Innovations In Teaching

by Tanya Telegadis, Pharm.D. - PGY2 Pain and Palliative Care Pharmacy Resident, University of Maryland School of Pharmacy

Boesen KP, Herrier RN, Apgar DA et al. Improvisational Exercises to Improve Pharmacy Students’ Professional Communication Skills. Am J Pharm Ed. 2009; 73: 1-8.

This article caught my eye because I have a special place in my heart for effective communication. As pharmacists, we are the most trusted healthcare professional and this is in large part due to our accessibility to the public. Patients rely on us for sound medical advice and as a platform to bounce ideas off of and to vent frustrations. In a community pharmacy setting, we have one, two, maybe three minutes with a patient and in this time, we need to establish a relationship with them. We need to be able to listen to what is said, come up with an appropriate response and then relay the information in an effective and appropriate matter (urgency, emergency, sympathy, empathy, concern, etc). In interactions with pharmacists throughout the years, I have seen those who I try to model and those who, quite frankly, make me thankful I am not the patient. In school, we do an excellent job of training in the necessary sciences and technical evaluation skills. My fear is that communication skills are compromised as students hone in on proficiency in the information they need to know and the technical skills they need to demonstrate. This article looks at improvisation, a very interesting way to incorporate communication skills into the pharmacy school curriculum.

The authors implemented twelve 1-hour improvisational sessions into an existing communication course in order to improve listening, observing and responding. They require a course in interviewing and communication skills for the first year students. In this course, students must pass a mock-patient (instructor) interview assessment by demonstrating minimum competencies in interviewing and counseling techniques as well as be able to adapt these to real world situations. They found that a majority of the student struggled with how to quickly recognize cues that would tell them when to address the patient’s emotional state and new physical symptoms. The students were so focused on gathering the information that they missed the cues, so much so that the mock-patient had to resort to exaggerated cues before students recognized a need to change their interview techniques. With this realization, the instructors decided to implement this improvisation plan into their course. They used standardized patient exams to assess student performance in communication skills (the success of their educational program), and reflective journaling and student evaluations to evaluate student’s perceptions of the improvisational exercises.

The purpose of these exercises was to enable students to: (1) develop additional expertise in the “art” of basic communication skills (2) improve the ability to think on their feet (3)understand the importance of emotion and relation in communication (4) become more comfortable in communicating in large groups (5) recognize basic dynamics of group communication and (6) learn to stay “in the moment” focusing on the patient/healthcare provider while recognizing when to change techniques and avoiding the temptation to anticipate. I think that all of these attributes are extremely important to being an effective patient educator … and even during non-professional interactions. These are life skills that some students already possess but can improve … and other students need to acquire.

The researchers addressed each goal with a specific exercise. In the interest of time, I will not explain each exercise but get at what the exercises were intended to achieve. They used “repeated patterns” as not only an ice-breaker but as a means of teaching students to listen for cues, respond accordingly, and ignore everything else in the environment. This is important because pharmacies are busy places and this should not compromise one’s attention to the patient's needs.

A second exercise involved advancing a conversation with “yes and…” Students were given their relationship to one another, their environment, and a topic to discuss. The goal was to continue to move the conversation forward. This technique was then applied to short scenarios with the goal of stressing the importance of status and emotion in every conversation.

Group communication focused on the dynamics of group communication. The goal was to maintain a single focus verbally and nonverbally.

The exercises that they implemented were very successful. Students improved on their skills (and grades!) significantly. The authors admit that some exercises made some students very uncomfortable. But I suspect that these are the students who most benefited from the exercises. Students who felt uncomfortable improve just as much as those who did not complain of discomfort. It is important for all pharmacy students to have good communication skills when working with patients and other healthcare providers.

In Educational Theory and Practice we talk about learning styles, teaching styles and implementing courses/lectures/classes successfully. It is important to keep in mind that many students are driven by grades and will easily lose sight of the whole-picture. When they lose sight of the whole picture, they are losing sight of the “whole patient”. It is our job, as educators, to emphasize the importance of good communication skills and seeing the details in the big picture. It is also our job to serve as role models of these skills and focus not just on the details but the “whole” student. Improvisation helped these researchers achieve their goals. Improvisation appears to be a innovative and fun way to teach an important but difficult skill.

