Educational Theory and Practice

Teaching Pharmacy Students to be Excellent Communicators

2012-01-26T14:00:00.011-05:00

By Allison Lardieri, PharmD, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

After completing four years of undergraduate education, four years of pharmacy school and now six months of PGY1 pharmacy residency training, I’ve come to the realization that communication skills are perhaps the most important skill I need – and I continue to work on them! Being a skillful communicator does not require one to know the mechanism of action of a specific drug, disease pathophysiology, or the most recent CHEST guidelines – not that these concepts aren’t extremely important. But, I have found that the importance of effective, clear, and assertive communication by pharmacists surpasses drug knowledge.

Communication skills are vital to pharmacists every day, regardless of whether they work in a community or hospital setting. As pharmacists move from a medication-dispensing role to a patient-centered role, they must communicate regularly with other health care practitioners and patients. In the hospital setting, a clinical pharmacist participating on interdisciplinary rounds needs to feel confident speaking up at the appropriate time and needs to know how to make recommendations in a manner that is well-received by the team. I believe this is a skill that does not come naturally, but rather can be practiced and refined. Whether in the hospital setting or community pharmacy, pharmacists have opportunities to counsel patients and need to master the best way to illicit pertinent medical information from patients. Pharmacists in the community are often pressed for time, and it is important to convey the critical counseling points to patients in a caring and knowledgeable way. Lastly, communication between pharmacists is another area where being open and assertive allows workflow to go smoothly. Pharmacists and technicians working together should be constantly communicating about tasks that need to be completed and patient care issues that require resolution.

There are countless times where communication is critical, and as future pharmacy educators we need ensure we train students to become excellent communicator. In the article, “A Tool to Teach Communication Skills to Pharmacy Students” by Susan Hasan, students developed scripts to illustrate interactions between physicians and pharmacists.¹ Three different scripts were developed based on three communication styles: assertive, aggressive, and passive. One of the scripts was turned into a multimedia CD and used for future students. This activity allowed pharmacy students to explore different communication techniques and improve their communication skills.

For a majority of pharmacy students, clinical rotations are where they refine their professsional communication skills. Optimally students should model the behaviors and communication style of their preceptors. McDonough and Bennett describe several effective strategies for preceptors to improve pharmacy students communication skills. This includes a thorough orientation to the practice site, establishing pharmacist-patient relationships, and using a counseling model.² They emphasize that students cannot improve communication skills by just observing, but rather must participate in communication encounters. The authors point out that feedback immediately after the student-patient encounter is critical as this will help students to improve. The authors recommend that preceptors think of students as an extension of themselves and train them to be an active participant in the workflow of the practice.

During my advanced practice experiences as a student and now as a resident, I have noticed that medical students are taught about communication skills and case presentations very early in their education. Beginning in their third year, medical students are required to do a patient presentation daily to the interdisciplinary team and to work throughout the day on patient care issues. I think pharmacy students would benefit from earlier exposure to inter-professional interactions. Even as first or second year students, I think activities requiring students to discuss patients with each other and present their pharmaceutical plans to preceptors would help them to improve their communication skills. This could also be accomplished by having students practice counseling patients in front of other students, where feedback is provided at the end of the session. By incorporating these informal activities earlier in pharmacy students’ education, it will help students gain confidence.

One interesting and creative communication activity involves the use of simulated patients and video review. In a study conducted at the South Dakota State University College of Pharmacy, video review increased first year pharmacy students’ counseling skill achievement scores and helped to develop their self-assessment skills.³ Video review really helps when giving feedback to students. I think it is important to have informal opportunities for students to learn from video review prior to using video recording for assessment purposes.

Communication skills must be taught and students can only improve their communication skills through practice. I recommend a mix of formal assessment activities and informal opportunities to practice communication beginning early in pharmacy students’ education. Informal activities can include having students present a patient to a faculty member or counseling a simulated patient as part of a group activity. The formal and informal use of video review is also helpful. Feedback by the faculty member and peers can be provided to each student following the activity. I think we teach pharmacy student to be excellent communicators, but only if we start early!

References

1. Hasan S. A tool toteach communication skills to pharmacy students. Am J Pharm Educ. 2008;72(3): Article 67.

2. McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effectiveprecepting. Am J Pharm Educ. 2006;70(3): Article 58.

3. Mort JR, Hansen DJ. First year pharmacy students’ self-assessment of communication skills and theimpact of video review. Am J Pharm Educ. 2010;74(5): Article 78.

The Socratic Method - Asking the Right Questions

2012-01-16T10:08:00.002-05:00

by Whitney Chaney, Pharm.D., PGY2 Critical Care Pharmacy Resident, University of Maryland Medical Center

If you are like most pharmacy students or residents completing clinical rotations, you have probably come into contact with a preceptor whose main teaching strategy is to fire questions, one after another. This can be a good learning experience or a very bad one. Imagine going on patient care rounds with a preceptor. As you discuss various diagnoses and treatments, you are asked a series of very pointed questions to which the preceptor is looking for very specific answers. You may know a few answers.   Some questions you are unsure what the preceptor is asking. And sometimes you have no idea what the correct answers are. As this goes on you get more and more nervous, blurting out a few too many "I don’t knows," and the scenario ends with the preceptor giving you a long lecture about the disease state … very little of which you remember because you have become so flustered, frazzled, and distracted by your thoughts. The strategy of teaching through questions is often called the “Socratic teaching” method. The Socratic method can be very useful and effective, but all too often it is misused and abused.

Defining the Socratic teaching method is challenging – there is a lack of consensus on the exact definition. Much of the information describing Socrates' teaching comes from the writings of his students. They describe conversations with deep inquiry and intense debates on philosophical topics. Generally speaking, the Socratic method involves asking a series of questions in a logical manner until a common “truth” is reached. The goal of this type of inquiry is to stimulate critical thinking and lead to discussion in which the learner must use their baseline knowledge and analytical skills to reach a well supported conclusion. This method is also meant to point out unsubstantiated, preconceived notions and gaps in knowledge. In this process of inquiry, less emphasis was placed on the final answer, and more was placed on the thought process. While Socrates generally used his method to explore and answer moral concepts, this strategy of questioning can be and often is applied to clinical teaching.

As pharmacy students and residents complete their pharmacy practice experiences, this method of questioning and discussion can be a very effective learning tool. One key way in which it applies to healthcare is that good clinical practice (so called "truths") must be critically evaluated and supported by good evidence. Teaching with Socratic questioning forces the learner to not only know the "answers," but also to understand the background and reasoning to support them. Thus, the learner must be able to defend her/his recommendations and conclusions. Furthermore, as the Socratic method helps build critical thinking skills, it prepares the learner to become an independent practitioner in an environment where the standard of care continues to change as new information becomes available. Lastly, this method is very useful in experiential clinical settings because questioning and discussion can occur as situations arise in practice.

In order to effectively use the Socratic method, it is important to make sure that teachers and preceptors are asking the right questions – ones that stimulate discussion. Questions should be asked in a thoughtful and logical manner in order to guide the learner to appropriate conclusions. Using a variety of question types is more likely to achieve the learning objective. Questions can be exploratory ... these types of questions probe for basic knowledge. Challenge questions are intended to scrutinize conclusions and assumptions. Diagnostic questions probe for causes, connections, or cause-and-effect relationships.   Extension questions are meant to expand on the discussion. It is often useful for the instructor to use priority questions to help identify the most important points and, at the conclusion of the discussion, ask summary questions. Questioning can also be categorized by the type of cognitive level following Bloom’s hierarchy of cognitive skills: knowledge, comprehension, application, analysis, synthesis, and evaluation. In addition to the type of question, another strategy is to think about the order of the questions. Specifically, are the questions going from general to specific, simple to complex, or convergent to divergent? Finally, as the teacher probes the learner, the teacher’s response to the answers also impacts the learning process. It is important for the teacher to listen to the entire answer and use non-verbal cues that signals that he/she is interested in the learner’s thoughts. Correct or well-reasoned answers should be appropriately praised, while partially correct answers should be accepted and the learner should guided down the correct path with additional inquiry. Incorrect answers should be tactfully corrected in a non-judgmental manner.

The Socratic method of questioning and discussion can be a valuable teaching tool, especially in the setting of clinical pharmacy training. The secret to using this teaching tool is the appropriate use of questioning strategies and responding to the learner’s answers. The Socratic method should be used to facilitate an open dialog and the instructor must take care to create a non-threatening learning environment, where learners are free from fear and anxiety. Its important to keep an open mind, accept feedback, and be prepared to adjust the questioning strategy to ensure that every student and resident gets the best learning experience.

References
1. Oh RO. The Socratic Method in Medicine—The Labor of Delivering Medical Truths. Fam Med. 2005; 37:537-9.
2. Lewis DP. Using the Socratic Method in Office-based Teaching. Fam Med 2004; 36:162-3.
3. Edwards S, Bowman MA. Promoting Student Learning Through Questioning: A Study of Classroom Questions. Journal on Excellence in College Teaching.1996; 7: 3-24.

Practicality and Relevance in Pharmacy Education

2011-12-22T10:38:00.001-05:00

By Sarah R. Thiel, Pharm.D., PGY-1 Pharmacy Resident, the Johns Hopkins Hospital

It’s an eye-opening experience when a student steps out of the classroom and into a real-world work environment. The ideals of how things should be done (as taught in the classroom) do not always reflect the way they are actually done. This is because there often be workplace barriers, such as the financial and political issues, that hinder the best practices from being fully implemented. The modern-day pharmacy curriculum has put a great deal of emphasis on developing and practicing clinical skills. Relying on experiential learning as the only mechanism to learn about issues that arise in the day-to-day practice of pharmacy may be putting students behind their other health-care professional colleagues. In order to develop pharmacists with a more solid foundation and critical thinking skills, it is absolutely necessary to bring practical issues into the classroom!

As adult learners, information that is relevant and useful is more likely to be retained and applied. Therefore, teaching students practical information and practical ways to apply the information, appeals to the needs of the students without sacrificing content. I’m sure many of us have experienced a class where we think to ourselves “Why am I here? How is this relevant to me? I’m never going to use this information anyways!” Wouldn’t it be wonderful if instead students would think to themselves “Wow! This information is important! I may not need it tomorrow, but I’ll at least appreciate and understand how to use it when I do.” As our profession continues to strive to be patient-centered instead of product-focused, shouldn’t our pharmacy curricula follow suit and be student-centered? Shouldn’t we be developing our students to identify workplace practices that are not up to the standards taught in school? And by doing so, give students the foundation to help improve the practice of pharmacy? As future teachers and preceptors, we should do our students the favor of bringing more practical and relevant examples, experiences, and stories to their attention. Other professional curricula, such as law, have already started to do this.¹

William Lubawy, Ph.D., a faculty member at the University of Kentucky College of Pharmacy, suggests that demonstrating relevance of the presented material to students is one of many ‘Best Practices’ in teaching.² Specifically, the best practice is to:

“provide evidence of the relevance of course material. Do the students understand why it is important to learn the material? Are real world, practical, contemporary examples presented? Is basic science presented in the context of application to practice-related problems, commonly used drugs, common disease conditions, etc? What does the instructor do to provide evidence of relevancy?”

Furthermore, Dr. Lubawy considers relevancy a key for developing critical thinking and problem solving abilities in students.²

While there may not be many resources that explore the concept of practicality in didactic training, it’s an important one to think about. For example, Think Watson, an affiliate of Pearson Learning, reports that employers rated critical thinking skills of four-year college graduates as “excellent” in only 28% and as “adequate” in 63%.³ Do you think pharmacy graduates would be rated much higher? I think that increasing practicality and demonstrating relevance in classroom-based instruction could help improve this critical thinking skill statistic. Teaching students practical questions to ask and evaluate will improve their ability to handle similar issues in the future. While there may need to be a ‘right’ answer for an exam, adding practical, real-life twists will help improve student knowledge and application of skills. For example,the best therapy for a patient may be a medication only available as an intravenous formulation. But what if the patient does not have IV access? Community pharmacists know all too well that the ‘best’ therapy can turn into no therapy if that patient’s insurance won’t cover the medication. Introducing students to practical issues, questions, and approaches while they are still in the classroom can help get our students ahead when they begin introductory and advance practice experiences.

I was inspired to delve into the topic after reading my college of pharmacy alumni announcement about the 2011 recipient of the Teaching Excellence Award. This award relies heavily on student input regarding the impact of the instruction provided by the nominees. I went back through the previous winners and thought to myself, what is one attribute that each of these teachers share? They all strived to make instructional practical and relevant!⁴ The 2011-2012 President of the American Association of Colleges of Pharmacy, Brian Crabtree, Pharm.D., considers relevance an important component in evaluating teaching excellence.⁵ Shouldn't we make it a priority to bring practicality and relevance into the classroom?

References

1. University of Michigan Law School. The Practicality of the Practicum.

2. Lubawy, WC. (2003). Evaluating Teaching Using the Best Practices Model. Am J Pharm Educ. 2003; 67(3):1-3.

3. Applied Critical Thinking: A 3-Phase Approach to Developing Problem Solvers and Efficient Thinkers.

4. University of Michigan School of Pharmacy. 2011 Teaching Excellence Award Winner.

5. Crabtree BL. Excellence and Relevance. Am J Pharm Educ. 2011; 75: Article 173.

Fears of the Nontraditional Student: A Focus on E-Learning

2011-12-20T13:16:00.002-05:00

by Jennifer Dress, Pharm.D., PGY2 Psychiatric Pharmacy Resident, University of Maryland School of Pharmacy

Non-traditional adult learners inevitably face barriers related to pursuing a college degree. These barriers tend to differ from those experienced by traditional learners. Essentially, non-traditional adult learners (i.e. part-time students, full-time workers, parents, and those not pursuing a college degree immediately after finishing high school) may encounter limited access to classes at a convenient time and place. A recent blog published by Dr. Flemming highlights some of the issues encountered when “teaching across ages.”¹ However, there seems to be opportunities to develop strategies to increase course access and overcome these issues. Some may think the answer is at our fingertips. What better way to solve the problem than to offer online courses!

Online courses may overcome some of these situational and dispositional barriers. Specifically, they may circumvent situations in which adult learners find it difficult to attend classes on campus. Non-traditional students may also feel segregated from traditional learners because of differences in age, responsibilities, and energy levels. This may be overcome by the anonymity and flexibility that online courses offer. Consequently, nontraditional learners may begin to feel their opportunities and educational experience align with traditional students. Or don’t they?

Although online courses may prove beneficial for busy adults, a new barrier may surface: fear. Instead of reducing the limitations facing non-traditional students, e-learning may bring forth fear of the unknown, fear of technology, and fear of losing control.² A recent study conducted at a college in Boston highlighted some fears students have regarding e-learning. A survey sent to 64 faculty members and 234 part-time students taking courses in the summer of 2008 revealed that students and faculty members were least comfortable with online courses and social media sites when compared to websites that were used for informational purposes or had transactional tools.²

However, only 74.4% of students and 33.3% of faculty had actually taken/taught an online class.² Furthermore, those individuals who had not participated in an online class were significantly more likely to rank the online classes as more difficult than face-to-face courses (p<0.05). Despite the small sample size and pooled analysis of both teachers and students, an inference can be made from the study. E-learning naive respondents seem to be afraid of losing control over their learning environment and the means of communication.

