the AMA report also acknowledges that student debt is a major factor that contributes to burnout.

Another strategy to decrease burnout is to optimize the institution’s learning environment and cultivate a supportive community. This can be done through displays of support from faculty and empowering students in the clinical setting to build confidence and inspiration within themselves. Step 6 is to promote self-care and resiliency. Why is this step 6?  This is intentional. A student can only progress and excel in an environment that supports and nourishes growth. Trying to have discussions about self-care to students who do not feel supported by their institutions or who feel discouraged during their clinical experiences will not go far. Once empowered and given appropriate resources to prevent burnout, students may begin to understand their self-doubt and how their thoughts may be a source of discouragement.  It is imperative that students are given time to reshape their thoughts and work through these feelings without added pressure from their institutions. This can be accomplished through designated well-being days, specific quiet areas, and free counseling services. Step 7 is to provide adequate services for students are already affected by burnout or distress. Lastly, the AMA report encourages the funding of studies that measure the impact of organizational changes on student well-being.

Pharmacy students also experience burnout.  The American Association of Colleges of Pharmacy (AACP) has a Community for Wellness and Resiliency with the goal of providing “quality resources and ideas to infuse well-being science into pharmacy education.”  This is a great start for pharmacy schools — addressing mental health in students “has been on the back burner for several years.”² Given the added stress of the COVID-19 pandemic, it is imperative that programs not only be developed, but enforced.  I believe an individualized student-specific approach will result in improved mental resilience that will carry the student from the classroom throughout their career.

A valuable starting place to support the well-being of a student is to show them that they are not just a generic student, but rather, an individual who has needs. One way we can do that is by allowing the student to have at least one day per month that they can use, similar to how a full-time employee would use paid time off. Explanations would not need to be given and the day can be used however the student needs. Other methods of demonstrating respect and understanding for students is for professors to talk about personal and professional hardships, during class sessions or advising meetings, and what they did to overcome or learn from those experiences.  This can help students realize they are not alone as all of us have experienced difficulties and hardships. It takes both an institutional approach and an individual willingness to reach out and truly assist learners to reduce the risk of burnout. Addressing these issues while students are in school can help ensure that their future patients’ lives are in confident and competent hands.

References

1. Tang L, Zhang F, Yin R, Fan Z. Effect of interventions on learning burnout: A systematic review and meta-analysis. Front Psychol 2021; 12: Article 645662.
2. Rooney J. A Renewed Focus on Resilience. Academic Pharmacy Now 2020: https://www.aacp.org/article/renewed-focus-resilience
3. Brook J, Aitken L, MacLaren J, Salmon D. An Intervention to Decrease burnout and Increase Retention of Early Career Nurses: A Mixed Methods Study of Acceptability and Feasibility. BMC Nursing 2021; 20(1):19.
4. Harris R. Embracing Your Demons: An Overview of Acceptance and Commitment Therapy. Psychother Austr 2006; 4:1-7.

Should TBL Readiness Assurance Tests Be Graded?

by Kaylee Hall, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Team-based learning (TBL) is a learning strategy that requires students to prepare for topics prior to class and be ready to apply that knowledge to solve problems in a group setting. In professional schools, this is typically done by working through patient cases and clinical questions as a team. TBL is structured so the class starts with an Individual Readiness Assurance Test (iRAT), typically consisting of multiple-choice questions designed to test if the student is prepared to work through the cases/questions during that class. Following the iRAT, students then complete the group Readiness Assurance Test (gRAT), which consists of the same questions from the iRAT; however students work together in groups to answer the questions, facilitating group discussion and problem-solving. Students typically receive immediate feedback on the gRATs to promote conversations within the group and a deeper understanding of the subject matter. While the RATs are an important part of the learning process, controversy exists on whether the RATs scores should be counted towards students’ grades or counted as participation (i.e., the student is awarded full credit for being present and completing both the iRAT and gRAT).¹

A recent study conducted at the University of Tennessee College of Pharmacy assessed student performance when RATs were graded versus ungraded in a TBL course. They compared results from an elective course offered in the spring of 2020 and 2021. RAT scores were graded in 2020 and not graded in 2021. After the 2021 course, students were asked to take a survey to assess class preparation and perceived team accountability. The investigators found no significant difference in student exam performance when comparing the ungraded versus graded cohorts and concluded that ungraded RATs did not adversely impact students' examination performance.²

Pros to counting RAT scores

Assessment drives learning. Having RAT scores count towards the students' grades may provide them with extrinsic motivation to complete the pre-class materials which are essential for TBL. Previous investigations have looked at how grading iRATs affected class preparation and performance. They found that when iRATs were graded, students were more likely to download pre-class materials and performed significantly better on iRATs. When they compared the download frequency of preclass materials, it dropped by about 30% for Year 1 and by nearly 50% in Year 2 courses when iRATs were ungraded compared to graded.³

Cons to counting RAT scores

An assessment focus rather than a mastery focus. Assessments may promote cramming of material and superficial learning of the subject in order to pass the quiz or examination without truly understanding the concepts.⁴ Grading RATs may also encourage students to use a performance or performance-avoidance approach to learning, where students focus on the assessment with the goal to perform well or outperform their peers. This orientation toward learning promotes superficial learning of the material without encouraging students to master the subject.⁵

Negative effects on group cohesion. Grading RATs may push students to focus on individual efforts instead of working as a team. Poor group cohesion may promote social loafing where students give less effort because they can rely on other members of the team to do the work.⁶ In contrast, not grading RATs may encourage students to work together to achieve mastery of the subject. Without the need to achieve a grade, group assessments encourage students to prepare for the materials based on their intrinsic motivation and the desire to contribute their ideas. When students are intrinsically motivated, they tend to be more engaged and stay engaged longer than students who are extrinsically motivated.

Indeed, student surveys have found that ungraded cohorts feel more responsible for the team and have a greater desire to contribute to the group’s work. Students also report that they felt their contributions were important, indicating good group involvement and cohesion. Additionally, the majority of students reported that class preparation is necessary to perform well in the course.²

Increased pressure to perform. The pressure to perform well on assessments may encourage academic dishonesty and promote unneeded stress. Without the pressure to perform, students are able to focus on a deeper understanding of the material and are less likely to engage in superficial learning simply to perform well on examinations.

Conclusion

Few studies have looked at student performance when RATs are graded versus ungraded in the Team-Based Learning model.  Professional opinions differ on which approach is best. Historically, we know that assessment drives learning, but graded assessments may not be the most appropriate approach to the team-based learning strategy and may have unintended consequences. Grading readiness assurance tests may promote superficial learning of the material, lead to poor group cohesion and inflict unnecessary stress on students.  At least one study suggests that ungraded RATS does not harm student grades. Removing grades may diminish extrinsic motivation for students to prepare for readiness assessments but allows students to foster their intrinsic motivation — to be motivated more by the desire to contribute to the group and to master the material. More evidence is needed to truly assess the pros and cons of graded versus ungraded readiness assurance tests in professional schools.