[Editor's Commentary: Communication is a fundamental skill and, more than any other skill in modern life, closely correlated with one's success in nearly every profession and field. Our ability to communicate as health care professionals is a key ingredient to achieving optimal patient outcomes. As educators, pharmacists must be able to effectuate behavior change in various audiences - peers, patients, and prescribers. However, just as lecturing is not the most effective way of teaching our students, simply conveying information is not the most effective method of communicating with our patients. Both require us to know our audience, to care about them, and to listen (and talk less). Both require us to be attuned to the unspoken, non-verbal clues that our patients (and students) send to us ... and to adapt and respond to their needs. Some people are innately gifted communicators (and teachers). The rest of us can build our skills through guided practice and feedback. Teaching students to become effective communicators is perhaps the greatest gift any teacher could aspire to "give" ... and yet, its something we spend far too little time exploring and developing with our students and trainees. We need not do so in explicit ways (as the authors of this teaching innovation did) but in implicit ways by embedding opportunities to build our communication muscles in every course and learning experience. S.H.]

Integrated Medical School Curricula

by Julie Waldfogel, Pharm.D. - PGY2 Pain and Palliative Care Pharmacy Resident, Johns Hopkins Hospital

I recently passed a stand with the Johns Hopkins Hospital in-house newspaper and on the front cover was an article about the School of Medicine’s complete restructuring of their curriculum. I found the story intriguing and grounded in many of the fundamental principles of learning we’ve been discussing in this course.

The restructure curriculum is called Genes to Society – a curriculum that integrates basic science with clinical practice throughout the entire 4 year program of study. With this new model, first year medical students see patients within the first 6 months and 4^th year students combine their clinical training with bench work in the lab. Students also get the chance to work at the Simulation Center, practicing procedures and assessment techniques before using them on real patients.

When viewed as an educational model, Genes to Society incorporates the major educational theories: Behaviorism, Constructivism and Social Learning. Behaviorism is a theory that learners follow a pattern dictated by the teacher. This is most visible in the traditional class structure of lectures and exams and is still present in the new John’s Hopkins curriculum. Constructivism relies more heavily on the learner for independent study and self-motivation and is seen through the school’s focus on clinical practice. Students will be seeing patients almost immediately and this environment is more conducive for self-directed learning. And the use of Social Learning is seen through the application of the Simulation Center. Social Learning is based on the theory that students learn best through example. By being able to observe a procedure and then practice it themselves, students get the benefit of modeling a behavior before applying it . By combining all three educational theories into their curriculum, the Johns Hopkins School of Medicine is building a program that engages multiple types of learners at once.

But the Johns Hopkins University is not the only program moving away from the traditional medical educational model. For example, McMaster University in Canada has developed the COMPASS curriculum. This model focuses on problem based learning (PBL). Students are divided into small groups, each with their own mentor. These small groups are given a series of problems from which they develop their own learning objectives and negotiate how to approach their learning tasks. Students in this curriculum are also exposed early in their training to clinical practice and patients. From the description of this curriculum, it’s easy to see that the major paradigm shift at McMaster is away from Behaviorism and towards a curriculum that focuses primarily on Constructivism and Social Learning as the major educational models.

But medical schools are not the only ones that can learn from these changes. Pharmacy is another health profession that could benefit from incorporating multiple educational theories into its teaching model. While I was in pharmacy school, the majority of my learning was in lecture-based format. In part due to the relatively rigid format and partly due to the nature of multiple choice exams with a single correct answer, I saw many choices as black and white. Medication decisions were clear-cut because they were based on guidelines and evidence-based medicine. However, as I’ve progressed through my residency training, many of the certainties that I once learned as a student have taken on shades of grey; because medicine is patient specific. And every day, as new information arises about the genetic basis for disease, the practice of medicine becomes even more personalized.

It’s this shift in the medical approach that has necessitated a change in medical education. With Genes to Society, it’s the cohesiveness of the curriculum that makes the model so appealing and so applicable to today’s medical practice. It integrates biological, societal and environmental components to help medical students evaluate the entire patient and provide the best care possible.

Of particular interest to me is the rejection of the concept of “normal” biology. In the classic medical educational model, students are taught to think of the body like a machine. A patient’s body is “broken” by a disease and it’s up to healthcare professionals to “fix” it. But many health professionals lack training regarding the emotional, spiritual, societal and ethnic issues that can also impact a person’s health. With their new curriculum, the Johns Hopkins University Medical School is saying “…no one is ‘normal’. Everyone is on some kind of continuum, and we need to understand why they’re presenting the way they do at any given moment in time.” The result is, hopefully, a more balanced clinician who can see each patient as an individual and has experience in addressing all aspects of health.