Evidence from a study conducted in 2008 shows a benefit from blending both an online and face-to-face teaching component for students in an interprofessional team development course.³ The students, majoring in pharmacy, medicine, nursing, and other health care fields, were divided into groups attending traditional face-to-face lectures and those enrolled in the blended classes. Results from pre/post tests, in-class observation, and student polling showed no significant difference between the team process skills both groups acquired. Therefore, the quality of blended classes and face-to-face classes appear equal, but the importance of carefully considering the percentage of each component needed to satisfy learning objectives is crucial.³

Despite the new obstacle introduced by technology, there is hope. First, we need to address the lack of confidence and fear of technology exhibited by students and faculty. Faculty can receive support through instructional designers and pedagogical training in order to gain confidence and develop interesting and appropriate course designs.^2,4 We can also learn by example from the University of Maryland, who successfully implemented a strategy to increase innovation of online teaching tools in early 2000 through provision of mini-grants for support and incentive.⁵ Finally, a less costly idea would be to develop a mentoring program to provide support to faculty and students involved in e-learning. Coming from someone who has feared technology at times, I feel these ideas are a good start to get all students united in their pursuit of a college degree. In conclusion, the hope is that students, including myself, taking online courses will begin to feel the same as the learner captured in the following quote:

“I feel that I am able to express myself more effectively when
I have more time to think about the issues and questions.
I know that I will be able to contribute more to class and to the discussions.”²

References

1. Fleming, J. Teaching Across Generations. Baltimore (MD): Educational Theory and Practice; 2011 Nov 27.

2. Sendall P, Shaw RJ, Round K, Larkin JT. Fear Factors: Hidden Challenges to OnlineLearning for Adults. In: Kidd T, editor. Online Education and Adult Learning: New Fronteirs for Teaching Practices. Pennsylvania: IGI Global; 2010. P. 81-100.

4. Carbonaro M, King S, Taylor E, Satzinger F, Snart F. Integration of e-learning technologies in an interprofessional health science course. Med Teach 2008; 30:25-33.

5. Educause Learning Initiative (2008, August). Educause. Fritz, J. Lessons learned from a faculty incentive grant program. Educause Mid Atlantic Regional Conference (MARC); 2004; Baltimore, Maryland. Educause; 2004.

Going Paperless in the Classroom

2011-12-17T13:45:00.003-05:00

by Kate D. Jeffers, Pharm.D., PGY1 Pharmacy Resident, The Johns Hopkins Hospital

Over the past years, there has been a push to “Go Green.” Alongside this push, has been the revolution in digital publishing, with digital readers such as the Kindle and Nook, and the ability to digitally access digital material through Google Books or textbooks via the school library. But what does this mean for the classroom? Is there such a thing as a “required textbook” anymore?

The “green” classroom movement has taken an recent turn with the advent of the iPad. Apple and its affliated “app” developers have created increasingly sophisticated applications for use in education. iPads have been integrated into numerous schools around the country—from high school down to kindergarten!^1,2This push has begun to creep into medical education. The teaching hospital at which I am completing my residency gave each of the medical interns an iPad and the Department of Pharmacy purchased laptops for each of the PGY2 pharmacy residents.

A high school English teacher, James Harmon, from the Cleveland area conducted an experiment to determine if the iPad actually improved learning in the classroom. His findings? His students learned better with the aid of iPads—when used correctly. He began the experiment after the school was provided 24 iPads by the school district. The school primarily serves a low-income population, and traditional approaches to teaching reading and writing weren't working. Harmon hypothesized that the iPads would help the school's English teachers find new, creative approaches to teaching the content. He also wanted to justify asking for more iPads with data-driven evidence.

Harmon divided the sophomore English class into two groups, one iPad-free control group, and one that had access to these tablet devices at school. He ensured that all sophomore English teachers taught the same curriculum for that school year. According to his end-of-year data, students with access to an iPad were more likely to pass both the reading and writing sections of the state standardized test. The teachers also reported that the devices made their lessons more engaging and helped them connect with students, adding that the iPads allowed them to give students "more frequent and timely feedback on writing." Additionally, student surveys revealed that the iPads increased students' motivation to learn. Of course, the excitement behind the use of novel technology might wear off with time. Which would mean their value would diminish unless teachers take other steps to make their material engaging.³

In addition to motivation that new technology like the iPad can engender, the paperless classroom has other benefits. For starters, it cuts the cost of purchasing printed textbooks, which may or may not be used by students. By allowing students to access textbooks digitally, this allows them real time access to material. For example, if a student completes a lecture and has further questions regarding the topic, they are able to log onto the library website and read a textbook chapter immediately, rather than wait hours to return home (and perhaps forget to look up the material). This allows the student to formulate informed follow-up questions for the professor and quickly reinforces concepts covered in the classroom. Further, teachers are able to pick and choose what readings they require. Rather than requiring students to buy multiple textbooks and using isolated sections from each, professors are able to customize their reading requirements to the most relevant sections from various texts.⁴

A potential issue with all of this technology is the loss of the tactile sensation of pen to paper. Students learn in different fashions—some may be auditory, some may be visual, while still others may be tactile. Throughout my education, I have found it necessary to highlight and take notes on various book chapter or articles. Some technology, such as Adobe Pro, allows you to highlight and comment on electronic documents. During my first year of pharmacy school, I printed each slide set to take hand notes. As the courses got more difficult, I took notes on my computer, which I then had to convert into a word document alongside the slide information. And then I printed it to study for exams.

An additional concern becomes the reliability of the technology itself. I watched many students loose all of their hard work during computer crashes. This highlights the importance for backing up files regularly. Finally, with all of the computers in the classroom, it can be distracting for students. Students may be tempted to instant message, check out Facebook, or surf the web; all of these would be counterproductive to the purpose of being in the classroom.

Is it ever possible to “go paperless” in the classroom? Probably not. On the other hand, it is feasible to use “less paper,” bringing new meaning to the “Go Green” movement.

References:

1. Hu, W. Math that moves: Schoolsembrace the iPad. New York Times 2011 Jan 4 [cited 2011 Nov 26].

2. Dwyer, L. iNsane? Auburn, Maine,is giving an iPad2 to every kindergarten student. Good Education 2011 April 11 [cited 2011 Nov 26].

3. Dwyer, L. Teacher’s iPadexperiment shows possibilities for classroom technology. Good Education 2011 Sept 9 [cited 2011 Nov 26].

4. Kupetz, AH. Is the paperlessclassroom possible? BizEd 2008 Jan/Feb: 36-40 [cited 2011 Nov 26]

An Interprofessional Approach to Teaching

2011-12-16T15:10:00.000-05:00

by Raymond F. Lamore III, Pharm.D., PGY1 Pharmacy Resident, the Johns Hopkins Hospital

The strategy of treating patients as a part of a “multidisciplinary team” has become common in many progressive medical centers. Utilizing the various skills of different members of the medical team can lead to significant improvements in patient care. Recently, literature has been published demonstrating the impact that pharmacists can have on patient outcomes as a part of the multidisciplinary team.^1-3 Based on this body of literature, there has been a surge of opportunities for pharmacists to participate in point-of-care treatment as a part of an inter-professional team.

As a part of the medical team it is a necessity for the pharmacist to be able to appropriately interact with the other members and understand their point of view. This expansion in our “job description”, begs the question: Are we trained to do this!? I am not questioning a newly trained pharmacist’s ability to answer pharmacological questions and make clinical decisions, rather asking if we have been properly trained to be an effective member of the medical team. Unless you have had a job within a hospital as an intern, your interaction with various members of the medical team was probably minimal; with most occurring during your final year in school during advanced pharmacy practice experiences (APPEs). Many have concluded that the difficulties encountered in working with multiple professions stem from a lack of knowledge regarding the different roles and a relative absence of teamwork skills.⁴ In 2007, the American Association of Colleges of Pharmacy (AACP) Professional Affairs Committee advocated that “all colleges and schools of pharmacy provide faculty and students meaningful opportunities to engage in education, practice, and research in interprofessional environments to better meet the health needs of society.”⁴

This leads to a second question. Should students be introduced to the different members of the medical team during classroom-based instruction. Interprofessional education can add many benefits to a college of pharmacy’s curriculum.⁵The World Health Organization defines interprofessional teaching as “…students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁵ An expert panel from the Interprofessional Learning Collaborative suggested the following key objectives for interprofessional teaching:⁶

· Relationship focused

· Process oriented

· Linked to learning activities, educational strategies, and behavioral assessments

· Able to be integrated across the learning continuum

· Sensitive to the systems context/applicable across practice settings

· Applicable across professions

· Stated in language common and meaningful across the professions

· Outcome driven

Interprofessional teaching would also add depth to the students’ ability to perform analysis, as different members of the medical team utilize a variety of thought processes in clinical decisions. These perspectives and processes differ from a pharmacist’s. Educational researchers have found benefits to this teaching modality, as it helps students to recognize bias, think critically, tolerate ambiguity, and acknowledge and appreciate ethical concerns.⁵ Introducing students to different members of the medical team may also increase their confidence when communicating recommendations. This interprofessional model of teaching and learning could seamlessly progress from the classroom into experiences partnered with students from many health professional programs.

In 1995, a nursing and pharmacy school completed an interesting clinical collaborative project, in which students from each school were paired so that they could utilize their “profession specific” skills in patient care situations.⁷During the project, students met weekly in the hospital to jointly present at case conferences to their peers. The students worked in pairs, one from each discipline, in selecting a patient case, plan a case study, and present the results to the group. This experience required the students to collaborate, utilizing negotiation skills and critical thinking processes. Common issues that were addressed by the nursing students, included: physical signs and symptoms, medication administration, laboratory values, discharge needs, and self care abilities. Whereas, student pharmacists would address pharmacological therapy, allergies, polypharmacy, pharmacokinetics, contraindications, route of administration, and adherence.

After the completion of the project student comments were positive. They expressed appreciation for a collaborative approach to patient care. This project demonstrated great success as both groups of students expressed an appreciation for the complementary nature of the two health care professions. This early experience lead to expanded implementation of these experiences in the respective curriculum.⁸ This form of interprofessional education is a great way to collaborate with other members of the team and gain an early appreciation for their roles in patient care. The only foreseeable complication in this approach would be possible scheduling complications between academic institutions and having resources (hospital, staff, etc.) to allow for team meetings and collaboration.

Taking a interprofessional approach to teaching and learning is a tool to enrich the curriculum of any college of pharmacy. Utilizing this approach to educate pharmacists will open the doors for early interaction and collaboration with the various members of the health care team and broaden learning experiences for students.

References:

1. Marshall J, Finn C, Theodore A. Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay. Crit Care Med. 2008;36:427-433

2. Cohen V, Jellinek S, Hatch A, et al. Effect of clinical pharmacists on care in the emergency department: A systematic review. Am J Health-Sys Pharm 2009;66:1353-61.

3. Gattis W, Hasselblad V, Whellan D, et al. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team. Arch Intern Med. 1999;159:1939-1945

4. Page R, Hume A, Trujillo J, et al. Interprofessional Education: Principles and Application. A Frame Work for Clinical Pharmacy. Pharmacotherapy 2009;29(3):145e–164e.

5. Romanelli F, Bird E, Ryan M. Learning Styles: A review of theory, application, and best practices. Am J Pharm Educ 2009;73:1-5.

6. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

7. Science Education Resource Center at Carlton College. Starting Point: Teaching and Learning Economics. Why Teach with an Interdisciplinary Approach? Accessed: November 6, 2011.

8. Robertson K. Interdisciplinary professional education: A collaborative clinical teaching project. Am J Pharm Educ 1995;59:131-136.

Teaching Challenges in Religiously Diverse Classrooms

2011-12-16T14:40:00.002-05:00

By Jennie Piccolo, PGY1 Pharmacy Resident, Carroll Hospital Center

“We are a nation of Christians and Muslims, Jews and Hindus – and non-believers.” In his inaugural address, President Obama used religious diversity as one of the many illustrations of diversity in America, proclaiming “our patchwork heritage is a strength, not a weakness.”¹He did not address the challenges this often presents, however, in the classroom. Sara Shady and Marion Larson of Bethel University ruminate on this ever present challenge to educators at American colleges and universities: “How should we handle the presence of different religious views in the classroom? How can we best prepare students to constructively engage a world of competing religious truths?”²

The pharmacy curriculum and curricula of other health professions are certainly not strangers to this concept. Science and faith oftentimes clash when controversial topics, such as oral and emergency contraception, methadone clinics, and many others are discussed. I will always remember my class on oral contraceptives, where our professor firmly proclaimed her views, disregarding the beliefs of many of my classmates. When one of my fellow students confronted her, stating his views which contradicted her teachings, an argument ensued. Each was firm in their views and the disagreement lead nowhere; neither side relented and both just agreed to disagree (and the class simply ended). A similar disagreement occurred the following year during a class that discussed the use of methadone as treatment of drug abuse. With so many controversial topics as essential components of a pharmacy curriculum, how can we avoid these conflicts?

While few pharmacy professors approach this topic, Jan Worth, an English professor at the University of Michigan, admits that faith based topics “sometimes intersect in troubling ways with my own prejudices and personal history as a teacher and person.”³ She confesses to having trouble separating teaching from her personal beliefs and recognizes that educators often view faith as negative. Career tracks that are strictly science based, such as pharmacy and other health sciences, tend to be even less open to combining scientific teachings with diverse religious views. Many feel that logic and faith cannot coexist. I can attest to feeling the need to downplay my religious upbringing and beliefs to gain respect from my teachers and peers. Worth acknowledges “in teaching, we must respect our students—both the complicated personal histories and experiences with which they come to us.”³ She continues “it takes patience and fortitude, and, sometimes, conscious self-restraint.”³College and universities strive to attract a wide variety of students, from a wide variety of cultures. Pharmacy educators must be prepared to embrace this diversity when approaching a difficult subject.

You may be asking, what tactics can we use in such a volatile situation? Pharmacy educators need to resist forcing what they see as truth on their students without taking into consideration the diversity of views in their classroom.² One of Worth’s tactics is to bring the conversation back to a text book, where the facts can be presented, hopefully free of cultural controversy.³ Other strategies could include phrases that do not over generalize, such as “some people..” or “in my experience…” to help prevent students from feeling that their cultures or beliefs are under attack.⁴ Allowing students to express their views in a low risk setting, such as an ungraded assignment or a small group discussion, helps to create a safe environment to express views on the subject matter.² By staying as unbiased as possible, a teacher can help promote healthy discussion rather than fuel arguments and controversy.

In a world where pharmacists have refused to fill prescriptions based on their personal, moral, and religious beliefs, controversy will continue to fill the curriculum of pharmacy schools as well as other health professions. Our college and university classrooms are full of cultural and religious diversity. If pharmacy educators can remain unbiased in their teachings and prevent imposing their own views on their students, they can help foster a safe learning environment.

References:
1. Obama B. “Inaugural Address.” January 21,2009.
2. Shady S. and Larson M. Tolerance, Empathy, or Inclusion? Insights from Martin Buber. Educational Theory. 2010; 60:81-96.
3. Worth J. Hot Spots and Holiness: Faith-Based Topics in Freshman Composition. 2002. Paper presented at the Annual Meeting of the Conference on College Composition and Communication.
4. Liggett T. and Finley S. Upsetting the Apple Cart: Issues of Diversity in Preservice Teacher Education. 2009

Breaking down the primary literature: the role of the journal club

2011-12-16T14:09:00.007-05:00

by Emily C. Pherson, Pharm.D., PGY1 Pharmacotherapy Residency, the Johns Hopkins Hospital

As pharmacy students, we have courses where we are instructed on the key elements of a research study and we are tasked with trying out our literature evaluation skills by writing evaluations of major drug trials. As pharmacy residents, we are faced with reviewing multiple pieces of primary literature nearly every day in order to find the best data we can to inform the drug treatment decisions we are making for our patients. Leading journal clubs has helped me develop the skills I need to break down the primary literature.