Resources:

1. Hrynchak P, Batty H. The educational theory basis of team-based learning. Med Teach. 2012;34(10):796-801.
2. Eudaley ST, Farland MZ, Melton T, et al. Student Performance on Graded Versus Ungraded Readiness Assurance Tests in a Team-Based Learning Elective. Am J Pharm Educ. 2022;86(9): 8851.
3. Koh YYJ, Rotgans JI, Rajalingam P, et al. Effects of graded versus ungraded individual readiness assurance scores in team-based learning: a quasi-experimental study. Adv Health Sci Educ Theory Pract. 2019;24(3):477-488.
4. Epstein RM. Assessment in medical education. N Engl J Med. 2007;356(4):387-96.
5. Meece JL, Anderman EM, Anderman LH. Classroom goal structure, student motivation, and academic achievement. Annu Rev Psychol. 2006;57:487-503.
6. Karau SJ, Williams KD. Social loafing: A meta-analytic review and theoretical integration. Journal of Personality and Social Psychology. 1993;65(4):681–706.

Leading Future Leaders? Developing a Curriculum to Enhance Leadership Skills

by Blake Mangum, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

When enrolling in a professional health program such as medicine, pharmacy, or nursing, many students must adjust to the demands of their program. The material is complex, the workload is demanding, and there are often co-curricular organizations and responsibilities to make time management even more complicated. Didactic instruction is critical in career development to understand the core material needed, but it's equally important to develop the professional and leadership skills required to excel. We often focus on helping students develop as future clinicians and instill the requisite foundational knowledge for their chosen professional field. But it is easy to overlook the importance of helping students develop as future leaders. Organizations that accredit professional programs, such as the Accreditation Council for Pharmacy Education (ACPE), require the curricula to address professional development and leadership.  However, the method and material to be covered are left to the individual program. This introduces some variability between programs as institutions have various philosophies on the optimal method to deliver this material and may even define leadership differently. Do you structure the leadership curriculum by delivering a series of lectures, a couple of exams, and a final project?  Or do you divide students into teams and have small-group discussions?  Or do you send students out on their clinical rotations to develop their leadership skills in the "real world"? This essay will reflect on methods currently used in leadership development education and the outcomes reported by those using these methods.

Optimal Structure of a Leadership Curriculum

During my time as a pharmacy student, I took several professional and leadership development courses that were required in my program. I had assumed the structure and methods used would be similar at every health professions program. My classes started by taking a strengths finder analysis and discussing the impacts that various skills could have on team dynamics and performance. While researching what goes into making a leadership development course, I found that some programs take a similar approach, but others are very different. A recent scoping review examined fourteen published reports on leadership education in PharmD programs.¹ Of those, only six employed traditional didactic lectures in the required curriculum. Others relied on co-curricular activities, elective courses, and leadership retreats. Even didactic lectures had variable content and schedules. Another systematic review provides insight into what components give us the most return on investment.² The review used Kirkpatrick levels of evaluation to determine the effectiveness of each intervention or approach. They found that leadership interventions that combined didactic lectures with projects, lab activities, and small groups were more effective than didactic lectures alone.² Both papers report that students prefer a multimodal approach. The course structure is not the only variable to consider.

Optimal Duration of a Leadership Curriculum

We have all heard that practice makes perfect. It is important to consider how long it takes to conduct a program aimed at leadership development and how often the participants should meet. The literature is quite variable in this regard.  Some programs met once monthly for a semester or entire academic year, while others consisted of a 5-module series over multiple years, and others were a single-day leadership retreat.^1,2 The exact length of a program and how often to meet will depend on several institution-specific factors, such as the availability of professors to deliver lectures, the schedules of students' other classes, physical facilities, and more. Based on a review of the literature, longitudinal courses have greater efficacy than shorter program durations; however, programs that lasted half a day were compared to programs that lasted the entire four-year curriculum.² The answer to how long to teach and how often to meet is debatable, but a good starting point would be a standard semester-long course.

Optimal Class Size

The literature reviews report cohorts ranging from 6 to over 200 students.^1,2 Smaller cohorts scored higher on efficacy rankings than large cohorts. This area is a little harder to navigate as not much can be done about a class size if you require the entire student body to complete the program. One possible method of ensuring smaller cohorts would be to divide classes into sections, with some sitting in a lecture for one week while the other section is involved in a skills lab, and perhaps dividing up the cohort into even smaller groups for discussion sessions. This method would provide students with a multimodal learning experience and more direct learning opportunities.

Optimal Course Development

The University of Massachusetts Medical School recently created a course to enhance medical students' leadership and teamwork skills.³ The course objectives included leadership style, communication within the health care team, giving and receiving feedback, delegating responsibilities, and setting direction for a team. These leadership skills were identified as core competencies in a previous needs assessment survey. The course involved six 90-minute sessions.  A portion of each session was a didactic lecture, plus there were interactive activities to reinforce the material, post-session questionnaires, and individual reflections. Similar to previous studies, the authors used pre- and post-course surveys to gauge course impact. Students completed a survey eight months after the course conclusion to assess the long-term skill use and effects of the course. The authors documented increased student confidence related to each course objective and the key skills learned during the course were still being used in everyday life eight months later. This model indicates that surveying students about impact is a best practice to assess the effectiveness of a course. Of note, the creators of this course were students themselves! This underscores the fact that students actively seek to strengthen their leadership skills and, in this case, help others develop them as well. Healthcare is a team sport, and having the ability to lead the team in your area of expertise is an essential skill.

Leadership skill development is not routinely considered when entering a clinical profession. However, these skills are critically important and need to be considered when developing a curriculum. The optimal methods will vary between institutions, but using a multimodal approach with lectures, longitudinal projects, and having smaller cohorts in classes are factors that can improve the effectiveness of a leadership course.

References

1. DeVolld T, DiPietro Mager N, et al. Management, entrepreneurship, continuing professional development, and leadership education in United States doctor of pharmacy curricula: A scoping review. Curr Pharm Teach Learn 2022;14(6):798–808
2. Evans MA, James EJ, Misa Mi. Leadership training in undergraduate medical education: A systematic review. Int J Med Students 2023;11(1):58–66.
3. Richard K, Noujaim M, Thorndyke L, Fischer MA. Preparing medical students to be physician leaders: A leadership training program for students designed and led by students.. Med Ed Portal. 2019; 15: 10863

Biases, Microaggressions, and Stereotype Threat and Their Impact on Learning

by La’Kendra Bell, PharmD, PGY1 Community Pharmacy Practice Resident, University of Mississippi School of Pharmacy

As an African American woman, I have had a front-row seat to the many microaggressions, biases, and stereotypes that come with being black. I, however, did not let it hinder my growth, as I aspired to be a healthcare professional and make a difference in communities that look like me. This essay focuses on how biases, stereotypes, microaggressions, and stereotype threats can negatively impact learning and the strategies educators could use to prevent and manage them. Let’s first make sure we agree on some definitions:

• Bias: An inclination of temperament or outlook. A personal and sometimes unreasoned judgment¹
• Stereotype: something conforming to a fixed or general pattern.¹
• Microaggression: a comment or action that subtly and often unconsciously or unintentionally expresses a prejudiced attitude toward a member of a marginalized group (such as a racial minority)¹
• Marginalized populations: groups and communities that experience discrimination and exclusion (social, political, and economic) because of unequal power relationships²

Growing up in a mostly separated community, I avoided most of these encounters, as most students went to a school with other students of the same race. Therefore, I did not experience microaggressions, biases, and stereotypes from my peers. However, I had to face them with teachers. Being in a low-income, rural area, many teachers would come to our school for a short period of time and did not stick around to invest in our education and development. For them, it was an opportunity to “pay back their loans.” Feeling unwanted by teachers was the first step in the broken system. From time to time, there were statements that made me feel like I couldn’t make it and that I wasn’t good enough. These were subtle statements and attitudes from people with physical characteristics different from me and sometimes even from those who looked like me.