Whether this new curriculum helps produce better practitioners remains to be seen. But I’m relieved that the effort is being made to move us forward and into a new era of medical education.

[Editor's Commentary: From its founding in the late nineteenth century, the Johns Hopkins Hospital and the Johns Hopkins School of Medicine have been leaders in medical education. It was the first teaching hospital (as we understand them today) where the hospital, the medical school, and its faculty were fully integrated. It was not uncommon at the turn of the twentieth century for medical schools to be diploma mills in rented facilities with little or no clinical training prior to graduation. It wasn't until the publication of the Flexner report in 1910 that modern medical education took shape - and the model he espoused was largely based on the Johns Hopkins model of integration between didactic and clinical education. In the century that has since passed, other medical schools have adopted equally bold and innovative curricula. Problem based learning was pioneered at McMaster University in the 1970's and the concept was taken even further in the Compass Curriculum adopted a few years ago. But are these innovations in medical education really all the revolutionary? Not really - Maria Montessori developed curricula for pre-school and elementary education in which children were free to explore and learn in a carefully constructed environment. In this method, students directed their own learning through their interactions with the environment and with teachers as guides. Its seems medical (pharmacy and nursing) curricula are moving closer and closer to Montessori's vision. One wonders whether we need a didactic component in our curricula at all. S.H.]

Expanding APPEs – Meeting Future Needs

by Jennifer Thompson, Pharm.D., BCOP - Oncology Clinical Specialist, University of Maryland Medical Center

Due to the current pharmacist shortage and predictions of increased demand for pharmacy services, there has been rising pressure to create and expand PharmD programs. Subsequently, this creates more demand for personnel (preceptors) and resources (rotation sites) for advanced pharmacy practice experiences (APPEs) within the PharmD curriculum which is critical for the successful training of future pharmacists. This topic is of personal interest to me as an APPE preceptor at an acute care institution with several pharmacy residency programs. I will attempt to explore the topic stepwise by discussing a recent needs analysis, the standards, and my evaluation.

Brackett and colleagues performed an APPE organizational needs analysis for pharmacy schools based in the states of Georgia and Alabama (See: Am J Pharm Educ 2009; 73 (5) Article 82). The analysis was performed through the collaboration of the Southeastern Pharmacy Experiential Education Consortium (SPEEC) which includes: Auburn University Harrison School of Pharmacy, Mercer University College of Pharmacy and Health Sciences, South University School of Pharmacy, and The University of Georgia College of Pharmacy. The authors performed a gap analysis by comparing past APPE needs to forecasted future needs. Data regarding APPE class size for the 2006-2007 academic year, number of non-community APPEs needed per class, and total non-community APPE availability was gathered from the Experiential Education Management Systems database. Each SPEEC institution’s experiential learning director estimated needs for the 2010-2011 APPE year based upon their knowledge of anticipated changes in class size or curriculum. The 2006-2007 non-community APPE needs and availabilities were 3,590 and 4,427 sites, respectively, with a surplus availability of 837. Combined projected 2010-2011 non-community APPEs were estimated at 4,309. Assuming 2006-2007 non-community availability remained unchanged, the surplus declined to 118. The authors discussed many limitations to their analysis and acknowledge that they may have overestimated the APPE surplus. Indeed, they anticipate if they had separated required and elective rotations, accounted for rescheduling variables, and worked within a less complex system this surplus might evaporate.

Part of the motivation for Brackett and colleagues to conduct their research was the Accreditation Council for Pharmacy Education (ACPE) revised accreditation standards and guidelines for the PharmD degree adopted in 2006. These standards require that APPEs comprise a minimum of 25% of the curriculum and be at least 1440 hours in length. Standards set for preceptors include: they should be oriented to goals and objectives of the APPE PharmD curriculum and should be well versed in teaching methodologies that enhance learning. Preceptors need to be aware of students' prior knowledge and experience relative to the rotation's objectives so that they may tailor the rotation to maximize the educational experience. (See: ACPE. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree.)

Based on the analysis and standards described, one can summarize that expanding APPE availability is complex. I applaud the efforts of Brackett and his peers. The methods and the results can perhaps be extrapolated to other geographic regions. The top two factors on my mind are balancing the increasing numbers of PharmD students with limited availabilities in acute care settings combined with the economic crisis faced by many health systems. Hospital practitioners with the required skills and training may not have adequate time to precept students during APPE, especially if they also have institutional obligations to pharmacy residency training. Practitioners’ workloads need to reflect their educational commitments. As schools and colleges of pharmacy adapt to the new ACPE standards, scheduling students for APPE rotations should be synchronized and balanced with residency schedules. We can also empower residents to co-precept students.