As a pharmacy resident at Johns Hopkins, I was excited to discover that the first record of a medical journal club was one founded in 1875 by Sir William Osler, a renowned physician with Hopkins roots. He originally described the journal club as facilitating the distribution of unaffordable periodicals, and later evolved it into a book and journal club that met over dinner to discuss the latest in medical research.¹

A journal club is a teaching tool that helped me digest large amounts of information in limited amounts of time. When I started to think more about how I could conquer breaking down the necessary information in a journal article for a journal club, I realized that an easy way to do this would be to apply Gagne’s 9 events of learning, one of the many educational strategies we have been exploring in the Educational Theory and Practice Course.

To really engage participants in a journal club, you need to gain their attention. I find that applying the journal article to a patient case is a good way to get participants to relate to the content. It is also important to emphasize that at the end of the journal club, all attendees should understand the clinical implications of the data presented. This is always a recurring key objective for a journal club. It also important to give a bit of background on the disease state or therapy being addressed in the article as a way to stimulate recall of prior learning and help the attendees draw on information they already know about the topic. As far as presenting the content, a 2004 overview in the American Journal of Health-System Pharmacy points out three key steps to providing adequate discussion about an article.² First, the presenter must determine the relevance of the study (something I accomplish by laying out my objectives). Next, the validity of the trial must be determined. This is where the patient population, the study design and how the study was conducted are all evaluated. Lastly, the results must be evaluated. Askew suggestions that you list all of the efficacy endpoints of the study and then calculate the relative risk reduction and the absolute risk reduction.² Other important things to look at include the statistical analyses. It may be helpful to calculate the number needed to treatment (NNT) and/or the number needed to harm (NNH). It is also important to consider if the study was adequately powered to assess the defined outcomes.²

In order to provide learning guidance and engage learners, its helpful to prepare some discussion questions to get the conversation started. These questions should be focused on the application of key study findings. If you started the journal article with a patient case, this can be a good time to bring the case back into discussion.

Its also important to have an evaluation tool available to assess the learners performance and provide feedback on the presentation. A 2007 article in the American Journal of Pharmaceutical Education provides an extensive evaluation rubric that was piloted with pharmacy students. In addition to the rubric, the students were also provided with an outline of important considerations for each section of the study. The authors provide a truly comprehensive tool that’s very useful for providing feedback to learners.³

The last event that Gagne proposes is that we must enhance retention and transfer knowledge. At the conclusion of every journal club, its important to summarize the discussion and talk about how the information can be applied in practice. Some days later, I invariably find myself applying what I’ve learned during a journal club to specific patient cases I see on my rotations. I encourage participants to think about when they might use the information in the journal article again.

I would challenge any educator who is faced with the task of discussing the primary literature with learners, to considering using a journal club format and applying Gagne’s 9 events of learning when conducting them.

References:

1. Greene WB. The role of journal clubs in orthopaedic surgery residency programs. Clin Orthop. 2000;373:304–310.
2. Askew JP. Journal club 101 for the new practitioner: Evaluation of a clinical trial. Am J Health-Syst Pharm. 2004;61:1885-1887.

3. Blommel ML and Abate MA. A rubric to assess critical literature evaluation skills. Am J Pharm Educ. 2007;71:1-8.

Pharmacists Education: B.S.Pharm to Pharm.D. — the Evolution of a Profession

2011-12-16T12:53:00.002-05:00

by Ashley McCabe, PharmD, PGY1 Community Pharmacy Resident, University of Maryland School of Pharmacy

If you or someone close to you has recently graduated from pharmacy school, you know the Doctor of Pharmacy (Pharm.D.) degree is the degree that all pharmacists now earn. However, not every pharmacist in the pharmacy world has a Pharm.D. In fact, the education of pharmacists has evolved as the profession has transformed. The Pharm.D. degree is a relatively new standard in the profession. As someone who works in a community pharmacy setting, where more pharmacists have a Bachelor of Science in Pharmacy (B.S.Pharm) rather than a Pharm.D., I am intrigued by the differences between the two degrees and how professional education has changed over the years. I intuitively understood that the doctorate required more years of school but, why did the doctorate become the standard? As a student of education, I wondered what drove educators to alter the curriculum so drastically. More importantly, as we are undergoing another phase of healthcare reform, it is vital to look at that process, in the event that education will need to transform again based on the needs of the profession and the patients we serve.

Through my investigation, this is what I discovered. The B.S.Pharm degree was the norm until 1997 when the Accreditation Council for Pharmacy Education (ACPE) re-evaluated the needs of entry-level pharmacists and patients.¹ The changes made were based on recommendations for healthcare provider competencies identified by the Institute of Medicine (IOM). In 2000, the new ACPE standards went into effect. Therefore, if you graduated pharmacy school in 2003 or later, the doctorate became the entry-level degree. As the profession and medical care in general evolved, so did the education of the pharmacist. The doctorate of pharmacy put more emphasis on medication management – and this proved important when the Medicare Modernization Act passed in 2003.¹ Pharmacists needed to employ their cognitive skills to an ever expanding population in need.

Pharmacy practitioner Paul W. Abramowitz clarified this concept perfectly in his Harvey A. K. Whitney Lecture by describing the transition of pharmacy practice throughout his career.² He painted a picture of pharmacy practice in 1974, the start of his career, as more humble clinically with limited inter-professional exchanges. He continued with how the profession morphed as pharmacists became more involved in acute care settings and as the repertoire of medications expanded along with medication-related problems and the pressure to make cost-effective decisions. Moving into the current practice model, he expanded his story by describing how curriculums now require one year of advanced practice experience in order to fit into the new healthcare model of inter-professional care. Thus, Mr. Abramowitz helped answer how the doctoral degree evolved, but there is definitely more to it than that. What were the educators thinking?

In a recently published article by former dean of the University of Maryland School of Pharmacy, Dr. David A. Knapp, highlighted the thoughts of educators, policy makers, alumni and other stake holders at the time of the transition.³ The article illustrates the lengthy debate and political upheaval that the all-Pharm.D. inspired. Support from research studies and practice analyses done by both sides of the debate exemplified how difficult the transition really was. Faculty and staff members at the school were burdened by trying to put additional requirements into a 5 year program. Adding 2,000 supervised practice hours and 6 months of externship into a packed course load with limited elective opportunities stressed an already bloated curriculum. However admirable it was, an all-PharmD was despised by many employers, pharmacists, and state legislators who saw a doctoral education as costly and unnecessary, amongst many other perceived undesirable characteristics. But as we all know, in the long run, the all-Pharm.D. transition occurred.

From an educator perspective, the necessity of transitioning from 5 years to 6 years of education was related to a needs analysis. The transformation was inspired by the evolving advance clinical roles pharmacists were taking on. These roles were first explored by practitioners and educators in the 1960’s, 70’s, and 80’s. In the current economic and political climate, the pharmacy profession is facing different challenges. Educators and practitioners are sure to have opinions on the topic, but none are as potentially influential as the current students who will become the future of the profession. Therefore, a needs analysis of the current students could hold the key to where professional education needs to go.

With the transformation of pharmacy education in mind, as highlighted by Mr. Abramowitz and Dr. Knapp,^2,3 I believe it is fair to question where this evolutionary trend in pharmacy education will lead. This is especially vital when considering the perceived needs of current students as they begin their careers in pharmacy. Will it be residencies for everyone in order to enhance the retention and transfer of the advanced knowledge and skills first taught in school? I believe that assessing the needs of the learner, in this case pharmacy students, as well as the needs of our patients should provide the data we need to make informed decisions about the future of pharmacy education and training.

References

1. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Accreditation Council for Pharmacy Education. Chicago; 2006.

2. Abramowitz PW. Harvey A. K. Whitney Lecture: The evolution and metamorphosis of the pharmacy practice model. Am J Health-Syst Pharm. 2009; 66:1437-46.

3. Knapp DA. The rocky road to educational change: Adopting the entry-level Pharm.D. at Maryland, 1989-93. J Am Pharm Assoc 2011; 51:712-719.

Preparing Pharmacy Students for Residency Training

2011-12-14T14:50:00.002-05:00

by Diane E. Hadley, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Maryland School of Pharmacy

Over the past few years, I have been asked at three different pharmacy schools by first year students “What can I do to become the perfect residency candidate?” Perhaps the better question is, what we can do as pharmacy educators and schools of pharmacy to prepare students to “put their best foot forward” for the ASHP Midyear Clinical Meeting (ASHP MCM) and residency interviews? As the demand and the competitiveness for pharmacy residency training increases, acquiring accurate information about residency training and preparing students for the interview process becomes increasingly important. In most doctor of pharmacy programs, students learn about residency training and preparation methods primarily by informal methods through peers as well as preceptors during advanced pharmacy practice experiences (APPE’s). Although beneficial, it may leave the prospective residency candidate with incomplete information regarding the type of residency to pursue and may not adequately prepare students for the interviewing and matching process. Would a more formal approach, such as a pre-residency curriculum, be more effective than the current informal methods?

Experiential learning is a crucial part of the doctor of pharmacy curriculum that exposures students to current pharmacy practice models. Ideally, APPE rotations should serve as an introduction to residency training. Unfortunately, schools don’t control the “hidden curriculum” taught during APPE rotations.¹ An article published in Academic Medicine, observed that values such as professionalism was often taught informally more often by peers during off hours instead of traditional methods from an instructor.² This article illustrates how the “hidden curriculum” is often driven by peer influence. This notion is further supported by an article published in Clinical Orthopedics and Related Research Journal.³ Indeed, informal one on one and group interaction can impact opinions, most often in a negative way.³ Thus information and attitudes about residency training may be acquired through a “hidden curriculum” and these may be driving decisions related to residency training that are not envisioned or endorsed by the school.^1,2,3 Thus a formalized pre-residency curriculum may help diminish the potentially negative influences of the “hidden curriculum.”

An article published in American Journal of Pharmaceutical Education supports the potential benefits of developing structured pre-residency instruction at the University of Buffalo School of Pharmacy.⁴ The author surveyed sixty-eight pharmacy students that attended either the ASHP MCM in 2007 or 2008 or both.⁴ Prior to attending ASHP MCM, students attended a one hour presentation and receive a handout regarding the residency process.⁴ The educational seminar included information about residency terminology, benefits of attending the ASHP MCM, time management, and the pre-during-post ASHP MCM meeting residency selection.⁴ The survey asked about the helpfulness of the structured educational event and had an impressive 97% response rate.⁴ A majority of the students, 73%, ranked the educational event as extremely helpful in preparation for the ASHP MCM.⁴ A 2010 survey of seventy-one colleges of pharmacy showed that sixteen pharmacy institutions now have a pre-residency program in their pharmacy cirriculum.⁵ Of these sixteen schools, nine provided information on their pre-residency curriculum.⁵ The curriculums offered a variety of traditional and non-didactic learning activities including: lectures on residency training, pre-residency pathways, mentoring programs, and research project development.⁵

Schools of Pharmacy should provide residency information using a structured approach. Such instruction has become crucial because the American College of Clinical Pharmacy has proposed that residencies become mandatory for pharmacists who work in direct patient care roles by the year of 2020.⁶ As leaders in our profession, we need to take action to formalize the instruction about residency training to keep students well informed. We need to reduce the likelihood that students will make ill informed decisions based on misinformed that practitioners or peers may have given. Ideally a pre-residency curriculum should be created that incorporates didactic presentation on the ASHP MCM meeting and residency interviewing process, encourages experimental learning rotations that increases a student’s preparedness for residency training, a pre-residency mentor, and opportunities to get involved with clinically oriented research projects. A combination of all these elements would provide a sturdy foundation for students to become the “perfect residency candidates.”

References:

1. Gardner S. Car Keys, House Keys, Easter Eggs, and Curricula. Am J Pharm Educ. 2010; 74 (7) Article 133.

2. Stern DT. In Search of the Informal Curriculum: When and Where Professional Values are Taught. Acad Med. 1998:73:S28-S30.

3. Gofton W and Reghr, G. What We Don’t Know WE Are Teaching: Unveiling the Hidden Curriculum. Clin Orthop Relat Res. Number 449. Augest 2006. Pages 20-27

4. Prescott WA. Program to prepare pharmacy students for their postgraduate training search. Am J Pharm Educ. 2010; 74 (1) Article 9.

5. Dunn B, Ragucci K, Garner S, et al. Survey of Colleges of Pharmacy to Assess Preparation for and Promotion of Residency Training. Am J Pharm Educ, 2010. 74 (3) Article 43.

6. Murphy JE, Nappi JM, Bosso JA et al. American college of Clinical Pharmacy Vision of the Future: Postgraduate Pharmacy Residency Training as a Prerequisite for Direct Patient Care Practice. ACCP Position Statement. Pharmacotherapy 2006; 26 (5): 722-733.

Bridging the Multicultural Divide

2011-12-08T14:46:00.007-05:00

by M. Amjad Zauher, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

I still remember the thoughts running through my mind as I walked into my first class in my undergraduate program. Here I was, in a new country, coming from Colombo, Sri Lanka, a city with a population of over five million, to Clarion County, Pennsylvania, with a population of twelve thousand. I was clearly an outcast – from the color of my skin to my accent, everything was different. Rural Pennsylvania seemed far from welcoming. All I knew was the British educational system. Multiple-choice exams were a foreign concept and I was accustomed to completing all assignments by hand. Graphing calculators were used in science fiction movies, not in college classrooms. I had to quickly learn how things worked in America.

As the semester rolled on, some professors were exceptional in helping me, explaining what was expected, and how to complete required assignments. More importantly, they brought down that invisible wall in the classroom that made me feel ostracized from everyone who was not like me. I was by no means unique; they were doing this for all the students, whether they were from down the road or from half way around the world.

To bridge the cultural divide that often separate students who come from diverse backgrounds, educators can incorporate techniques such as these:

During the first class, have the students say something about themselves. If its a bigger class, have them write specific information on note cards (city of birth, hometown, hobbies, etc.) for later discussion.
Take time, either before or after class, to talk to students about how they are handling the change in academics, atmosphere, and society. Get to know more about each person’s background, ethnicity or culture.
Small group projects, in or out of class, promote interaction between students and increase the amount of discussion with classmates with whom they would not ordinarily interact.
BaFa BaFa!

Although I can only speak about my own experience as an international student, I believe I represent minorities in many classrooms. Minority enrollment in colleges and schools of pharmacy across the United States have increased from 10.6% to 14.0% between 1988 and 2002.¹ And the number of students enrolled at the University of Maryland School of Pharmacy who come from minority backgrounds is greater than 50% (Asian = 45%, African American = 10%, and Hispanic = 2%).² However, little to no data is available regarding the diversity of pharmacy students in other aspects (e.g. socioeconomic status, sexual orientation, physical ability).

Why is it important that diversity be addressed? It is not simply a matter of making students from various backgrounds feel more comfortable within the classroom, but rather how it shapes us as pharmacists down the road. In 2005, immigrants made up 11.5% of the US population, an increase from 4.7% in 1970 with, approximately 1.5 million immigrants arriving to the United States each year.³ People from different cultures have their own health beliefs and as pharmacists, it is our duty to understand and address the belief systems of our patients. The more experience and practice we get as students through interaction with a diverse group of people, the better prepared we will be at resolving health disparities.¹

Here are a couple of specific classroom-based examples I found to be beneficial to help address students of diverse backgrounds:

Professor Deborah Ball at the University of Michigan pointed out some techniques she employs during her lectures to engage students.⁴ These include: maintaining eye contact with students throughout the classroom (not just in the front row), initiating “small talk” among the students (by posing questions and having neighboring students discuss), and asking for opinions from different students in every class.