As I went off to college and then became a pharmacy resident, there were other instances where I felt bias and stereotypes were influencing people’s statements and behaviors; but at this point, I am a professional and must behave appropriately. For recipients, microaggressions can be distracting, exhausting, and painful. One must try to figure out the meaning and intent of the microaggression and then decide whether and how to respond.³

For me, figuring out how to respond is very challenging because I want to avoid coming off as aggressive. When educators and other individuals understand microaggressions, they are in a better position to be sensitive to how a person might perceive comments, create a culture where microaggressions are openly discussed, and support students when they experience them.³

Examples of microaggressions: ⁴

Theme	Microaggression	Hidden Message
Alien in own land. When Asian Americans and Latino Americans are assumed to be foreign born.	“Where are you from?” “Where were you born?” “You speak English?”	You are not American. You are a foreigner.
Ascription of intelligence. Assigning intelligence to a person of color on the basis their race.	“You are a credit to your race.” “I wasn’t expecting you to do so well.” Asking an Asian person to help you with a math problem or science problem. Asking a black person if they played sports. “Are you my nurse?”	It is unusual for someone of color to succeed All Asians are good in math or science All black people play sport or are athletic Assuming a female can only be a nurse and no other healthcare professional
Criminality/ assumption of criminal status	Clinching purses as someone approaches you. A store owner or employee follows you around the store	You are a criminal You are going to steal and assuming you don’t have money
Denial of individual race	“I’m not racist. I have several black friends “I do not see race”	I am immune to racism because I have friends of color Dismissing one's background

Stereotype threat is a disruptive psychological state.³ Underrepresented minority students may be affected by the notion that they are not motivated, capable, and/or academically prepared for higher education. When a student experience stereotype threat, they avoid behaviors that might affirm the stereotype.  For example, a Latino student might not seek help from the Writing Center on campus because it would reinforce the stereotype that they don’t speak or write English well. Or a Black student might not speak up during class for fear they might be perceived as aggressive.  Many studies have demonstrated that stereotype threat can cause hypervigilance, impair working memory, and inhibit academic performance. When stereotype threat is triggered, the energy that could be spent on learning is lost to vigilance, worry, and anxiety. It can lead students to avoid communicating with instructors, studying, or coming to class, ultimately leading to increased student attrition.³

Navigating these stereotypes and biases can be difficult, as they can be based on gender, race, socioeconomic status, religion, and more. Microaggressions negatively impact one's ability to concentrate, solve problems, and learn new material.⁵ Studies suggest that hostile racial climates perpetuated through microaggressions on college campuses disrupt students’ ability to participate in class discussions. Moreover, experiencing microaggressions in the classroom has been linked to feelings of invisibility, isolation, and self-doubt, all impairing one's ability to focus on tasks and solve problems.⁵

What can educators do to prevent and manage these threats to the learning environment? If an educator realizes after the fact that they have just said or witnessed a microaggression, the easiest thing to do is to simply apologize to the hurt individual.

Ways to apologize

Purpose

If committed in your presence but did not address the situation when it occurred: Ten minutes ago/yesterday/last week, a statement was made in class that I did not address at the time but want to do so now.6 If you committed a microaggression: [Student], I want to apologize for the comment I made yesterday. My intention, although poorly articulated, was to say [this]. I understand, however, that my words conveyed incorrect and harmful assumptions about you. Please know that I intend to be more mindful and reflective about what I say in the future.6

Apologize for the delay and acknowledge that by not responding immediately, you (as the instructor) may have given the impression that you condone the behavior and comments that caused. 6 Identify the problematic statement(s) that caused the high emotions. 6   State your commitment to responding to incivilities more quickly and desire to better support the learning and well-being of all students.6

As a student in a health professions program, I sometimes felt that I couldn’t be my authentic self because I did not want to affirm others' negative beliefs or be seen as unprofessional. Though some may not have experienced bias, microaggressions, or stereotype threat, I think it’s important to understand how they can negatively impact learning.  These issues are complex, multifaceted, and layered, but raising awareness is a critical first step.

References:

1. Dictionary by Merriam-Webster: America's most-trusted online dictionary. Merriam-Webster, 2011.
2. Glossary of Essential Health Equity Terms. National Collaborating Centre for Determinants of Health
3. Ackerman-Barger K, Bakerjian D, and Latimore D. How Health Professions Educators Can Mitigate Underrepresented Students’ Experiences of Marginalization: Stereotype Threat, Internalized Bias, and Microaggressions. J Best Pract Health Professions Diversity 2015; 8(2): 1060–1070.
4. Sue DW, Capodilupo CM, Torino GC, et al. Racial Microaggressions in Everyday Life. Am Psychol 2007; 62 (4): 271–286.
5. Torino GC, Rivera DP, Capodilupo CM, Nadal KL, Sue DW. Microaggression theory: influence and implications. Hoboken, NJ: Wiley Publishers 2019. pp 11-12.
6. Huston TA and DiPietro M. In the eye of the storm: Students’ perceptions of helpful faculty actions following a collective tragedy. To Improve the Academy 2017; 25 (1): 207-224.

Co-Learning: Students and Faculty Learning Together

by Victoria Goodman, PharmD, PGY1 Community Pharmacy Practice Resident, University of Mississippi School of Pharmacy

As someone who graduated from a professional degree program and returned from the workforce to complete a PGY-1 pharmacy residency, I feel there were few opportunities to truly collaborate with my professors/preceptors until after graduation. There were set roles; I was the student, and they were the teachers. This dynamic was emulated throughout schooling at most institutions. It felt like there was a stark divide between the faculty and students. But upon graduation, students are expected to flip a switch, spring into their professional role, and even teach others.

This style of teaching and learning, where there are strict roles and responsibilities, is common in many fields, including the health professions. The typical class consists of a faculty educator standing and delivering a lengthy presentation that the students are expected to commit to memory. Information flows in one direction to students as they attempt to absorb as much as possible. Unfortunately, this is not the most effective method of retaining knowledge. In recent years, many courses have incorporated active learning strategies.  This is certainly an improvement but can we improve the learning process by building more connections between our educators and students? One potential technique is a concept called co-learning.

Co-learning is the act of grouping individuals to share the workload of a given learning task or share perspectives in a conversation. Group members learn from each other's unique insight and provide a mechanism for each participant to be accountable for contributing to the learning process.¹

The concept of co-learning is not new, but the practice of co-learning among educators and students is underutilized.^2,3,4 When including the educator in the co-learning group, the teaching strategy is similar to Socratic teaching with students and teachers engaged in dialogue and learning from one another. The educator is not the only person speaking or delivering knowledge; instead, students are encouraged to pose questions and further the conversation.

The Cornell University's Center for Teaching Innovation webpage on Collaborative Learning details the benefits of co-learning between faculty and students.  This includes building rapport, improving faculty-student relations as well as increasing retention rates, experience, idea sharing, and organizational involvement.^2,3 All of which lead to more meaningful learning experiences and strengthen the program.

Rapport Building/Deepening Connections. The opportunity is provided for students and educators to interact in a learning setting that opens doors. The traditional roles can be disbanded, allowing for new bonds to be forged. This is called “flattening the hierarchy” of the power differential between students and teachers.²

Increased Frequency and Quality of Faculty-Student Interactions.  Once the lines of communication are paved, this allows for more frequent and higher-quality interactions between the students and educator. Talking about areas of uncertainty are more likely to be discussed and this increases the confidence in both learners and teachers alike.²

Improved Retention Rate.  The practice of nurturing positive relations between students and educators will naturally begin to build positive and uplifting morale throughout the institution. Having a more understanding and embracing work/school environment will help each member of the institution to feel a higher sense of belonging and value within the program.

Sharing Ideas and Perspectives.  Through open and honest communication, everyone will have the opportunity to share the perspective they have on the situation or subject matter.^2,3

Greater Organizational Involvement. Exposing students to professional organizations through the perspective lens of the faculty member will help the learner gain a better understanding and appreciation for these organizations during their tenure and post-graduate.^2,3 Serving alongside each other would be less of a foreign idea and more of an ushering experience.³

Here are some helpful ideas a teacher can use to foster a co-learning model. Activities aimed at increasing social awareness, cultural competency, and connectedness often work well.⁴ Activities such as storytelling to get to know each member, role-playing to gain an understanding of diversity within the group, and then debriefing at the end of each activity to explore the perspectives about the activity itself.⁴

Another activity might involve one member of the group interviewing another member to complete a survey on socio-demographic information.⁴ The other members of the co-learning team can be assigned as observers of the interaction. The purpose of this is to demonstrate support, empathy, and cultural sensitivity. If it’s not possible to divide students into small groups, each with an educator as a participant, the practice and observation activity could be performed on a larger scale with larger classes. This activity will require members of co-learning teams to interact and analyze information in real-time to come together as a group to decide. Group members engage in open discussion and respect one another’s perspectives.

Dialogue and shared decision-making activities, which include the teacher as a group participant, are ideal - allowing greater time and fostering intimate connections within the group. Experiential learning is where co-learning between students and preceptors often occurs.  Using a similar model in the classroom, teachers and students can discuss and grapple with real problems that don’t have easy solutions, making learning relevant, meaningful, and transformative.

Happy Learning.

References

1. Co-learning in education works wonders for future generations [Internet]. Inventionland Education. 2018 [cited 2023 Mar 26].
2. Haddock L, Rivera J, O'Brien B. Learning together: Co-learning among faculty and trainees in the clinical workspace. Acad Med 2023; 98 (2): 228-236.
3. Collaborative Learning [Internet]. Center for Teaching Innovation, Cornell University. teaching.cornell.edu. [cited 2023 Mar 23]
4. Nguyen-Truong CKY, Fritz RL, Lee J, Lau C, Le C, Kim J, et al. Interactive co-learning for research engagement and education (I-coree) curriculum to build capacity between community partners and academic researchers. Asian Pac Isl Nurs J 3(4):126–38.

The Advantages and Disadvantages of Social Media in Learning Environments

by Chelsea Watts, PharmD , PGY1 Community Pharmacy Resident, Mississippi State Department of Health

Social media has had a significant impact on our society. In January 2023, there were 4.76 billion social media users.  That’s nearly 60% of the total global population.¹ Regardless of individual socio-demographics, nearly everyone is connected through social media. Social media platforms allow users to create and share ideas with people from all walks of life through photo and video sharing, blog postings, short-form communications, and more. Although social media was not created for educational purposes, it has infiltrated learning environments and this has led to research to determine the positive and negative aspects of social media use.

BetterYou, a digital wellness platform, identified five areas of a student’s life affected, in some cases positively but also negatively, by social media:²

• Social well-being:  The fear of missing out (FOMO) and setting unrealistic life goals can create social isolation.
• Emotional well-being:  Seeking validation through likes and peer approval creates a mental strain on students to meet certain expectations.  
• Academic well-being:  Social media is a major distraction and can lead to poor academic performance. Another cause is lack of sleep due to late-night browsing.
• Peer connection:  Students can stay in touch with their support system and build relationships with people who share common interests.  
• Spreading the word: The latest news or announcements can be shared on a larger scale.  

The use of social media can negatively affect students’ social, emotional, and academic well-being, whereas connection with peers and communication about professionally related opportunities might be advantageous.

Networking is a key component of professional development. There are many avenues available to network. Building a successful network includes meeting people in different settings, even virtually. Social media platforms, such as LinkedIn, allow students to create digital portfolios and share them with peers, potential employers, and others they may not have the opportunity to interact with in person. I believe it is important to equate engagement with connections. For example, if I create a post on Facebook or Twitter about a professionally related topic, the engagement (likes, comments, and reshares) I receive may reach someone with a similar interest.

One drawback to social media engagement is echo chambers. Most social media feeds conform to the user’s perspectives and beliefs, which limits interactions from those with opposing opinions. Students should be encouraged to apply critical thinking skills in their social media use. Questioning the information, confirming sources, and analyzing for bias are ways students can learn how to use social media platforms thoughtfully and maximize their engagement.

Improving students’ communication skills is another potential advantage of using social media. On many platforms, a user is limited by a maximum word (or character) count. Twitter, for example, has a 280-character limit for each “tweet.” Therefore, the user must be precise with their word choices in order to communicate their ideas effectively and coherently. To develop this skill, teachers could create an assignment requiring students to develop thoughtful responses to a question prompt or case scenario. The students would formulate their responses as a “tweet”. After creating the post, students can interact with other peers’ responses. This skill can be transferred to written communication skills in a professional setting. One study that examined the impact of Facebook on undergraduate students’ writing skills found that active participation in online discussions improved the content and organization of their written communications.³ The authors also concluded that the social media platform enabled students to learn in a stress-free environment and from peers through collaborative learning.³ 

Although there are some advantages to using social media in higher education, educators must be aware of the negative effects of social media. Students can become easily distracted and excessive social media use can have a negative impact on student’s mental health. Distractions created by social media can be classified as internal or external cues.⁴ Mind wandering to social media platforms when completing learning assignments or tasks is considered an internal distraction.⁴ External factors come from the environment. An example of an external factor is receiving a social media notification that inclines the student to stop the task.