A cultural competence lesson that I hadn't experienced until coming to the University of Maryland was the BaFa’ BaFa’ cultural simulation game.³ The game involves splitting the class into two groups (Alphas and the Betas). The rules of the game are explained to each group seperately. The Alpha group was a relationship oriented society with strict rules about social behaviors, whereas the Beta group was a trading society that communicated via a complex language. Gradually, members were exchanged between the groups without explanation of how to communicate with the members in the other group. Once everyone had attempted to communicate with the opposite group, the class met as a whole and discussed the experience. Fun as it was to try and figure out what was going on, an incredibly valuable lesson was learned: the feeling of being in a “foreign” culture. We discussed misconceptions that we might have developed through our brief “clash of cultures” and we talked about our past experiences. I was easily able to relate to the exercise but many of my peers had never personally experienced this sensation.

We live in a world that, with every passing moment, is having its cultures intertwined. This is resulting in an amalgam of ideologies from all corners of the globe. Teachers will need to implement their own method for breaking down cultural barriers, whether it is through a cultural competence lesson (such as in the BaFa BaFa experience) or creating an “open floor” style of classroom where everyone has an equal say (such as Dr. Ball's small talk exercise). The ability of an educator to communicate with students in a manner that is transcendent is imperative if we want all students to be successful. As an international student being in a classroom where I felt initially separated from the group, a teacher who was able to bridge the gap brought us together.

References

1. Nkansah N, Youmans S, Agness C, Assemi M. Fostering and Managing Diversity in Schools of Pharmacy. Am J Pharm Educ. 2009; 73: Article 152

2. University of Maryland School of Pharmacy – Fact Sheet.

3. Westberg SM, Bumgardner MA, Lind PR. Enhancing cultural competency in a college of pharmacy curriculum. Am J Pharm Educ. 2005; 69: Article 82

4. Arthur F. Thurnau Professors/Engaging Students in the Classroom and Beyond [Internet]. Ball D. Engaging Students in Larger Classes. Center for Research on Learning and Teaching: University of Michigan; 2000.

To Pass/Fail or to Not Pass/Fail

2011-12-01T23:00:00.003-05:00

by Maisha Haque, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

One of the most talked about topics among my friends in pharmacy school is grades! This led me to research a very relevant question: should pharmacy schools adopt pass/fall grading criteria for their courses? Or should they stick with a traditional A through F system of grading? The type of grading system can cause changes in classroom behavior and perhaps the outcomes of student learning. As future educators I think it’s very important for us to understand the different grading systems in order to maximize the learning environment. This blog essay covers the summaries of three articles I found regarding the effects of different systems for assessing student performance.

In the first article, the researchers studied the benefits of a pass-fail grading system on stress, mood, group cohesion, and test anxiety. This prospective study was conducted at the Mayo Clinical College of Medicine in Rochester, Minnisota.¹ The Mayo Clinic College of Medicine recently changed over their grading system from a 5-interval grading system to pass-fail grading system. This allowed the authors to compare the graduating class of 2005 (which experienced the traditional grading system) to the class of 2009 who experienced only the pass/fail grading system. The two groups were compared at three time points: at the end of their first year, the end of their second year, and after step 1 of their licensing exam.¹ The results showed that the students graded on the pass-fail system had significantly less perceived stress and greater group cohesion. The authors also observed that letter grades represented extrinsic rewards (such as when someone else tries to motivate you to do something) rather than intrinsic rewards (internal and personal motivating factors). Thus, traditional grading systems, by their nature, tend to transform intrinsically motivated learners into extrinsic learners.¹

In another study, the authors examined the student’s perspective on the two grading systems and the affect they have on student motivation.² A questionnaire was given to law students whose curriculum changed from pass-fail to a letter grade system. The responses revealed that students believed there was a higher concern for their standing in relation to other students and their position in the eyes of the professors. There was also more competition in letter graded courses than there was in pass/fail courses.² The respondents indicated that students were less embarrassed to ask questions in a pass/fail classroom.² This seems like a very important learning tool that was somewhat inhibited under a letter grade system. The authors concluded that students were more oriented towards social comparisons and competition in a letter graded class … and less oriented towards task mastery.²

The final paper examined whether a pass/fail system adequately reflects student progress or not.³ The primary purpose of any grading system is to measure student achievement and to establish the development of needed competencies.³ In letter-graded classes students are perhaps more motivate while a pass/fail class establishes only the minimum requirements.³ The authors contend that a letter grading system encourages the habit of always aiming for the best which would be a positive thing if translated into the work environment even when grades are not allocated. The interesting observation made by the authors is that faculty role modeling, selection of criterion, careful and inclusive selection of the qualities that are being assessed, and the use of criteria based grading system are more important contributors to student learning than whether or not letter grades are assigned.³

After reading the different sides presented by these articles, it’s evident that there is not one clear winning strategy for student assessment. Doctoral and graduate degree programs are always going to be very rigorous and stressful learning environments. The evidence indicates that the pass/fail system leads to less stress, increased group cohesion, and increased task mastery. Thus I believe the pass/fail system should be adopted in all graduate schools. The competition and pressure to get good grades is commonly experienced during undergraduate education – thus people admitted to pharmacy (and medical and law) school have a proven ability to succeed in a competitive environment. I believe once you start your graduate program the focus needs to be on learning rather than promoting competition between students.

The most important principle, and the part that I think applies to this class, is that it’s the educator’s role to facilitate student learning, and this is based on how they teach, not grade. Professors can balance the positive and negative aspects of both grading systems, but this requires understanding the effects of both systems. It’s up to the professor to maximize the benefits of both and leave the students with the best education possible.

References:

1. Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The Benefits of Pass-Fail Grading on Stress, Mood, and Group Cohesion in MedicalStudents. Mayo Clin Proc. 2006; 81(11); 1443-48.

2. Michaelides M, Kirshner B. Graduate Student Attitudes toward Grading Systems. College Quarterly. 2005; 8(4).

3. Miller BM, Kalet A, Van Woerkom RC, Zorko N, Halsey J. Can a Pass/Fail Grading System Adequately Reflect Student Progress? Virtual Mentor 2009; 11(11): 842-51.

Can Empathy in Patient Care Be Taught?

2011-11-30T21:58:00.003-05:00

By Niki S. Mehdizadegan, Pharm.D., PGY1 Pharmacy Resident, Union Memorial Hospital

I entered a patient’s room in the Anticoagulation Clinic. A middle-aged lady wearing a colorful scarf was sitting quietly in her wheelchair. “Hello Miss. M! How are you doing today?” I said with a smile. She remained quiet and barely raised her head. In the three seconds between saying hello to her and pulling the chair to sit in front of her I thought to myself: “Oh, she is so friendly! (sarcasm). Let’s see how this goes.”

We often form our opinion of individuals in the first few minutes of meeting them. Malcolm Gladwell, the author of the book Blink defines our ability to make a decision or form an opinion within a limited period of time of facing a situation as “thin-slicing.”¹ He explains that although in most instances having a limited amount of information can be sufficient in decision making, sometimes our unconscious prejudice and stereotypes can bias that decision.

In a society with significant cultural and socioeconomic differences, it is inevitable that as healthcare professionals we will interact with a diverse group of patients whose behavior, expectations, and lifestyles are vastly different from ours. The question is: can we teach health care professionals to be empathetic towards patients in spite of these differences? Empathy has been defined as the “ability to behave in a caring manner toward a patient while demonstrating to the patient that his feelings are understood.”²

In one study that was a joint collaboration between two schools of pharmacy, the authors employed Patient Empathy Modeling (PEM) pedagogy to teach pharmacy students empathy towards underserved patients.³ The students were enrolled at two schools of pharmacy located at a rural and an urban site in the United States (Purdue University School of Pharmacy and University of Connecticut School of Pharmacy). Students were given a patient scenario simulating the life of a patient with multiple chronic illnesses who was coping with a socioeconomic, cultural, or communication barrier. The student then had to live the life of that patient for ten days. For example, one student role-played “Jamie Illiterate” - a patient who had multiple chronic illnesses, had financial problems, and had a learning disability that prevented her from learning how to read. The student was given prescription vials labeled in unintelligible texts. Assignments during the 10 days included: (1) having a one-time counseling session with a pharmacist (role-played by another pharmacy student) which simulated the challenges a patient might encounter, (2) setting up pillboxes or other reminder systems to take medications (vials containing placebos were provided), (3) observing the surroundings and attempting to read signs and other everyday objects for half an hour each day and recording feelings in a journal, (4) preparing a list of resources for illiterate patients in the area where the student lived, and (5) developing a medication brochure for illiterate patients.

The effectiveness of this pedagogical approach was quantitatively and qualitatively assessed using the Jefferson Scale of Physician Empathy for Health Care Professionals (JSPE). In addition, the authors assessed student journal entries as well as a final reflection paper. JSPE is a validated tool which analyzes 3 factors related to empathy: perspective taking, compassionate care, and the ability to stand in a patient’s shoes. The scores of the students participating in patient scenarios improved after completing the assigned activities. Three major themes were identified from student’s journal entries and reflective papers: (1) greater appreciation for the difficulty in medication adherence, (2) increased empathy for patients from different backgrounds, and (3) improved ability to apply the lessons learned to real patient scenarios during their advanced experiential rotations.

My first impression of the lady that I saw that day in the anticoagulation clinic was perhaps not the most positive. However, during that office visit I discovered that she was diagnosed with acute deep vein thrombosis (DVT) that day and that she had been scheduled to have knee replacement surgery. Due to the DVT diagnosis, her surgery would now be postponed. This meant that she would suffer from continued pain from severe arthritis. She also needed treatment for her DVT. This would require an injectable medication for a few days followed by an anticoagulant that required frequent blood tests and monitoring for the next few months. That day I tried my best to be empathetic towards her. I told her that I realized how painful her arthritis can be (perspective taking) and that my mother suffers from arthritis too (the ability to stand in a patient’s shoes). I told her that I was more worried about her going into surgery with a new clot in her leg than postponing the surgery. It was important that she receive the best possible treatment so that she can recover and be the healthiest she can possibly be prior to her surgery (compassionate care). She smiled and nodded her head and said that she understood.

As the study I have cited demonstrates, pharmacy students can be taught to be empathetic by engaging in role-play and facing difficulties from a patient’s perspective. Schools of pharmacy across the country have designed various activities to teach empathy in their curriculum. Empathy does not require a genetic predisposition, but rather facing situations similar to those faced by our patients. It is through these experiences that we can learn to relate to the similarities that bind us together rather than the differences that divide us.

References:

1. Gladwell, M. Blink. New York : Little, Brown and Co., 2005

2. Lonie JM, Alemam R, Dhing C, Mihm D. Assessing pharmacy student self-reported empathic tendencies. Am J Pharm Educ. 2005; 69:Article 29.

3. Chen JT, LaLopa Jb, Dang DK. Impact of Patient Empathy Modeling on Pharmacy Students Caring for the Underserved. Am J Pharm Educ. 2008; 72: Article 40.

Teaching Across Generations

2011-11-27T21:28:00.000-05:00

by Joshua Fleming, Pharm.D., PGY-2 Ambulatory Care Pharmacy Resident, The Johns Hopkins Hospital

“There are three things to remember when you are teaching: know your stuff, know who you are stuffing, and then stuff them elegantly.” – Lola May

When you take a look at many pharmacy schools, you’ll notice students from different generations present within each class. We are likely to see the middle-aged adult who has decided to go back to school. This middle-aged adult has made pharmacy their second career. And they are likely to be sitting next to a 20-something student. This younger student has gone straight from high school, to college, and now pharmacy school. This presents a challenge to us as we face a student body from multiple generations. Their expectations in terms of preferred learning methods and teaching styles are often different.

The generations we are most likely to encounter in our teaching careers include Generation X and Millennials. Each of these generations differs slightly in their preferences and overall attitudes toward assignments. In order to understand some of the differences between each generation, it is important to take a step back and review the events that shaped each generation.

Generation X (1964-1979)¹: People from this generation are the product of the work-driven Boomer generation. They experienced single parent homes, the advent of MTV, the Challenger explosion, and were the first generation of latch-key children. This is the first generation to use computers in their homes and to experience the Internet. Gen Xer’s are driven by money, crave balance in their lives, are self-reliant, and value free time.

Millennial (1980-2001)^1,2: This generation is also known as the “Nexters” or Generation Y. This generation encompasses the majority of the pharmacy students today. The events that shaped this generation include the Columbine shootings, Oklahoma City bombing, and September 11^th tragedy. This generation has grown up with technology and expects it in every aspect of their daily lives. Millennials are self-reliant, mobile, addicted to media, brand-conscious, and family-oriented in times of crisis.

A study that examined the attitudes of Generation X students in pharmacy school found that these students have a higher preference for professors that are friendly and warm.³ They also believe that grades should be based on knowledge and performance of a subject, and believe that the average grade for a course should be a B. In a follow up study, researchers found that Generation X students were: technologically literate, independent problem solvers, and more likely to believe that learning should be fun, crave stimulation, personal contact, follow rules after explaining significance. Moreover, they were more likely to desire learning relevant to work, experiential leaning, feedback, evaluation, and expect immediate answers.⁴ The authors then designed a course that would meet many of these desires. During the course the used games, engaged the students in small group and individual activities, provided an online site to support the course, learned students’ names, communicated via email, and provided ways for students to obtain instant feedback. They then evaluated their performance in the “re-designed” course and compared the results to a traditionally designed course. They found that when the course met as many of these expressed desires as feasible, the students performed better and student feedback was more favorable.

A meta-analysis published in 2009 focused on the challenges of Millennial students in the classroom.⁵ Millennial students have a slightly differing attitude towards learning and formal education. These students have high expectations and have a tendency to be over-confident. They have been told to “shoot for the stars” by their parents and may come to class with a sense of entitlement. Millenials have a strong desire for connection and will generally “multi-task” through assignments and during lectures. Strategies used to reach this generation in the classroom include adding more hands-on learning activities, delivering lectures in short chunks, and using technology such as YouTube.

In a study by Borges and colleagues, a 16 personality factor assessment was given to 809 medical students at a single institution.⁶ The students’ responses were compared based on their generational cohort. Millennial students scored higher in areas of rule consciousness, social boldness, and perfectionism. Generation X students scored higher in self-reliance. An additional study by Borges and colleges focused on the differences in motives of Generation X and Millennial medical students.⁷ In this study they found that Generation X seemed be driven more by power. Millennial students were driven more by achievement and affiliation.

So, how can we best approach different generations of students and achieve our desired educational outcome? Unfortunately, there is little literature about how best to meet the needs of a generally diverse classroom, but its seems wise to make sure that rules (e.g. course policies) are clearly defined and learning objectives are measureable. Both Generation X and Millennials are comfortable with technology and expect to use it in the classroom. On demand podcast lectures (and vid-casts) have been used at some universities followed by classroom case discussions. This would meet the desire for technology and independent learning as well as giving the student an opportunity for social learning in the classroom. Both of these generations have a strong desire to succeed. As future educators its going to be challenging to provide the best education to students that have demanding expectations, but if you “know who you are stuffing”, it makes the task much easier.

References

1. King D. Defining a Generation: Tips for Uniting Our Multi-GenerationalWorkforce. Career Planning and Management, Inc. Accessed 20 November 2011.

2. Oblinger D. Boomers, Gen-Xers, and Millennials: understanding the new student. EDUCAUSEReview. 2003;July/August:37-47.

3. Romanelli F, and Ryan M. A Survey and Reviewof Attitudes and Beliefs of Generation X Pharmacy Students. Am J Pharm Educ. 2003;67(1):72-79.

4. Ryan M, Romanelli F, Smith, K, and Johnson MMS. Indentifying and Teaching Generation X Pharmacy Students. Am J Pharm Educ. 2003;67(2):1-6.

5. Twenge JM. Generational Changes and theirImpact in the Classroom: TeachingGeneration Me. Med Educ. 2009;43:398-405.

6. Borges NJ, Manuel S, Elam CL, and Jones BJ. Comparing Millennial and Generation XMedical Students at One Medical School. Acad Med. 2006;81:571-576.

7. Borges NJ, Manuel S, Elam CL, and Jones BJ. Differences in Motives between Millennial and Generation X Medical Students. Med Educ. 2010;44:570-576.

To Record or Not To Record

2011-11-20T17:16:00.003-05:00

By David E. Zimmerman, Pharm.D., PGY1 Pharmacy Resident, The Johns Hopkins Hospital

The video recording of lectures was implemented during my P3 year at the Philadelphia College of Pharmacy. At first I did not see a need for the technology because I was one of the students who always went to class. But I felt that it might benefit some students to see and hear the lecture for a second time. It did not occur to me that students might routinely skip class and simply watch the recorded lecture online. This soon became the norm … and my class of approximately 220 dwindled to only 50-100 student during most lectures.

A recent article published in the American Journal of Pharmaceutical Education, the authors discussed the pros and cons of recording lectures.¹ Some of the proposed benefits include repeated exposure to lecture material, the capability of reaching students at satellite campuses, and re-purposing the videos for other uses. I believe the first point can be a significant benefit. Recording lectures is perfect for students who may need repeated exposure to the material or who missed a key concept. Moreover, there will always be times when a student cannot attend a lecture due to illness or an unexpected event.

The main disadvantage to using this technology is decreased student attendance. Would students come to class if they had the opportunity to watch lectures within the comfort of their own apartment or dorm room? Many students won’t. I saw this first hand at my college … but this need not happen. To “encourage” attendance, instructors started using an audience response system, a polling technology that collects and displays aggregate responses. The technology is often used to assess the audiences’ understanding of the material or to generate discussion. The instructors also used the technology to record attendance and the data was used to determine the participation component of each student’s course grade. This worked fairly well (in terms of improving attendance) but it required all students to purchase a clicker device and register it with the course. A downside to this method was the occasional technological malfunction that can occur. In addition, there is the potential problem of a student’s clicker being lost or stolen. This would require the student to purchase another clicker and re-register it with the course. Another option would be to take attendance manually (the old fashioned way) but this may not work for large classes as it would take away from valuable class time. A third option is to stop the video recording before class ends and then discuss material that would be appear on an exam.

A study was conducted by Bollmeier and colleagues at the St. Louis College of Pharmacy evaluated the performance of pharmacy students (P2) after they had been given access to recorded lectures in a therapeutics course.² The recorded lectures were available online for a period of 72 hours after the lecture. Attendance at each of the lectures, student scores on the final exam, overall course grades, the number of times students accessed the recorded videos, and the length of time that the videos were viewed were recorded. Although students performed better on the final exam when compared to historical norms, there was no correlation between a student's final course grade and the number of lectures he/she accessed online. In addition, there was no correlation between class attendance and the number of minutes that videos were viewed online. The authors also noted that the use of the online lectures was far less than expected. Overall, the study showed that video recording did not have a negative impact on lecture attendance.

In the end, it is about students learning and not about showing up to class. We can all agree that students learn differently and for some, watching a recorded lecture may be the best method. The best way to determine if class attendance impacts learning is to measure grade performance (short term) and by examining the NAPLEX/MPJE pass rates. Unfortunately, assessing the impact on NAPLEX/MPJE pass rates would take several years and can be confounded if there are significant changes in the curriculum.

The decision of whether or not to record lectures should be addressed at each academic institution. The course instructors should determine if there are particular class sessions where attendance would be of particular benefit to students. Examples might include guest speakers or the use of active learning techniques that require in-class participation. The course instructors and the pharmacy administration should also evaluate the cost, available IT support, and predicted use of the recordings.

References:

1. Romanelli F, Cain J, and Smith KM. To record or not to record? Am J Pharm Educ 2011; 75(8): Article 149.

2. Bollmeier SG, Wenger PJ, and Forinash AB. Impact of online lecture-captureon student outcomes in a therapeutic course. Am J Pharm Educ. 2010; 74(7): Article 127.

Mentoring: Give Back and You’ll Get More

2011-11-20T16:30:00.000-05:00

By Jasmine Shah, Pharm.D., PGY1 Pharmacy Resident, Suburban Hospital

In middle school I joined a community tennis program which met every weekend year-round. For the first few years, my only focus was to improve my tennis skills and endurance … until one day my coach asked me to become a mentor for the new students that had just joined the program. I agreed, not really knowing what my responsibilities would be. I thought it would be fun! Little did I know I would be tutoring, counseling, assigning “homework,” and (of course) teaching tennis! I was starting to feel like I was becoming a role model for these students, especially when they would come to me seeking advice from anything related to tennis, school, friends, family, and more.

Mentoring can be simple or complex, depending on the situation and commitment from both the mentor and the mentee. Research from the University of Glasgow describes mentoring as “a supportive relationship; a helping process; a teaching-learning process; a reflective process; and a career development process.”¹ Clearly, this definition exhibits complexity, but that’s the beauty of mentoring. Mentoring can be basic counseling to career development and spans across many fields from the educational setting to work.

There are different types of mentoring including: classic mentoring (one-to-one), individual-team mentoring, friend-to-friend mentoring, peer-group mentoring, and long-term relationship mentoring.¹ After reading about these definitions, our tennis mentoring program exhibited the qualities of all these types of mentoring. Mentoring is all about making a difference in someone else’s life, and the research from University of Glasgow states that “the more experienced shall care for and train the less experienced, in a non-judgmental manner.”¹ I can honestly say that after I became a mentor, I learned more about myself and how to be a better role model.

Research published in Advances in Health Sciences Education² explored mentoring in health care educational programs. The researchers specifically focused on the professional development of medical students. The authors of this study wanted to explore one-to-one mentoring of medical students and examined its influence on theoretical knowledge and clinical competencies. This was a voluntary program with 122 medical students. Mentors were able to meet with their mentees 1-3 times per semester. The authors concluded that students enrolled in the program had a positive experience and the mentors were able to facilitate their professional development. Students felt a sense of security because they had a mentor to talk to and gain support when needed. Personal issues were also addressed. Lastly, the authors commented that the students enrolled in the program exhibited increased professional competence by “handling relationships, interacting with colleagues, patients and others in a good way and gaining insight into social codes associated with the profession.”²

Mentoring programs in grammar and high school can change a student’s life. The Department of Education designed a mentoring program to expand and improve mentoring for children with special needs. There are several examples of how these programs help students all over the nation. For example, students interested in medicine are able to shadow a plastic surgeon in San Diego. In another program, students are able to enroll in SAT mentoring programs to improve their scores. If one is fortunate to have a supportive mentor, education and professional development can positively be influenced. You never know when your advice and leadership can lead to someone else’s success.³

How does one become a mentor? I hate to break it to you, but you do not become a mentor overnight. A good mentor must first believe in themselves and believe that they can make a difference. The best mentor is someone who has been in situations similar to those faced by the mentee and can relate to their situation. A mentor must have a plan regarding how they will help their mentee and how they will help them acquire new knowledge, skills, and attitudes. I would recommend reading teaching and mentoring books in order to gain insight on how to be a great mentor. Most importantly, a mentor must consistently be in contact with their mentee in order to establish a lasting relationship. Phone calls or regular face-to-face discussions are a must.

Some experts say that mentoring is not well-defined and is poorly-researched. This may be true, but I strongly feel that mentoring has as much to offer.¹ After being part of the tennis program for nearly 7 years, I started a tennis program with two of my colleagues. We are still in touch with every one of our students that we mentored. The best part is that these students have now become mentors to a group of newer students. It’s a rewarding to see new mentors for a new generation!

References:

1. Hall JC. Mentoring and Young People: ALiterature Review. Research Report 114 (2003). Web. Date Accessed: 5 Nov 2011.

2. Kalén S, Ponzer S, Silén C. The core ofmentorship: medical students'experiences of one-to-one mentoring in a clinicalenvironment. Adv Health Sci Educ Theory Pract. 2011 Jul 27.

3. About the U.S Department of EducationMentoring Program. U.S Department of Education. Web. Date Accessed: 6 Nov 2011.

Problem-Based Learning in Pharmacy Education: Effective or Problematic?

2011-11-20T15:54:00.001-05:00

by Kelly Parsons, Pharm.D., PGY1 Pharmacy Resident, Union Memorial Hospital

Problem-based learning (PBL) is a teaching strategy used among many pharmacy and medical schools that strives to teach students using realistic scenarios. The purpose behind this educational approach is to increase retention of learning by having students think independently and problem solve. There are two key features of PBL. The first feature is student-centeredness. Learning takes place in small groups and is facilitated by instructors. The second feature is problem solving. The goal is to have students solve specific problems and thereby enhancing the skills necessary to perform well throughout the curriculum (and in life). When PBL is successfully implemented, the presentation of clinical material serves “as the stimulus for learning” and this “enables students to understand the relevance of underlying scientific knowledge and principles in clinical practice.”¹

Many research studies have analyzed PBL and compared this teaching strategy to more traditional approaches such as a series of didactic lecture. Leslie Nii and Alfred Chin compared PBL to lecture-based instruction by randomly assigning students to these two forms of instruction during their third year of pharmacy school and assessing the mean grade point averages (GPA) of each group.² The goal of the course was to help students acquire the skills necessary to manage patients’ drug therapy. Faculty members served as resources for students during PBL class sessions and facilitated meaningful discussions, with emphasis on skills necessary for pharmaceutical care. Students assigned to the traditional didactic lecture group were taught via presentation-style lectures. At baseline the GPA of two groups was not statistically different during the first two years of school when all students received traditional didactic lectures. However, there was a significant difference in GPA during the third year of school when PBL was implemented. Students who received PBL instruction had significantly higher GPAs during fourth year rotations than students received traditional didactic instruction. This suggests that PBL gives students a set of skills that enable them to more quickly become competent and self-sufficient, and may be more effective than traditional lectures.²

Robert Cisneros and his colleagues completed a systematic review of PBL in pharmacy education based on research articles published between 1980 and 2000.³ In their review, several examples of PBL were described including the use of PBL in an introductory pharmaceutical care course, a therapeutics course, as well as throughout the second and third years of a pharmacy curriculum. Most examples in the systematic review incorporated PBL after students had completed introductory science courses where they received didactic instruction. In only one case, where PBL was used in an introductory pharmaceutical care course, that students were introduced to PBL early in the pharmacy curriculum prior to receiving other forms of instruction. The results of these studies indicated that PBL was an effective method of instruction and could be successfully implemented during any year of pharmacy education.³ Given these positive findings, it is not surprising that PBL continues to be implemented in many pharmacy school curriculums today. Pharmacy education programs have placed more emphasis on patient care and PBL is well suitable to teaching students the skills needed in practice.

When considering Grasha’s Five Teaching Styles, PBL is best matched with the facilitator teaching style.⁴ Instructors guide students through the learning process while encouraging independent thinking and responsibility. Students are perhaps more engaged because “real life” scenarios are presented. Students are expected to consider the “whole patient” as opposed to one specific issue.

As a recent pharmacy school graduate, I have experienced PBL first-hand during a therapeutics course. My experience was similar to the one described by Calvin Meaney in the “Creating a Critical Learning Environment” blog.⁵ Students were divided into groups of ten and each group was given several patient case scenarios to research, identify pertinent medical problems, and develop a therapeutic strategy. This approach fostered critical thinking and was an effective teaching method when group members reviewed material prior to attending the group sessions and actively participated during scheduled class times. However, in my experience, attendance was poor at many sessions and many students worked independently on the case studies. Thus, the opportunity to capitalize on the strengths of PBL were often lost. Many students elected to forego attending PBL sessions when exams were scheduled in close proximity. Students wanted to use the time to study. In order to overcome this problem, it’s important to schedule PBL sessions at least two or three days apart from exams to encourage student attendance. As an alternative, teachers could make attendance a requirement. In general, I found that pharmacy students appreciated the PBL sessions and benefited from the learning experience when they were focused on the material.

PBL is an instructional method that can, should, and does play a significant role in pharmacy education. It fosters strong critical thinking skills. Although initial findings seem to have positive, there is need for more research to evaluate the effectiveness of PBL in pharmacy education. Challenges will arise as PBL is more frequently used, but these can be overcome as educators become more experienced in this teaching strategy.

References:

1. Novak S, Shah S, Wilson J, Lawson K, Salzman R. Pharmacy students’ learning styles before and after a problem-basedlearning experience. Am J Pharm Educ 2006; 70: 1-8.

2. Nii L, Chin A. Comparative trial ofproblem-based learning versus didactic lectures on clerkship performance. Am J Pharm Educ 1996: 60: 162-164.

3. Cisneros R, Salisbury-Glennon J, Anderson-Harper H. Status of problem-based learning research in pharmacy education: a call for future research. Am J Pharm Educ 2002; 66: 19-26.

4. TeachingStyles and Instructional Uses of the World Wide Web [Internet]. Terre Haute (IN): Indiana State University; 2011.

5. Meaney C. Creating a critical learning environment [Internet]. Educational Theory and Practice Blog. Baltimore (MD): University of Maryland; 2011.

Teaching of Communication Skills to Pharmacy Students

2011-11-09T13:51:00.000-05:00

By Eamonn J. Murphy, Pharm.D., PGY1 Pharmacy Practice Resident, Georgetown University Hospital

A key concept that I learned during pharmacy school is the importance of communication. Several classes in the pharmacy curriculum put a strong emphasis on communication. There were therapeutics labs that incorporated one-on-one counseling of mock patients on medication adherence, side effects, and techniques for using inhalers and medical devices. However, working with various students and teachers in lab is quite different than practicing as a pharmacist. This practice was a great stepping stone, but it is vital that students get structured counseling and feedback while interacting with actual patients.

I recently read an article, Improving communication skills of pharmacy students through effective precepting, by McDonough and colleagues.¹This article emphasizes the importance of students developing and practicing their communication skills during their advance pharmacy practice experiences (APPEs), especially their community-based rotation. This article brings up an interesting concept, “see one, do one, teach one”. A pharmacy student is going to shadow a preceptor and follow their example. Every interaction a pharmacist has on a daily basis goes back to the principles of communication, and the student will be influenced by these observations. Whether talking to a patient, a physician, a nurse, or another pharmacist, these skills will used every day.¹

To help develop and teach professional communication during the APPE, it would be beneficial to students to have the preceptor introduce all staff members and their respective roles (or position) in the pharmacy. This would be the first step in creating professional relationships in which the student would feel comfortable relaying information and asking questions to staff.¹

Now that I am in the fifth month of my pharmacy residency, I have had precepting experiences and I will be responsible for co-precepting P4 pharmacy students in the future. I have been thinking about some lessons that a preceptor should teach to a student. Even though this article by McDonough focuses on community pharmacy, several of the lessons are equally applicable in hospital pharmacy and precepting in that setting. A pharmacist in an institutional setting should perform medication reconciliations every day and go into patient rooms to discuss new medications that have been prescribed. One style of teaching is through direct observation of a preceptor conducting medication reconciliations and discharge counseling. While conducting medication reconciliations and discharge counseling on new medications, it would be appropriate to use the Indian Health Service questions. A pharmacy preceptor should make sure to teach these questions to their APPE student. Before the student first observes the preceptor patient counseling, time should be spent discussing and rehearsing the Indian Health Service questions with the student. These questions focus on the patients understanding of what medications they are taking, why they are taking them, and what they can expect.