There is  a growing concern for students’ mental well-being because social media has deviated from its initial purpose of bringing users together. The authors of a study published in 2021 concluded that emotional investment in social media is correlated with a significant increase in anxiety and depression in university students.⁵ The emotional attachment can lead to disappointment due to the desire to acquire materialistic things and unrealistic lifestyles. It is, therefore, important for students and educators to use social media platforms with intention. Being intentional includes restricting in-class use for educational purposes, setting a goal before each use, and creating an allotted time spent on social media.

I believe the advantages of social media use in learning environments outweigh the disadvantages. When used properly, social media can facilitate professional networking and improve communication skills. Since social media platforms have an enormous impact on daily life, using these platforms in educationally oriented and intentional ways would be beneficial for students.

References:

1. Global Social Media Statistics - DataReportal – global digital insights [Internet]. DataReportal. [cited 2023Feb14].
2. Zwart H. Effect of social media on college students. BetterYou. [cited 2023Feb14].
3. Shahzadi A, Kausar G. Using Social Media to Improve Students’ English Writing Skills: A Mixed Method Study. J Res Social Sci 2020; 8(1):124-140
4. Koessmeier C, Büttner OB. Why are we distracted by social media? distraction situations and strategies, reasons for distraction, and individual differences. Frontiers in Psychology. 2021;12:Article 711416.
5. Alsunni AA, Latif R. Higher emotional investment in social media is related to anxiety and depression in university students. Journal of Taibah University Medical Sciences. 2021;16(2):247–52. 

Does Working in Groups Result in Higher Academic Performance?

by Joshua Chang, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

Students often face different study environments and styles when preparing for exams. The debate regarding the benefits of group studying compared to studying alone remains an ongoing discussion.  Which ensures students achieve optimum learning (and exam scores)? From personal experience, studying in groups has several advantages, including retention of information, opportunities to clarify ambiguous topics, and teaching others while simultaneously solidifying one’s knowledge.  Collaborating in groups can be constructive when students are assigned a rigorous assignment that requires critical thinking and planning to execute it efficiently.

Unfortunately, working in groups has several pitfalls, such as the difficulty in arranging times for the group to gather.  This is especially true when group members are heavily involved with organizations, work, and family obligations. The number of participants in the group also is a factor. As the number of students in a group increases, distractions (such as mobile devices) and engaging in side conversations can hinder progress.  Research sheds some light on when individual vs. group study might work best.

In 2015 qualitative study performed at five Universities in Pakistan, the investigators conducted group interviews using a semi-structured questionnaire.  They found that approximately 30% of the students leaned towards individual study. This group of students emphasized that individual study allows them to remain in focus, achieving maximum concentration, which strengthens their confidence to solve difficult assignments and be less dependent on others. Additionally, these students believed that group study was too time-consuming and would only do group study when directed by the instructor. The second group, which consisted of 10% of the student population, preferred group study. They believed that it allowed them to share their knowledge, express their thought process, and assist each other when completing difficult assignments. The most important factor for favoring group study was the increase in motivation to study and the assistance that weaker students gained when working in groups.¹

Interestingly, the largest population of students (60%) took advantage of both styles of study. They asserted that both are equally important for enhancing their learning. They state that every member of the group possesses a different perception and view on the material and group study facilitates the sharing of different ideas.  On the other hand, individual study allows for fewer distractions and the freedom to plan one’s study session. Students in this study emphasized that a group size of no more than 5 students was key to effective group work. An excessive number of members limits the opportunity for students to speak, participate, and contribute frequently.  It is important to take into consideration that this study was conducted at five different Universities with varying curricula – but they were not structured to promote either individual study or group study.¹

In a 2014 case study that focused a Collaborative Learning Environment among 122 university students enrolled in an Engineering and Molecular Biology program explored group work versus individual work. The study recorded each student’s performance for 3 different course assignments over one semester. The study utilized a software called Moodle that allowed for file sharing and synchronous group work.  Using this technology, the instructors were able to monitor each student’s actions in real-time. Each individual student’s work was color-coded to differentiate participation and involvement as they completed assignments.²

The study highlighted various models of collaboration that played a vital role in each group’s progress. Some groups engaged in real-time collaboration, having their members work simultaneously alongside one another from start to end, while other groups utilized a self-paced model, having their members work individually at their leisure. The frequency of contribution was a key factor. Some students only contributed once, while other students would review their colleague’s work, improving and editing the composition. Another factor was the effort and quality of work. Groups that were dominated by one student had performance scores ranging from 55% to 100%. The wide gap in scores for these groups is likely attributable to the quality of work from that single member.  Groups with 4 to 6 members that divided the work but had low-level contributions generally had a narrower span of scores - from 70% to 90%.  However, the study did not report data regarding large groups with higher-contributing work to have an appropriate comparison.²

One important aspect that the study focused on was assessing each student’s individual performance and using that score to predict an expected group performance score. They found that the group performance score, on average, was much higher than the predicted group score and higher than the mean individual performance scores. The study was not able to study groups larger than 5 students and the three assignments used for analysis were not explicitly open for review. The type of subject, level of difficulty, familiarity, and time commitment needed for the assignments are unknown. Overall, the study asserts that the defining factor for higher performance is not merely the size of a group but the level of contribution.²

There are advantages and disadvantages to both group and individual study. Although we may think that study habits are binary, research shows that both strategies can be beneficial, and academic performance may be related to one’s preferences. In my opinion, specific assignments that mimic real-life tasks where a practitioner acts independently should be done individually. Measuring a student’s growth is also more feasible when analyzing individual work. A student may prefer studying and working alone but being in a group offers several benefits and can also be useful for mimicking those real-world tasks done by groups of people.

References:

1. Kandhro, S. (2015). Impact of Group-Study and Self-Study on Learning Abilities of Students at the University Level. Case Studies Journal 2015; 4(2).
2. Cen L, Ruta D, Powell L, and Ng J. Learning alone or in a group — an empirical case study of the collaborative learning patterns and their impact on student grades. 2014 International Conference on Interactive Collaborative Learning (ICL).

Do NAPLEX or MPJE Preparatory Courses Improve Pass Rates?

by Jacey Gossett, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital North Mississippi

As a recent pharmacy school graduate, I took the National Pharmacy Licensure Exam (NAPLEX) and the Multi-state Pharmacy Jurisprudence Exam (MPJE). A hot topic of conversation among my classmates is the pass rates on these exams.  Being a “good” student who earned A’s and B’s throughout pharmacy school, I expected the NAPLEX to be something that I would be able to easily pass — boy, was I wrong! To my, my friends, and my family’s surprise, I received a “FAIL” on my first NAPLEX attempt. The word FAIL staring me in the face that day last June was a major kick in the gut. Since I passed my MPJE shortly after graduation in May, I thought the NAPLEX would be a similar outcome. Luckily, in July, I received a “PASS” on my second NAPLEX attempt.