Indian Health Service questions:¹

Prime Questions to ask patients who are receiving a new prescription:

What did your doctor tell you the medication is for?
How did the doctor tell you to take it?
What did the doctor tell you to expect?

Final verification or asking the patient for feedback

Just to make sure that I didn't leave anything out, please tell me how you are going to take your medication.

Strategy when a patient is receiving a refill

What do you take the medication for?
How do you take it?
What kind of problem are you having?

As a preceptor, you could demonstrate the use of these questions in front of a student, and then have them counsel patients once they are ready. Through discussion, memorization, practice, and then observation, an APPE student can become comfortable using these Indian Health Service Questions. Other important aspects of communication that could be focused on and discussed with P4 students while precepting is using open ended questions, good eye contact, and active listening. The responses to these open ended questions will help show what the patient truly understands about their medication and help direct a student or pharmacist toward what should be addressed.²This is especially important because, as Kripalani and colleagues state, only 12% of adults in the United States are proficient health literacy.³

Additionally, in an institutional or hospital setting it is important at the beginning of the APPE to discuss appropriate interactions with physicians. As a pharmacist, there may be several medication-related interventions that need to be communicated directly to the prescribing physician. A preceptor should spend adequate time discussing how the APPE student should interact with a physician. One method to teaching this type of communication is for the students to write up a series of hypothetical scripts they would use during telephone calls or face-to-face interactions. Hasan⁴ describes this method of teaching where the pharmacy students writes three scripts for telephone interaction with physicians. The script types including: passive, aggressive, and assertive. The purpose of this is for the student to think critically and to explore the various types of communication skills and determine which would be most effective. Once the student writes these, a preceptor can discuss the pros and cons of each of these styles. Having a student listen to several phone calls and interactions with physicians would also be appropriate. McDonough includes a brief list of things that should be discussed with a student.

How to Communicate Information to Physicians:¹

Keep patient focused
Provide the physician with meaningful background information
Clearly and concisely outline the problem the patient is experiencing with the drug therapy
Propose a solution
If face-to-face, request physician feedback regarding the solution

In order to be a pharmacist today, effective communication with patients and all members of the interprofessional team is vital. Preceptors play an important role by helping APPE students acquire the knowledge and skills needed to be effective communicators.

References:

1. McDonough RP, Bennet MS, et al. Community pharmacy improving communication skills of pharmacy students through effective precepting. Am J of Pharm Educ. 2006; 70 (3) Article 58. 1-12.

2. American Society of Health-System Pharmacists. ASHP guidelines on pharmacist-conducted patient education and counseling. Am J Health-Syst Pharm. 1997; 54:431–4.

3. Kripalani S, Jacobson KL, et al. Strategies to improve communication between pharmacy staff and patients: a training program for pharmacy staff. AHRQ Publication No. 07(08)-0051-1-EF. 2007

4. Hasan S, et al. A tool to teaching communication skills to pharmacy students. Am J Pharm Educ. 2008; 15; 72(3): 67.

Students Teaching Themselves: The Unschooling Movement

2011-11-08T14:27:00.002-05:00

By David Ngo, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

In our traditional schooling culture, there is a belief that children must be taught how to read, and most learn how to do so at a certain pace. In addition, the children who do not stay at the school curriculum’s pace are often looked down upon, while those who read at a higher grade level are applauded.¹ However, Peter Gray, a psychology research professor at Boston College, discusses the “unschooling” movement and the Sudbury “non-school” movement.² He claims that children can teach themselves how to read and will enjoy the process, rather than resent it like those who struggle with the conventional schooling system. The Sudbury “non-school” movement focuses on allowing the students to learn at their own pace, with no set syllabus or curriculum, among peers of various ages. Moreover, Gray summarizes the following principles:²

1) For non-schooled children there is no critical period/best age for learning to read

2) Motivated children can go from apparent non-reading to fluent reading very quickly.

3) Attempts to push reading can backfire.

4) Children learn to read when reading becomes a means to some valued end or ends.

5) Reading, like many other skills, is learned socially through shared participation.

6) Some children become interested in writing before reading, and they learn to read as they learn to write.

7) There is no predictable course through which children learn to read.

Gray brings up several salient points.² For example, his seventh principle discusses how each student is different; therefore, the method and time required to learn how to read will be different. This not only applies to children, but to learners of all ages. Everyone has a unique approach to learning. This is related to learning styles including Visual, Auditory, Reading, and Kinesthetic. Learners may dominantly learn best in a certain way or a combination of these styles. VARK and the “unschooling” movement are related because it shows that not only does everyone learn at their own pace, but also that they will learn best in their own specific way. A child may learn best visually, by associating the word with the visual image of the object; or a child may learn by hearing the word aloud and associating that with the word; or a combination of both. Through the “unschooling” method, the child will approach the parents/teachers and will learn how to read in the manner that suits them best. Therefore, the “unschooling” or Sudbury movements have implications for learning because it allow students to learn in their own way rather than following a set curriculum that forces each student to learn in one specific way.

Moreover, pushing the conventional reading method upon a child may breed resentment and disdain throughout a lifetime, doing more harm than good. Children will learn more easily and find it more enjoyable once they find their own motivation to read. Young learners may develop the desire to read because they want to know what a video game says, to write a story, or to emulate family and friends. This is related to the educational theory known as cognitivism. Cognitivism is interested in understanding how the brain functions, how learners think, and the influences of mood, feelings, motivations, and past experiences on learning. In Sudbury schools, children learn with other students of various ages. Gray talks about how the younger children wanted to learn to read to be like their older peers. Once a child is motivated to read, he or she can learn the skill quickly and fluently. Although unconventional, the “unschooling” movement provides some interesting insights about how best to educate young students, and these are strategies that traditional schools and teachers should incorporate.

If children are able to teach themselves to read, adult learners can successfully teach themselves as well. Self-directed learning is becoming more important particularly as online schools and degree programs are becoming more established. And more adults are going back to school. As a Shady Grove student at the University of Maryland School of Pharmacy, I was skeptical about how I could earn a Pharm.D. primarily through distance education and web-based strategies. I’ve seen through personal experience that “unschooling” can apply to pharmacy students. Personal motivation plays a major role in how well students learn in a self-directed, online learning format. Shady Grove students are able to watch lectures whenever they want — not restricted by set class times. I have seen that this works well for some and poorly for others. It works well for students that are motivated and set their own learning schedule. I found this freedom to be great, as I learn better in the afternoon and night. So I schedule myself to watch my lectures during the afternoon. Other adult learners with families also find this method to be great because they can take care of their family and set aside time to learn. However, some students have difficult with this level of freedom and do not do any work until an exam looms. Under extreme pressure, they have marathon lecture sessions, binging on as much materials as possible. This may be effective for short-term learning but this method does not work very well for long-term retention.

“Unschooling” applies to medical residents as well. A qualitative analysis regarding self-directed learning among medical residents found that they believe self-directed learning skills serve as the basis for a physician’s lifelong learning.⁴ Moreover, they found that most residents viewed self-directed learning as important to themselves and their patients. However, most medical residents felt that they lacked the skills to engage in self-directed learning and valued teacher-centered teaching approaches. Therefore, although self-directed learning has a lot of potential, motivation is important for it to be effective.

References

1. Anderson R. Junior Knows Best. Utne Reader. 29 Jun 2006 [cited 2011 Oct 17]

2. Gray R. Children Teach Themselves to Read. Psychology Today [Internet]. Freedom to Learn. 24 Feb 2010 [cited 2011 Oct 17]

3. Gray R. Nature’s Powerful Tutors; The Educative Functions of Free Play. Eye on Psi Chi. Psi Chi, The National Honor Society in Psychology. 12(1):18.

4. Nothangle M, Anandarajah G, Goldman RE, Reis S. Struggling to Be Self-Directed: Residents' Paradoxical Beliefs About Learning. Academic Medicine. 2011 Oct 25;Published Ahead of Print.

Teach Me How to Teach

2011-11-08T12:48:00.001-05:00

By Mallory Onisk, PGY1 Pharmacy Practice Resident, VA Maryalnd Health Care System

How many of you took a course in pharmacy school that taught you how to be a good teacher? I’m going to guess not many. I know at my college of pharmacy we weren’t given any teaching tools or tips aside from what we learned by modeling our professors. Nor were we trained on how to be a preceptor, give a lecture, engage a classroom, or evaluate students’ learning. I recently attended the ASHP Resident Visit Day where a poll was taken as to who was taught how to be a preceptor in pharmacy school. Not a single hand in the room (fifty residents) went up. At least I wasn’t alone. But how are recent graduates supposed to become the future leaders of the profession when we haven’t been given the tools to educate those following us? Unless you were fortunate enough to match to a residency program in a city that offers a teaching certificate program or a residency at a college of pharmacy, you might be on your own. But surely there has to be a better way…

The Southern Illinois University Edwardsville (SIUE) School of Pharmacy has developed “concentrations” or tracks for their students to focus learning on career interests. One track is an education concentration where students take 3 elective courses during the P3 year and an elective APPE in the P4 year with a teaching emphasis.¹ Drs. Poirier & Santanello describe this unique curricular concentration and evaluate its impact on students’ knowledge and attitudes in an article that recently appeared in the American Journal of Pharmaceutical Education.¹ The first course, Orientation to Teaching, explores learning theories and teaching philosophies. Students compose their own teaching philosophy and discuss with professors what they believe constitutes teaching excellence. The second course, Instructional Design and Strategies, highlights active learning strategies and different instructional methods. Students take turns facilitating class discussion using these different instructional methods. The third course, Assessment Strategies, familiarize students with various assessment strategies including learning portfolios, multiple-choice exams, and grading rubrics. During the APPE experience, students lead 2 small group discussions, give 2 lectures, maintain a teaching portfolio, and present an manuscript during an educational journal club.¹ An evaluation of this education concentration was done with knowledge tests and an attitudinal survey. The authors found that both attitudes and knowledge increased after completing the three elective courses.¹ Positive attitudes correlated with positive feelings about the subject matter and an increased likelihood of pursuing a career in academia.

This is not the first time I have heard about curricular tracks or pathways for students to follow their professional interests in pharmacy school. Giving students the opportunity to take multiple classes that focus on a particular career interest can be a great way to accelerate learning prior to graduation. The education concentration implemented at SIUE is a unique way to give interested students insight into the career of academia. Many students in school might think they want to teach but don’t actually know what being a faculty member entails. Giving a lecture may look easy enough, but what kind of time and preparation actually goes into creating the lecture? Prior to my experience with Educational Theory and Practice course I had very little understanding of educational theories. I’ve come to learn that active learning strategies and instructional designs are core concepts that aid in creating effective educational sessions. To students who may choose to pursue a career in academia, learning some of these fundamental models is beneficial and will help them become successful scholars.

But a career path towards academia still doesn’t meet the needs of students who will become future preceptors. What about the students who become clinical pharmacists working at hospitals or managers in community pharmacies? Surely many (if not most) at one point or another will become preceptors. A preceptor’s role is to create a positive environment where learning can be effective and efficient.² A pharmacy preceptor should convey “enthusiasm, professionalism, and knowledge.”³There are many factors that have increased the demand for quality pharmacy preceptors including the increased number of pharmacy schools and the increasing experiential requirements for ACPE accreditation.⁴Whether by interest or demand alone, chances are we will need most pharmacy students to become preceptors. Knowing these odds, shouldn’t we prepare students to be become dynamic preceptors?

There are more reasons to teach students how to teach. One of the most important roles of pharmacists is to serve as a patient educator. Being able to give effective, concise, and useful advice to patients is vital to aiding in their understanding of their disease process and the importance of their medications. Communicating information to patients requires that we assess audience characteristics through needs analysis, identify learning objectives, and employ effective teaching strategies. While we all might have been taught the basics of patient counseling in pharmacy school, my guess would be that most classes focused on what to say to patients (knowledge dumping) and less on how to do educate (assessing learning needs, selecting appropriate teaching strategies, and promoting self-directed learning).

I propose that students should have the opportunity in school to learn how to be successful preceptors and patient educators. This could be done through a classroom-based course, seminars, or other learning methods. Metacognitively students would benefit from understanding the role of a preceptor prior to advanced practice experiences. If students are taught how to teach, they could develop awareness and reflect during courses and APPEs on ways to improve as a learner and as a future teacher. Learning about who people learn and how to address learning barriers would make us better health professionals. With knowledge and experiences, students would be more prepared to precept students and educate patients. Incorporating such instruction into pharmacy school is important to strengthen the leaders and teachers of tomorrow.

References:

1. Poirier TI, Santanello C. Impact of a Pharmacy Education Concentration on Students’ Teaching and Attitudes. Am J Pharm Educ 2010; 74(2) Article 23: 1-8.
2. Kleffner JH. Becoming an effective preceptor [Internet]. Austin (TX): The University of Texas at Austin College of Pharmacy; 1998 [revised 2001, 2004, 2007, 2010; cited 2011 Oct 22]. Available from: Becoming an Effective Preceptor.
3. Skrabal MZ, Kahaleh AA, Nemire RE, et al. Preceptors’ perceptions on benefits of precepting student pharmacists to students, preceptors, and the profession. J Am Pharm Association 2006; 46(5): 605-612.
4. AACP: American Association of Colleges of Pharmacy [Internet]. Alexandria: American Association of Colleges of Pharmacy; c2011. Academic Pharmacy’s Vital Statistics 2011 July [cited 2011 Oct 20]. Available from: Academic Pharmacy's Vital Statistics.

Teaching Students with ADHD

2011-11-08T10:45:00.006-05:00

By Ava Azari, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

Often times, when I am sitting in a pharmacy school classroom listening to the professor’s lecture, I observe my classmates. I observe them as they check their email, browse through Facebook, or surf the web. I too am frequently guilty of not paying attention, particularly when the lecture is long and the power point slides are wordy. In the midst of my daydreaming, I often wonder what would make me more motivated and engaged in the class. Recently, I did some research about the specific learning needs that students with attention deficit hyperactivity disorder (ADHD) have and the most effective ways to engage these students.

Students with ADHD are at higher risk for having academic achievement problems and are less likely to complete post-secondary education.¹ Students with ADHD don’t lack intellectual ability when compared to their non-ADHD counterparts; however their hyperactivity, impulsivity, and/or inattention make concentration difficult and this negatively impacts their performance. Thus it is important for teachers to know about the specific learning needs of students with ADHD and how to more effectively engage ADHD students in the learning process.

ADHD students have diverse learning styles, similar to the rest of the population; however, it becomes vitally important to engage ADHD students because they often exhibit inattention, impulsivity, hyperactivity and lack of concentration to a greater extent. Frequently, students with ADHD are kinesthetic learners that need to engage in gross motor activity to learn most effectively.² Kinesthetic learners need to touch and feel things, try it themselves, and move their bodies in order to learn something new. These learners have realizations through doing, as opposed to having thought first before initiating action. Typically, these learners struggle to learn by simply reading or listening to a lecture. Some ways that teachers can engage kinesthetic learners is to encourage these students to take notes in the form of diagrams and models and require activities that require physically practice. A great example of incorporating kinesthetic friendly activities would be when teaching students CPR training. Kinesthetic learners learn best when they have practice dolls to practice their techniques.