It was shocking to me, but I was not the only one from my graduating class that had to retake the NAPLEX.  How in the world had we made our way through pharmacy school just to receive a big fat “FAIL” when taking our boards? Our school and the professors certainly did everything they could to push us toward success on our boards. We had a year-long NAPLEX prep course that ran concurrently with our advanced pharmacy practice experiences (APPE).  We were given various assignments to “ensure” that we were preparing ourselves for these challenging exams. We had multiple practice exams to give us experience. In December of my P4 year, I scored 69 on my first practice NAPLEX. Although this is not a “passing” score, I felt I was on the right track as I was just getting deeper into my studying. In the spring of my P4 year, I took another practice exam and brought my score up to 73.  I was improving but I recognized that had more studying to do.

There have been multiple studies published in recent years examining factors that might help students be successful on their board exams. One cross-sectional study sought to describe the characteristics of NAPLEX preparation programs currently offered by schools of pharmacy and the correlation between program characteristics and first-attempt pass rates. Fifty-eight Pharm D programs completed an online survey about their NAPLEX preparation programs. A majority (86%) of schools indicated they offered a NAPLEX prep program. But offering a NAPLEX prep program was not associated with higher first-attempt pass rates. Some concerns raised by the authors of the paper included student workload (e.g., balancing the demands of a prep program during APPEs) and the faculty workload associated with delivering these programs.¹

In a retrospective study, investigators compared NAPLEX scores (n=150) to several factors that might predict performance. The investigators found that the NAPLEX score was most strongly correlated with pharmacy GPA (r=0.66) and Pre-NAPLEX score (r=0.45) but also race/ethnicity, Pharmacy College Admission Test (PCAT) composite score and section scores, undergraduate GPA, undergraduate science GPA, and on-time graduation.²

In another retrospective study, the correlation between preparatory testing and other factors were compared to performance on the MPJE. This analysis showed that the Pre-MPJE scores failed to predict whether a student would pass the MPJE but a student’s performance in the pharmacy law course did.³

As you can see from the results of these studies, there is no clear correlation between prep courses and the odds of passing either the NAPLEX or MPJE. Therefore, simply having such courses available does not ensure success.  Thus, it is truly up to individuals to ensure that they are using prep courses, practice exams, and other resources to fully prepare themselves. It is difficult to find a quick and easy fix to improving first-time pass rates for board exams. There are many “tips and tricks” on the Internet. These “tips and tricks” seem to be consistent with things students have likely heard during pharmacy school – things like having a study plan, taking practice tests, creating self-testing materials, working with a study group, getting plenty of sleep, and not cramming.

Spaced repetition is a study technique that involves reviewing and recalling information at optimal spacing intervals until that information is deeply learned. This technique has students review materials, repeatedly, over a long period of time. Research has clearly shown that spacing out repeated encounters with material over time provides superior long-term retention.  Self-testing coupled with spaced repetition amplifies the benefits.⁴

As I’ve learned, it’s important to study and prepare for the MPJE and NAPLEX well in advance. I was able to pass my MPJE solely on the material learned during our pharmacy law course and our professor was very clear about how hard and tricky the exam could be. I was able to pass my NAPLEX on the second try by realizing my areas of weakness. I used the same study strategies, but by being more self-aware of my weaknesses I was better prepared for my second attempt. Perhaps the best approach is to help students figure out what they do not know and then encourage them to use effective evidence-based study techniques.

There are several evidence-based learning and studying techniques, like spaced repetition, that can be used to enhance a student’s recall of information, but it is truly up to the student to “take the bull by the horns” and get the studying done. Students need to know very early in their pharmacy school journey just how hard these exams can be.

References

1. Fiano K, Attarabeen O, Augustine J, et al. Association between Naplex Preparation Program Characteristics and First-Time Pass Rates. Am J Pharm Education 2022; 86(6): Article 8760.
2. Chisholm-Burns M, Spivey C, Byrd D, McDonough S, Phelps S. Examining the Association between the NAPLEX, Pre-NAPLEX, and Pre- and Post-admission Factors. Am J Pharm Education 2017; 81(5): Article 86.
3. Havrda D, Hall E, Spivey C, et al. Examining Preparatory Testing and Other Factors Associated With Performance on the Multistate Pharmacy Jurisprudence Examination. Am J Pharm Education 2022; 86(7): Article 8774.
4. Kang S. Spaced Repetition Promotes Efficient and Effective Learning. Policy Insights from the Behavioral and Brain Sciences(PIBBS) 2016; 3 (1): 12-19.

Resilience Training in Healthcare to Meet the Needs of Learners and Practitioners

by Lori Emory, PharmD, PGY1 Pharmacy Practice Resident, Mississippi State Department of Health Pharmacy 

Resilience is the ability to “bounce back” from challenges — to learn and grow from setbacks. An individual’s resilience is built up over the course of their life and is shaped by their actions taken prior to, during, and after difficult and often stressful situations.^1,2  

Stress is a natural response by the body to physical and mental challenges. While stress can be a motivating factor that prompts us to try new things as we face new challenges, too much stress over a prolonged period of time is unhealthy and can lead to anxiety and burnout. Anxiety is an overreaction to stress experienced from performing “ordinary” daily activities which can lead to significant impairment. Burnout is a diminished ability to respond to stressors and can lead to anhedonia and depression.^1,3 

In healthcare, providers are responsible for the well-being of numerous patients. Chronic stress – often unavoidable in healthcare – puts health professionals at a higher risk for developing anxiety or burnout, which, in turn, results in less than optimal care and increases the risk of errors and poor patient outcomes.^1,3,4 Thus, resilience strategies, often techniques learned from previous stressful situations, help providers meet new challenges.⁵ 

There are conflicting feelings about resiliency training in healthcare.  Some have argued that resiliency training focuses too much on individuals by teaching them how to adapt to and cope with the ever-growing demands of the profession while letting institutions off the hook by failing to address poor working conditions, such as chronic understaffing and addressing hindrances.^2,4 While data supporting resilience training programs in healthcare are limited, results show participants generally appreciate learning about the tools they can use to become more resilient and like being part of a community where they can share experiences with fellow health professionals.^1,2 

Although self-care has been around for many years, resiliency training was introduced to me as a formal concept while applying for residency. Many residencies now offer resilience training as a required component of their program structure. Given that most pharmacy jobs provide little to no social support for new practitioners, I believe having resiliency training incorporated into the residency experience can be very beneficial. 