Other learning styles associated with ADHD students are visual and auditory styles. Visual learners learn by seeing and responding to pictures, illustrations, written lessons, outlines, diagrams, charts, maps, and educational videos.³ Teachers can include a lot of these visual activities in their lesson plan which would make it easier for the ADHD students to learn. Auditory learners retain information best when they have an opportunity to hear it. These learners cue in to voice tone, speed, volume, inflection, as well as body language and learn best by hearing class lectures and participating and listening to class discussions. It may be helpful to allow these students to tape lectures so they can go back and listen to it again, as it would help them retain the material. It would also be a good idea for teachers to initiate class discussions frequently throughout a lecture to help the auditory learners.

Because college students with ADHD are at a higher risk of failing, it becomes especially important to identify factors that can predict their success.⁴ One study regarding learning styles and college students with ADHD found that using a positive explanatory style when teaching predicted better college grades. Optimistic people often possess positive explanatory styles and feel that positive events happened because of their own effort. They believe negative events will soon end and do not allow negative events to affect other aspects of their lives. Positive explanatory styles may aid learning in individuals with ADHD because their optimistic self talk during tasks guides them and helps them stay on track when a challenge arises.⁴ These students become more motivated and may think, “I can do this; this problem will be fixed if I keep trying.”⁴

In pharmacy school, there are numerous learning strategies that educators can utilize to help ADHD students. When introducing a new topic in class, educators can tell a story that relates to the subject matter. This would enhance imagination and visualization and allow them to draw their own connections to the subject. Using demonstrations in the classroom in the form of experiments and surveys would also be a great way for pharmacy educators to increase interest in a topic while promoting class participation. Frequently, pharmacy professors give lectures using PowerPoint presentations. It would be helpful if the instructor prepared slides that are concise by minimizing the number of words on each. In addition, professors can assign groups within the class and have groups give mini-presentations on important topics. Further, educators should continually offer extra assistance in order to reach the ADHD students.

Although it may be challenging to motivate students with ADHD; it makes it especially important for educators to employ strategies that keep these students engaged, motivated, and optimistic. ADHD students have diverse learning styles and it is beneficial to use a variety of teaching methods. It’s important to ask for feedback during the school semester. This would ensure that ADHD students have adequate opportunities to meet the course objectives and reaching out to them will help them succeed.

References:

1. Prevatt F, Reaser A, Proctor B, Petscher Y. The Learning/Study Strategies of College Students with ADHD. The Guilford Press. 2007.

2. Linksman, R. The Fine Line Between ADHD and Kinesthetic Learners. Association for Comprehensive NeuroTherapy. 2007; 1: 6.

3. Low, K. Understanding Your ADHD Child’s Learning Style. About.com. The New York Times Company. 2011 July 10.

4. Shmulsky S, Gobbo K. Explanatory Style and College Students with ADHD and LD. Journal of Attention Disorders. 2007; 10: 299.

Who’s Who: Getting to Know Your Students in Large Classes

2011-10-31T21:27:00.022-04:00

By Ashleigh Lowery, PharmD, PGY1 Pharmacy Resident, University of Maryland Medical Center

I walked into my undergraduate Organic Chemistry class ready to begin the semester. I had a new notebook, pencils, and the large expensive textbook. Our professor started by reviewing the syllabus, as expected, and then unexpectedly passed around a blank index card to each of the 120 students in the lecture hall. “I want you all to write your name, where you are from, your major, and something interesting about yourself. Telling me that you want to go to med school is not interesting. I want a real fun fact – like you were on Who Wants to be a Millionaire.”

I was impressed and surprised at the next lecture when he told us all about some of the people in our class. One had taught English in Thailand, one had just run his first marathon and one person, in fact, had been on Who Wants to be a Millionaire. I was even more impressed when I had an appointment for office hours later in the semester and the professor began by asking me about my hometown and interests. It was obvious he had pulled my index card. Over the semester, it was clear that this professor had developed great communication with our class and was able to form relationships despite the class size. He was not just teaching to anonymous faces in a crowd. I learned a lot that semester and was never hesitant to approach our professor when I had a question.

In large lectures, getting to know your students does not come as easily as it may in smaller teaching settings. However, it is just as important in order to create a positive learning environment for your students. It just may take some more creative approaches, or 120 index cards.

In an article in College Teaching, Jan Armstrong of the University of New Mexico describes a similar approach to getting to know her students.¹ The article is titled, “Write me a letter: challenging anonymity in large-enrollment classes.” Armstrong hands out sheets of lined paper and asks students to write an informal introduction letter, stating “Tell me a little bit about yourself and why you are taking this course. Tell me whatever you think I should know about you.” She then reviews all of the letters and spends a few minutes in subsequent class sessions introducing individual students to the class and incorporating noteworthy or humorous information.

The University of North Carolina Charlotte provides a “Survival Handbook for Teaching Large Classes,” which includes a section titled “How can I reduce the feeling of student anonymity.”² This provides an assortment of ideas, from taking Polaroid pictures of your students to greeting each student at the entrance of the classroom. Some of the other suggestions include:

- Ask students to wear nametags so that you can call on them by name

- Have students place name cards in front of them during exams so you can learn names while you wander the room

- Hand back tests individually to associate names with faces

- Arrive early to class and chat with students who are already there

- Stay after class to answer individual questions

- Invite groups of students to coffee to get acquainted

The University of Maryland Center for Teaching Excellence also provides a guide for teaching large classes.³ One of their interesting ideas is for professors to host an “open house” during the first class session when students have a change to meet and talk with the professor. They also emphasize the importance of having frequent and flexible office hours in order to meet and help more students.

Without a doubt, these efforts to get to know your students are worth it. A study at the University of Illinois at Chicago assessed the impact of student-faculty informal contact and college outcomes and found that significant positive associations exist between extent and quality of student-faculty informal contact and students’ education aspirations, their attitudes toward college, their academic achievement, intellectual and personal development, and their institutional persistence.⁴

Richard Tiberius of the University of Toronto described the importance of this relationship well by stating, “The relationship between teachers and learners can be viewed as a set of filters, interpretive screens, or expectations that determine the effectiveness of interaction between teacher and student…within [effective] relationships, learners are willing to disclose their lack of understanding rather than hide it from their teachers; learners are more attentive, ask more questions, are more actively engaged.”⁵

Regardless of your style, pharmacy education is bound to include some large lectures. We should all remember to make our best efforts to get to know our students, for both our benefit and theirs.

References:

1. Armstrong J. Write me a letter: Challenging anonymity in large-enrollment classes. College Teaching 2008; 56: 63.

2. Ives SM. A Survival Handbook for TeachingLarge Classes. University of North Carolina Charlotte Faculty Center for Teaching; 2000.

3. Large Classes: A Teaching Guide:Personalizing the Large Class. University of Maryland Center for Teaching Excellence; 2008.

4. Pascarella ET. Student-faculty informal contact and college outcomes. Review of Educational Research 1980;50:545-595.

5. Tiberius RG, Billson JM. The social context of teaching and learning. In Menges RJ, Svinicki MD, editors. College Teaching: From Theory to Practice. San Francisco: Jossey-Bass Publishers, Inc; 1991. p. 67-86.

The Benefits of Humor in the Classroom

2011-10-30T17:18:00.003-04:00

By Robert Eagen, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

They say that laughter is the best medicine and the effects of humor in medicine have long been studied. But what about the effects of humor on learning? This is the question that “Humor in Pedagogy: How Haha Can Lead to Aha!” by R.L Garner attempts to answer .¹ In the article, Garner, an associate dean at Sam Houston State University, details a study he performed looking at the effects of humor in asynchronous distance learning and discusses the merits and hazards of using comedy to teach. The study involved 114 students who watched a series of three forty minute recorded lectures on research methods and statistics.¹ Both the experimental group and the control group watched the same recorded lectures with one exception. Three humorous stories or metaphors included in each of the lectures in the experimental group were seamlessly edited out of the control group’s lectures. The subjects were asked to rate the presentations after watching each one and again after finishing all three. After finishing all three lectures, the subjects were assessed on their retention on the material presented.

The results of the study show that humor can be a powerful tool when used in the classroom.¹ The overall opinion of the lessons was significantly higher in the experimental group. Students indicated in the “humor” group that the information was communicated more effectively and gave the teacher higher ratings.¹ Further, the students in the experimental group were significantly more able to recall and retain the knowledge from the lectures.¹

Often times, our most memorable lectures (or professors) are those in which humor was used. Garner cites numerous studies that show the positive effects of using humor in the classroom. According to the article, humor is a powerful teaching tool that can create a positive “emotional and social environment” in which students can lower their defenses and focus more on what is being presented.¹ Garner also says that humor can “initiate and sustain student interest” as well as improve students’ divergent thinking and memory of the topic presented.¹

While there are many benefits, the use of humor when teaching a lesson can also have its down sides. After all, a teacher should teach not be a standup comedian! Humor is very personal and what is considered humorous varies from person to person. A comment that one person finds funny can completely fall flat with another, or even worse, be insulting. According to Lei, Cohen and Russler in their article “Humor on Learning in the College Classroom: Evaluating Benefits and Drawbacks From Instructors’ Perspectives”, humor that is offensive or degrading to students can have a negative impact on students’ learning.² Additionally they posit that too much humor can be detrimental as it can undermine the credibility of the instructor and result in a loss of focus of the instructional objectives.² Garner also warns that just because you are telling jokes does not mean you are teaching effectively. According to Garner, the humor needs to match 3 criteria to be effective. It must be specific to what you are teaching, targeted to enhance learning, and appropriate for the audience.¹

Humor is a powerful force. It can encourage an atmosphere of openness, develop students’ divergent thinking, improve their retention of the presented materials, and garner respect for the teacher. But like most things in life, it needs to be used in moderation. Too much humor can result in a loss of respect and inappropriate jokes or jokes at the students’ expense can create a hostile classroom environment. It is important to keep this in mind when teaching. Laughter isn’t just the best medicine, it’s a valuable teaching tool as well.

References

1. Garner LA. Humor in Pedagogy: How Haha Can Lead to Aha!. College Teaching. 2006. Accessed September 25, 2011.

2. Lei SA, Cohen JL, Russler KM. Humor on learning in the College Classroom: Evaluating Benefits and Drawbacks From Instructor’s Perspectives. Journal of Instructional Psychology. 2010. Accessed September 25, 2011.

Teaching Self-Directed Learning to Learners at All Stages of Development

2011-10-28T13:57:00.007-04:00

By Erin Rodems, Pharm.D., PGY1 Pharmacy Resident, Veterans’ Affairs Maryland Health Care System

Self-directed learning theory is based upon several fundamental concepts. First, all individuals have the capacity to engage in and develop self-directed learning skills. Second, learners can (and should) take greater control over the learning experience. Third, self-directed learning habits are transferable from one activity to another. Therefore, the teacher’s role is to assist the student develop self-directed learning skills by providing direction and support based on the needs of the student and the activity involved.¹

Grow’s staged self-directed learning model provides a method for teaching students to become self-directed learners. One of the fundamental principles of the model is that every student is different and not all students have the same capacity to self-direct their own learning. The ability to self-direct may vary greatly with different types of activities. For example, a student may be very skilled at self-directed learning in pharmaceutical calculations but may require a greater degree of direction in learning the pharmacotherapy of heart failure.

It is important to understand that self-directed learning is a skill that can be taught and Grow proposes the staged self-directed learning model in order to teach students to be more self-directed learners. According to the model, learners are classified into stages I to IV based on their readiness for independent learning. The teacher plays a different role at each stage of learning. Stage I learners are very dependent on the instructor to guide the learning process. The instructor serves more as a subject matter expert. Examples of stage I learning would be attending a biochemistry lecture or learning to counsel a patient by watching a teacher-to-teacher role play. At the other end of the spectrum, in stage IV, the students’ learning is largely self-directed and the teacher serves as a consultant. A few examples of stage IV learning would be 4^th year advanced pharmacy practice experiences (APPEs) and residency training.

In pharmacy education, all stages of self-directed learning are employed to some degree throughout the curriculum. Stage I learning is employed when formal lectures are given by a subject matter expert. The P1 year has the most stage I learning. Stages II and III are employed during the P1 through P3 years with the goal that by the P4 year students are on there way to be coming self-directed learners with a high level of independence who can make the transition to independent practitioners at graduation.²

By employing multiple stages of learning simultaneously throughout the pharmacy curriculum and gradually introducing more self-directed types of learning activities, students will start to make the transition to more independent learners. For example, in a study conducted at the University of Maryland School of Pharmacy that evaluated pharmacy students’ readiness for self-directed learning and the effect that APPEs had on students’ readiness for self-directed learning, it was found that the pharmacy curriculum prepared most students to have a high degree of self-directed learning prior to going on APPEs. 70% of students possessed a high degree of readiness for self-directed learning prior to APPEs and 81% after the completion of APPEs. This study is encouraging because it shows that the majority of graduating pharmacy students are prepared to assume the role of independent learner.³ Many aspects of the pharmacy profession require pharmacists to engage in self-directed learning. Responding to drug information questions and maintaining a current knowledge base as new therapies become available and as guidelines change are prime examples of when pharmacists would need to employ self-directed learning skills in their professional lives.

Given that learners at each stage have different needs, it is paramount that the instructor accurately assess the learning stage of their students and tailor the instructional methods to best facilitate student learning at each stage. At Stage I, teachers must gain the respect of the class by asserting him/herself as the subject matter expert. Students in stage I struggle when instructors have unclear expectations for assignments or exams, therefore, students at this stage require clear objectives, a comprehensive syllabus with assignments defined in explicit detail, and examinations that focus on course objectives in order to improve their success in the course.

Students at stage II are often highly motivated learners with a need to understand the relevance of the course material. A case study regarding a real patient with multiple medical problems would be an effective strategy to employ in stage II because it would allow students to apply their knowledge to a real-life scenario. Students will then be able to see the relevance of the learning activity and it would motivate them to want to learn more. Stage III learning should focus on teaching critical thinking and metacognitive skills to students who are ready to take responsibility for their own learning but need to learn the tools in order to do so. The teacher should serve primarily as a facilitator at this stage to help students develop metacognitive learning strategies. Students who are stage IV learners benefit most from a teacher who grants them autonomy. Teaching at this stage should focus on the teacher as a delegator who takes a more passive role in the students’ learning experience.²

For an instructor to teach their students not only to be self-directed learners, it is paramount for the teacher to identify where students are in the self-directed learning process and tailor their learning activities to accommodate the students’ varying capacities to self-learn. Instructors who are able to effectively assess their students and adjust their teaching styles to suit their students’ learning needs will not only win the respect of their students but they will be providing them with a lifelong skill. Teaching students self-directed learning habits will help them become independent learners.

References

1. Hiemstra R. Self-Directed Learning. Syracuse (NY): Syracuse University, Department of Instructional Technology and Adult Learning, 2004. Available from: http://www-distance.syr.edu/sdlhdbk.html.

2. Grow, G. Teaching Learners to be Self-Directed. Journal of Adult Education Quarterly Spring 1991; 41 :125-149.

3. Huynh D, Haines ST, Plaza CM et al. TheImpact of Advanced Pharmacy Practice Experiences on Students’ Readiness for Self-Directed Learning. Am J Pharm Educ 2009; 73 : Article 65.

Attitude on Aptitude

2011-10-28T12:48:00.004-04:00

by Yuze Yang, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

Most students have had to take several standardized tests throughout their academic careers. Some gauge students solely on their knowledge and expertise, while others assess students on their aptitude. Aptitude is defined as an innate ability, rather than an acquired knowledge, to perform certain tasks at a certain skill capacity. Standardized aptitude tests have been utilized in a variety of ways, from identifying children with learning difficulties as early as in elementary school, to conversely distinguishing gifted students with higher propensities for scholastic success. One of the most notable and notorious examples of an aptitude test, taken by millions of high school students each year to determine their readiness for college, is the Scholastic Aptitude Test (SAT). On the surface, the SAT evaluates students’ achievement in basic algebra, geometry, reading and writing. However, in deeper ways, the exam is also similar to an IQ test in measuring students’ abilities to interpret and analyze presented information and solve problems. Nevertheless, the validity and usefulness of employing aptitude tests to establish the paths in which students proceed in their academic careers still remains controversial.