Several studies have examined the elements of resiliency training that participants generally believe are needed for it to be most beneficial:  

1. Focusing on the experience of health professionals and students is vital in a successful program. ^1,2,4,5,6  Healthcare workers are exposed to difficult human experiences while working with serious injuries, illnesses, and even death.^1,2,4,6 Participants in resiliency training programs discussed the need for training to be guided by another health professional with a shared understanding of the many challenges that come with working in healthcare.^1,2,6 

2. Sharing experiences in a positive and non-judgmental manner builds community among healthcare providers who often feel isolated.^1,2  Many providers report feeling isolated and a desire to participate in a community of peer support.¹ Program participants reported small group discussions allowed them to recognize their own behaviors better and learn from others’ real-world experiences.^1,6 Participants often report preferring voluntary attendance at these sessions as they felt it helped ensure that all participants would come in with an open mind about sharing experiences and learning to grow from difficult situations.^2,6  

3. Following up with participants helps turn new skills into daily practiced habits. While the initial training session(s) were often considered to be helpful by participants, programs that included follow-up reflection, allow participants to expand on the skills they learned and think about how they could use those skills in their daily lives. ^1,2,6 

4. All health professionals can benefit from these types of programs, regardless of their current level of experience. Even students at the beginning of their training are exposed to the difficult realities of a career working in healthcare, and serving people who are experiencing some of the greatest stress in their lives.^2,5 Promoting resiliency training programs during early didactic coursework or introductory practice experiences may provide key life-long skills that participants will benefit from long-term as they progress through training and into their professional lives.^2,6 Students particularly report benefits from training programs that are structured to provide insight into stressors that they may experience, during their training and in practice.^2,3,6  

Offering resiliency training led by experienced faculty members should be considered at all educational institutions that are preparing the next generation of health professionals. Resiliency training programs should be voluntary, such as course electives or extracurricular meetings, where all students can participate without feeling the need to give up other interests. Placing participants in small groups of 8-10 with a mix of learners at various levels and faculty with guided discussion prompts can foster natural mentorships and a sense of community within groups. Providing this kind of support early and often throughout the professional degree program can provide a safe space where genuine conversations can take place. Regularly obtaining feedback from participants is important to tailor these programs to meet the needs of students and faculty based on schedules and topics of interest.  

References: 

1. Epstein RM, Krasner MS. Physician Resilience: What It Means, Why It Matters, and How to Promote It. Academic Medicine 2013: 88(3):301-303.
2. Johnson J, Simms-Ellis R, Janes G, et al. Can we prepare healthcare professionals and students for involvement in stressful healthcare events? A mixed-methods evaluation of a resilience training intervention. BMC Health Serv Res 2020; 20: Article number 1094.
3. Fares J, Al Tabosh H, Stress AH, et al. Burnout and coping strategies in Preclinical Medical Students. N Am J Med Sci 2016; 8 (2):75-81.
4. Murthy VH. Confronting health worker burnout and well-being. N Eng J Med 2022;387(7):577–9.
5. Kunzler AM, Helmreich I, König J, et al. Psychological interventions to foster resilience in healthcare students. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD013684:7-43.
6. Bird A, Tomescu O, Oyola S, Houpy J, Anderson I, Pincavage A.A curriculum to teach resilience skills to medical students during clinical training. MedEdPORTAL 2020;16:10975.

Teaching Health Professional Students to Manage Patient Bias

by Allison Wadlow, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Health disparities based on race have been a long-standing problem in the United States. Much light was shed on this matter in recent years prompted by numerous murders of minorities and the Black Lives Matter advocacy movement. It is well known that racial disparities exist within the healthcare system of this country. Even when patients have comparable incomes, similar education, and live in the same geographic location, minority populations sadly do not always receive the same standards of care as their white counterparts.¹

Many health professions programs offer training to learners on addressing bias and improving care delivery for all patients. Over the past decade, some popular training programs include Trauma Informed Care, Adverse Childhood Experiences training, and Multicultural Training. These programs have included materials to serve patients better, with the primary focus on patients, not the providers of care.

Bias towards healthcare professionals from underrepresented and marginalized groups is, unfortunately, commonplace. A recent study “Harassment and Discrimination in Medical Training” found that most health professional trainees have experienced bias at some point in their career, most often based on their race, gender, or sexuality.² 

To address this problem, medical students and faculty at multiple institutions in Northern Virginia and Washington, DC created a training program for medical students to manage patient bias.³ The goal of this program was to prepare students for the biases they may encounter in practice.  The investigators created a simulation exercise whereby participants learned, in a safe environment, to navigate these situations.³

The simulations involved encounters with standardized patients. During the encounter, the student was instructed to tell the patient about a follow-up appointment that had been scheduled with a provider who had a foreign-sounding name. The standardized patient was instructed to either accept this appointment or request an alternative provider. The student was then instructed to use motivational interviewing techniques to understand where the request to change providers stemmed from. The possible reasons for the patient’s request were:

• An untreated hearing loss made it difficult for the patient to understand accents
• A belief that “foreigners shouldn’t be taking American jobs”
• A preference to receive treatment from a physician who shares a similar cultural background due to the patient’s previous experiences of intolerance or disrespect

During the encounter, it was up to the student to determine the root cause of the request. In some instances, the request might lead to better patient care, and it should be honored. For example, in the case of a patient with hearing loss, switching to a provider without an accent, the patient might be able to better distinguish words spoken during the encounter. Of course, if the provider did not have an accent, the student should provide reassurance to the patient.  However, in some cases, the request to change providers was racially motivated. Of course, a surname does not always indicate the race of the provider. The point of this training experience was to allow students the opportunity, in a safe and controlled environment, to navigate through a patient request that, on the surface, may be motivated by racial bias. The goal is to develop the skills to uncover the root of these requests, rather than assuming that racism is the problem.

At the beginning and end of the course, students were surveyed to measure their growth. After completing the activities, students reported an increase in their confidence to explore intentions and beliefs, navigate a conversation with a patient exhibiting bias, and use nonverbal skills to demonstrate empathy.³

Addressing bias directed towards providers is not taught in most health professions' curricula or residency training programs. I think health-professional programs should begin to include this type of training so that students and residents are better equipped to manage patient bias.

The first step would be to give students exposure to patients who express a bias toward certain (commonly marginalized) groups. Nearly all students who participated in this simulation exercise stated they were very uncomfortable, but that it was a positive experience to be able to interact in a safe environment. The students stated they felt more prepared to manage these situations with real patients in practice.  Because learners should never be intentionally required to interact with people who have racial animus, they would learn how to assess patients’ requests, how to act in the face of bias, and how to move forward with patients who are explicitly or implicitly biased towards them or others. 

The next step would be to teach learners how to address patients who have explicit biases based on race, gender identity, and sexual preferences. Students must first be taught how to approach patients and uncover the rationale behind their biases. Once the student has uncovered the reasoning for the bias, there will be times when patients are explicitly racist, and students will need to be prepared (mentally) to manage the situation. Do they simply ignore and endure the bias? Do they refer the patient to alternative providers? Do they know when it is safe to speak up and say something to the patient? While there are no easy answers to these questions, the least we could do is provide students the opportunity to experience this type of conversation with patients before having to deal with it in the real world.