Admission to most pharmacy schools in the U.S. follows similar requirement patterns as to undergraduate schools, including the use of a standardized aptitude test as one of the key components. Endorsed by the American Association of Colleges of Pharmacy, the Pharmacy College Admissions Test (PCAT) has been the preferred qualification verifier for admission to pharmacy schools since 1975. It tests students in both aptitude and achievement in seven areas: verbal ability, quantitative ability, biology, chemistry, reading comprehension, and two writing sections. The objective of the exam is to determine if they are suitable for a future in pharmacy by assessing not only the depth of background knowledge candidates have acquired, but also their capacities to learn and process new information. The PCAT score is the most frequently used standardized test used as a selection criteria among colleges of pharmacy. Several studies have been conducted regarding the correlation of PCAT scores with academic success, most of which have shown them to be significant predictors of pharmacy students' first-year GPA.¹ Allen and colleagues examined several pre-pharmacy predictors of success in pharmacy schools and found PCAT scores to be one of the best predictors not only for the first professional year but also for success in practice-related courses and clerkships.² Despite these findings, some pharmacy schools have elected to NOT use the PCAT among their admission criteria and instead place more emphasis on prior academic achievements. One such example is the University of California San Francisco (UCSF), whose pharmacy program has been ranked #1 for several years according to US News and World Report.³ Numerous factors are used to determine whether or not a candidate is accepted to UCSF. Thus, opponents of standardized tests believe that such tests aren’t necessary to make good admission decisions and don’t enhance the successfulness of a school in terms of cultivating a student body or offering a excellent degree program. Furthermore, PCAT test scores have not been correlated with future job performance.⁴

Since pharmacy schools produce future medical professionals who will become responsible for the well-being of the public, they must use the highest standards for selecting top-quality students that can master the material. As more and more new schools of pharmacy open and accept growing pools of candidates to join the field, being able to discern who will excel in all aspects of pharmacy education, not simply test-taking and information acquisition, will be increasingly critical. Hence, the success of students’ careers, both academic and professional, will likely rely on gauging not only the aptitude for learning material and scoring well on tests, but also the degree of motivation, conscientiousness, and dedication to translating information to improved patient care. In other words, aptitude AND attitude are equally important.

References

1. Kuncel NR, Credé M, Woo SE. Ameta-analysis of the validity of the Pharmacy College Admission Test (PCAT) andgrade predictors of pharmacy student performance. Am J Pharm Educ. 2005; 69:3.

2. Allen DD, Bond CA. Pre-pharmacy indicators of success in pharmacy school: grade point averages, pharmacy college admissiontest, communication abilities, and critical thinking skills. Pharmacotherapy. 2001;21:842-849.

3. US news and world report pharmacy school rankings (2008). Retrieved October 23, 2011 from

4. Munson JW Bourne DW. Pharmacy College Admission Test (PCAT) as a predictor ofacademic success. Am J Pharm Educ. 1976; 40:237–9.

Does Matching A Student's Learning Style Really Help?

2011-10-25T16:08:00.008-04:00

by Sara Hummel, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

While browsing the internet, I came across something in The Chronicle of Higher Education entitled “Matching Teaching Style to Learning Style may not Help Students” by David Glenn.¹ This immediately caught my attention. For the past few weeks we have been discussing learning styles in this course and how knowing the students’ style can positively impact learning. Now someone proposes that this may not help us at all. I wanted to know more.

The article refers to a review of the primary literature done by Pashler and colleagues published in the journal Psychological Science in the Public Interest.² The authors contend that there is insufficient scientific evidence supporting the commonly held notion that matching one’s teaching style to your students’ learning style enhances teaching effectiveness. Pashler reports that they found little research regarding learning and teaching styles that used an experimental design. Glenn’s article points out that other researchers in the field and supporters of learning-teaching style “matching hypothesis” felt that Pashler’s statements seemed biased and “largely ignorant of the field”.

The “matching hypothesis” purports that a student learns best if his/her learning style is matched with a corresponding instructional method. However, Pashler found little to no evidence in support of the hypothesis. Indeed, many studies showed contradicting evidence. Instead, Pashler proposes, that it may be more important to match the instructional method to the content. In a study by Massa and Mayer, subjects showed no differences in performance when given instructional methods matching their preferred learning style.³ Subjects were given a computer based electronics lesson with help screens either matched or opposite to their learning style preference- either visual (pictures) or verbal (text). The researchers found no differences in performance among the subjects. Instead, the experiment found that all learners benefited more from visual than verbal help during the lesson.

Pashler gives another example (that I could well relate to) from a student’s perspective. When teaching molecular structure, students often learn better when taught with stick models (kinesthetic learning) than by reading assigned text book chapters (verbal learning) – regardless of the student’s preferred learning style. Other examples that come to my mind from personal experience is learning how to take a patient’s blood pressure (highly kinesthetic) or analyzing a poem in a literature class (highly verbal). The content of the instruction is probably most relevant in terms of deciding what teaching methods to employ – not the students’ preferred learning styles.

Another study done by David W. Laight used concept maps as an instructional tool to teach pharmacy students about health care.⁴ In his study, Laight asked students to report the usefulness of concept maps and participate in a learning style preference evaluation. Although this study was not designed to evaluate the "matching hypothesis" per se, the results showed no statistically significant association between the students’ reported usefulness of concept maps and their preferred learning style. This surprised me, since I would have expected visual learners to prefer such a tool when compared to verbal or kinesthetic learners.

So why should we learn about learning style in this class? Learning about learning style differences probably makes us better teachers. Knowing that students have individual preferences for receiving information helps us to be more open-minded and to consider incorporating different instructional methods into our teaching repertoire.

I personally think that Pashler brings up some valid points. I disagree with his view that there is no basis for matching the instructional method to learning style. He admits that matching the two results in higher student satisfaction. And we know that motivation is important to learning.

I do, however, agree that not all topics can be taught using any instructional method in an attempt to tailor it to a specific group of students or learning style. It seems logical to me to teach hands on (aka kinesthetic) topics with “hands on” instructional methods. It is important that one considers both, the topic to be taught, as well as, the learners’ preferences, before deciding on how to teach the content.

References

1. Glenn D. Matching teaching style to learning style may not help students. The Chronicle of Higher Education, December 15, 2009.

2. Pashler H, Mcdaniel M, Rohrer D. Learning styles: concepts and evidence. Psychological Science In the Public Interest 2009; 9: 105-19.

3. Massa LJ, Mayer RE. Testing theATI hypothesis: Should multimedia instruction accommodate verbalizer-visualizercognitive style? Learning and Individual Differences 2006; 16 : 321-5.

4. Laight DW. Attitudes to concept maps as a teaching/learning activity in undergraduate healthprofessional education: influence of preferred learning style. Med Teach 2004; 28: 229-33.

Creating a Critical Learning Environment

2011-10-20T15:33:00.006-04:00

By Calvin J. Meaney, Pharm.D., PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

In his widely celebrated book “What the Best College Teachers Do”, Ken Bain proposes that a vital asset of an effective teacher is the ability to create a “natural critical learning environment.”¹ In this environment, a student is able to apply prior knowledge and encounter a new idea or concept. In so doing, the student is require to critically evaluate the idea and draw conclusions based on guidance from the teacher and shaped by their own knowledge in collaboration with other students.

An atmosphere such as this would be ideal! But many educators struggle with implementation. Bain argues that such an environment can be created in nearly any class or discipline. Below is a step-wise guide:

1. Ask a question

By posing an intriguing question or problem to students they will be internally motivated and feel engaged in their learning. It demonstrates to the students that the teacher respects their autonomous thought process and has genuine interest in their assessment of the question. Selecting a provocative or controversial topic is an effective technique to stir the pot and stimulate student participation.

2. Explain the significance of the question

The context and importance of the question/problem needs to be emphasized by the teacher. This will further motivate students.

3. Encourage high-order intellectual activity

Bloom’s taxonomy recognizes that evaluation, analysis, and synthesis are at the top of the cognitive pyramid.² Engaging in these higher order activities are the goal of a critical learning environment. Bain defines effective learning in that it makes “a sustained, substantial, and positive influence on the way a student acts, thinks, and feels”. This is achieved through high-order intellectual activity. This step is the “meat” of the critical learning environment and often the most difficult to achieve. Engaging in active learning techniques is fundamental. Michael Prince reviewed the available literature on effectiveness of active learning techniques in an engineering curriculum.³ He concluded that all modalities of active learning have proven benefits, with problem solving and cooperative activities having the largest effect size.

4. Facilitate the student’s ability to answer the question

An effective critical learning environment should foster the ability of the students to draw conclusions based on evidence and prior knowledge. The teacher needs to recognize when re-direction needs to be given students or groups by evaluating their progress through the given problem. Key verbs are: encourage, engage, and challenge. Students should be motivated to make a stance and defend it. In order for a student to think critically they must feel comfortable. The atmosphere should be non-judgmental, feedback should be constructive and consistent, and collaboration between students should be encouraged.

5. Leave the students with a question

If the learning environment has been successful, students should leave with a thorough understanding of the topic, but should also be inquisitive about what comes next. The “so now what?” question should be raised at the end of class to emphasize this.

How do we apply this to pharmacy education?

In pharmacy education, the case-based approach appears to be the ideal mechanism by which to create a natural critical learning environment. This student and problem-centered approach to instruction has been shown to improve critical thinking and clinical decision making.^4,5 An active learning approach to the cases facilitates the learner’s involvement and can improve participation and motivation.

From my own experience in my doctor of pharmacy program, I can recall class sessions when active, case-based learning activities created an effective critical learning environment. My large class was divided into groups of ten students and each group was given a different case related to the same topic. There were four questions posed for each case that were intriguing because they were open, complex, and controversial. Each group was given time to research the case, consider the questions, and discuss their responses. The instructor would walk around the room during the small-group research/discussion period to foster critical thinking by asking additional questions, providing guidance in a non-judgmental fashion, and giving feedback on preliminary answers. Later, each group presented the case, questions, and answers to the whole class. As each group presented their case, the questions were displayed on the screen so that the other groups could consider what their own responses might be. The group would then present their responses, justifications, and defend them if questioned by other groups or the teacher. At the end of each session, students were asked to write on an index card two things that they learned and two unanswered questions.

This method incorporates all 5 steps outlined in best practices for creating a critical learning environment and was, in my opinion, a very effective teaching strategy. Indeed, the performance of the students on the exam we took after this session was one of the highest during our entire four-year program.

References

1. Bain K. What the Best College Teachers Do. Cambridge, Massachusetts: Harvard University Press; 2004.

2. Bloom B, Engelhart M, Furst E, Hill W, Krathwohl D. Taxonomy of educational objectives: the classification of educational goals. In: Green, editor. Handbook I: Cognitive Domain. New York: Longmans; 1956.

3. Prince M. Does Active Learning Work? A Review of the Research. Journal of Engineering Education 2004;93:223-31.

4. Fisher RC. The Potential for Problem-Based Learning in Pharmacy Education: A Clinical Therapeutics Course in Diabetes. Am J Pharm Educ 1994;58:183-9.

5. Cisneros RM, Salisbury-Glennon JD, Anderson-Harper HM. Status of Problem-Based Learning Research in Pharmacy Education: A Call for Future Research. Am J Pharm Educ 2002;66.

Professionalism: An Important Lesson

2011-10-20T14:58:00.005-04:00

by Brandon Shank, Pharm.D., PGY-1 Pharmacy Practice Resident, The Johns Hopkins Hospital

When I entered pharmacy school, the concept of professionalism was presented early in my program. I distinctly remember reciting the Oath of a Pharmacist at my white coat ceremony. However, at that time, I did not fully understand the importance of professionalism or the skills needed to behave as a professional. The American Pharmaceutical Association Academy of Students of Pharmacy (APhA-ASP) and the American Association of Colleges of Pharmacy Council of Deans (AACP-COD) Task Force on Professionalism defined professionalism as the demonstration of the traits of a professional.¹ The American Board of Internal Medicine describe professionalism as the commitment to the highest standards of excellence in the practice of medicine and in the generation and dissemination of knowledge, sustain the interests and welfare of patients, and the responsiveness to the health needs of society.²

The Ten Traits of a Professional according to APhA-ASP and AACP-COD are:¹

1. Knowledge and skills of the profession

2. Commitment to self-improvement of skills and knowledge

3. Service orientation

4. Pride in the profession

5. Covenantal relationship with client

6. Creativity and innovation

7. Conscience and trustworthiness

8. Accountability for his or her work

9. Ethically sound decision making

10. Leadership

When teaching professionalism, it is essential that educators lead by example. Faculty should act in a manner that exemplifies professionalism and creates an environment in which students can effectively learn. A systematic approach to teaching professionalism should be implemented. Having students set goals and objectives as well as tracking and assessing progress are important steps to fostering a student’s development as a professional. Expectations should be established early on in the pharmacy program. Opportunities for students to learn and practice professionalism should be made available. Such opportunities may include professional organizations, Introductory Pharmacy Practice Experiences (IPPEs), Advanced Pharmacy Practice Experiences (APPEs), community service, and work experience.

Assessing a student’s professionalism can be challenging. Dr. Chisholm and colleagues developed a pharmacy professionalism self-assessment instrument.³ Their 18-item instrument assesses six tenets: excellence, respect for others, altruism, duty, accountability, and honor/integrity. The authors compared the professionalism of first year pharmacy students with recent graduates. There were no differences between the two groups. Another study found that professionalism measured by this instrument was greatest during the first and fourth professional years of pharmacy school.⁴ Therefore, widely implementing this tool may have limited utility for the purpose of monitoring an individual student’s growth. Preceptor or faculty evaluation offers another avenue for evaluating professionalism in didactic and experimental components of a pharmacy curriculum. However, the opinion of faculty and preceptors can be subjective. Thus further research is needed to develop objective evaluation methods. At the present time, preceptor and faculty facilitated discussions and formative feedback is the most appropriate way to teach and assess professionalism until validated tools are created.

Professionalism remains a core element of a pharmacy student’s education. More research is needed regarding the effectiveness of various methods to develop student’s professionalism skills. Patient interaction throughout the curriculum, in the form of IPPEs and APPEs, will aid in fostering professionalism traits beyond what can be learned in the classroom. Schools of pharmacy should strategically integrate, assess, and track students’ professionalism.

References

1. American Pharmaceutical Association Academy of Students of Pharmacy and American Association of Colleges of Pharmacy, Council of Deans Task Force on Professionalism. White Paper on Pharmacy Student Professionalism [Internet]. 1999 July 1 [cited 2011 Oct 2]

2. American Board of Internal Medicine, Committees on Evaluation of Clinical Competence and Clinical Competence and Communication Programs. Project Professionalism [Internet]. Philadelphia, (PA): American Board of Internal Medicine; 1995 [updated 2001; cited 2011 Oct 2]

3. Chisholm MA, Cobb H, Duke L, McDuffie C, Kennedy WK. Development of an Instrument to Measure Professionalism. Am J Pharm Educ. 2006;70(4):1-6.

4. Duke LJ, Kennedy WK, McDuffie C, Miller M, Sheffield M, Chisholm M. Student attitudes, values, and beliefs regarding professionalism. Am J Pharm Educ. 2005;69:1-11.