As with the implementation of any new training, cost becomes a factor to consider. The cost of hiring standardized patients may not be feasible for many programs. One workaround is to have volunteers serve as standardized patients, which could include faculty, upperclassmen, or alumni. Another way to mitigate the costs could be to have recordings of patient encounters, pausing the recording at various times to discuss with the class what they are observing. This option could open a rich class discussion on the negative consequences of bias toward marginalized patients as well as providers.

Bias in healthcare is not something we can eliminate, but we can build our skills to recognize and mitigate it.  We can prepare our students to uncover and address the biases they may encounter, including the bias that patients may express toward them or their professional colleagues. It is not ethical to know a problem exists, one that can mentally harm our learners, and do nothing to prepare them. It’s time to talk about patient bias and teach health professional students how to manage it.

References:

1. Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health Care Financ Rev 2000;21(4):75-90.
2. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med 2014;89(5):817-27.
3. Zewdie M, Duval M, Liu C, et al. Virtual Communication Across Differences: Development of a Workshop on Managing Patient Bias. Acad Med 2023;98(2):209-213.

Professional Identity Formation (PIF) in Health Professions Education: Doing is Different from Being

by Lauren C. McConnell, PharmD, PGY1 Pharmacy Practice Resident, Baptist North Mississippi Hospital

Professional identity formation, or PIF, is the process through which a person becomes a professional — typically from student to practicing professional. The progression of PIF is uniquely individualized and superimposed on each student’s personal identity, values, morals, and beliefs.¹ The goal of forming a professional identity is to develop a resilient sense of belonging within a health profession.² PIF goes beyond students acquiring knowledge (‘thinking’) and demonstrating professionalism (‘acting’) to support one’s perception of self (‘feeling’).

Professionalism, as defined by The White Paper on Pharmacy Student Professionalism, is “the active demonstration of the traits of a professional”.³ Health professions students are intrinsically and extrinsically motivated to join a professional community and are willing to uphold certain professional expectations, such as wearing a white coat, communicating respectfully, and being accountable.^4,5 However, acting like a professional and being a professional are two different phenomena.

Interrelationship Between Professional Identity and Professionalism

Professionalism and professional identity are distinct yet related concepts, which makes the fluid relationship between the two challenging to describe (see Figure 1). Professionalism is an outward display of the conduct of a professional, while a professional identity is the internal perception of one’s role as a professional.⁶ Professional traits and behaviors are crucial for PIF, as ‘acting’ like a professional encourages assimilation to that role.⁷ Similarly, self-awareness of a professional identity is essential for developing a professional demeanor. Several stepwise models exist that have attempted to describe this relationship. Acts of professionalism are observable signs which indicate the concurrent development of professional identity.⁶ Therefore, my professors at Auburn University and I recently proposed a model to illustrate the infinite and undirected interplay between PIF and professionalism, the Möbius Strip.⁷

Figure 1: Professionalism-Professional Identity Möbius Strip

According to Moseley et al., “as the internalization process of PIF occurs, outward professional behaviors are displayed, and as one chooses to behave as a professional, their sense of identity blossoms”.⁷ This model aligns with the proposal that the end goal of health professions education should not just focus on ‘doing’ but also on ‘being’.⁸ As with all educational goals, methods for teaching and evaluating progress are essential. The conundrum is how this fluid process can be measured and supported.

PIF-Friendly Pedagogy

Obtaining a professional identity is the desired outcome in health professions education, as it is the backbone of all decisions students will make as professionals.⁸ However, many students (and admittedly, myself included) fail to recognize themselves as professionals early in their health education journey. For this reason, PIF has long been an elusive target amongst health professions educators. Furthermore, PIF is a non-linear process, and each student progresses toward their professional identity at a different pace, which makes it challenging to foster and evaluate progress.⁹ For this reason, health professions educators should incorporate PIF-friendly teaching strategies into curricula.

PIF pedagogy is the practice of teaching, facilitating, and coaching students through their PIF journey — teaching methods that support the development of an identity that aligns with the values of their profession. Educators are a fundamental component of the student’s journey. The formation of a professional identity is influenced by external factors, such as curricula, learning environments, expectations, mentorship, and feedback.⁵ I distinctly remember key preceptors who created positive learning environments and served as role models that positively impacted how I perceived myself as a future pharmacist. Therefore, it is important for educators to foster relationships and create experiences that are meaningful to students, as PIF is facilitated, not taught.

Self-assessment and self-reflection are two PIF-friendly strategies that educators can use in curricula to help students become more aware of their professional strengths and weakness.¹⁰ The ability of the student to be self-aware of their presence and growth within a professional community increases PIF and creates a sense of belongingness.⁹ Other meaningful relationships outside the formal education environment (e.g., with preceptors, other health professionals, and patients) play a similar and equally important role. To me, there is no replacing the feeling you get the first time a patient mistakenly refers to you as a pharmacist or when a physician shows appreciation by stating ‘good catch.’ Through these interactions, students gain recognition for their place on the healthcare team. Situated learning theory suggests that “learning should take place in a setting the same as where the knowledge will be used”.¹¹ Therefore, it is no surprise that students report early introduction to their profession, direct interaction with patients, and frequent collaboration with other health professionals as key drivers of identity construction.¹²

Because educators are facilitators of PIF, structured evaluations (e.g., exams or performance-based assessments) are not helpful measures of student progression, particularly given that PIF does not occur at a single point in time. Experts recommend that assessments of PIF should occur longitudinally to ensure that the student’s professional identity is progressively developing over time.¹³ Unfortunately, there are no standardized methods for measuring PIF, and assessments rely on student understanding of who they are within a profession. I remember creating short- and long-term career goals as a first-year student pharmacist, thinking I knew exactly who I was and what pharmacy career path I wanted to pursue. But with each semester, I revisited these goals and was honestly embarrassed by what I thought I knew about who I wanted to be. 

In one study, investigators designed a Professional Self Identity Questionnaire (PSIQ) that attempts to measure the degree to which health professions students identify as a member of their profession.¹⁴ Building on this notion, faculty at Auburn University Harrison College of Pharmacy recently created a PIF instrument to encourage students to reflect on their professional identity. This instrument asks students to self-assess fourteen qualities/behaviors, such as confidence, knowledge, personality, professionalism, and communication.¹⁰ These PIF-friendly exercises, using a combination of self-assessment and self-reflection, attempt to measure what educators cannot see: how students see themselves in relation to their profession.

There are several other activities and instructional strategies that can be used to promote PIF, such as feedback, experiential education, co-curricular activities (e.g., health fairs), mentoring/role modeling, student well-being groups, and white coat ceremonies.^7,15 Of course, most professional curricula already incorporate many of these pedagogical methods, but require active effort by educators to intentionally foster PIF. Reflecting on my time as a student, I now know why I have always appreciated professors who were passionate about what they taught, preceptors who encouraged autonomous work, and mentors who led by example – they intentionally helped create my professional identity. Educators should continue to purposefully use and prioritize PIF-friendly pedagogical methods, particularly early in curricula, to support the process of professional identity formation amongst their students.

References

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