As described in the ACPE Standards, schools and colleges of pharmacy need to review objectives and instructional activities and assess learning environments. The college or school must ensure that preceptors receive orientation, especially for first-time preceptors. Effective communication regarding student performance and expectations is critical. The defined procedures should be unambiguous and adhere to the task standards. Another method of standardization is through collaboration by consortiums of schools and colleges of pharmacy. Pooling resources between academia and practice sites could assist with preceptor development. Schools or colleges should provide structured feedback to preceptors based on their student evaluations and identify areas the require further development. I believe a combination of these strategies can assist us in meeting the projected APPE needs. By sharing resources and skills through partnerships between educators and practitioners and educational consortiums, future pharmacists and patients will ultimately benefit.

[Editor's Commentary: Preceptors, particularly those like Dr. Thompson in academic health science centers and teaching hospitals, are feeling the pressure to do more with less. Teach more students, train more residents, and see more patients with fewer resources. I'm afraid there is no immediate solution to this problem. On the one hand, pharmacists, particularly those with advanced training and skills, are needed more than ever. On the other hand, the free flow of money into healthcare systems is being increasingly scrutinized. Budgets are trimmed, cut, and slashed to meet immediate financial woes. And yet, inefficiency abounds, not only in patient care but also in the traditional methods we've used for decades to train pharmacists. Pooling limited resources and creating more efficient training models will certainly help. These problems aren't unique to pharmacy - clinical training in medicine and nursing have faced these same problems. Perhaps there are lessons we can learn from our clinical brethren? S.H.]

Patient Education and Health Literacy

by Jessie R. Lish, Pharm.D. - PGY2 Ambulatory Care Resident, Baltimore VA Medical Center

Educators are those who serve as learning facilitators, coaches, and guides to learners of all abilities and learning styles. No two learners are created equal, and no two educators teach in the exact same way. The unique teaching characteristics that educators possess are the reasons why they are able to teach courses and topics of all varieties. As an example, my father is a high school biology teacher, and my mother is a retired K-3 art teacher. My father teaches best through lecture in class with a little bit of laboratory work woven into his classes. My mother, on the other hand, taught mostly through hands-on art-making. For my father, using lecture and laboratory means to teach his classes was effective. In my mom’s art classes, younger children responded better to hands-on activities and would not have been well suited for a lecture-type of activity. The common theme in both examples is that educators portray information in ways best suited to their particular audience. As educators and pharmacists, we have to remember that even though we’re not in a formal classroom setting, our patients are learners and our “audience.” The same teaching principles hold true when we are educating and counseling our patients.

I recently read an article in Pharmacy Today (Ngoh LN. Health literacy: a barrier to pharmacist-patient communication and medication adherence. Pharmacy Today 2009;15(8):45-57.) – a publication of the American Pharmacists Association. The article is a review of existing literature regarding medication adherence, health literacy, and the use of written patient information in health care and pharmacy in particular. This article caught my attention because my PGY2 residency project is examining barriers to patient follow-up and monitoring in a psychiatric patient population taking second generation antipsychotic medications. After reading through the review article, I began to think that the patients we serve and educate everyday are kind of similar to our students that we teach in a more formal setting. Students come from a variety of backgrounds, learning styles, and interests. The same holds true for patients! Anyway, this article/review indicated that the health literacy skills of American adults have not changed considerably over the past decade. The author goes on to say that health literacy is a characteristic of a patient that may place him/her at higher likelihood of poor adherence to a medication regimen. I think about this everyday…how can we combat this and help educate our patients so that they truly learn about their health and the medications needed to control disease states?

I think it all comes back to a learner’s style of absorbing information presented to him/her. I relate this to Kolb’s learning styles. Kolb says that how we learn, or our “theory of learning,” is grounded in our experiences. He goes on to say that there are four styles through which learners glean information: 1) feeler; 2) doer; 3) watcher, and 4) thinker. Feelers learn best from specific examples in which they can be involved. Doers like to see everything and then determine their own criteria. Watchers learn best from demonstrations/lectures. Thinkers like to take new information and incorporate it into their own experiences. To relate this to our patients, a doer might be a patient who wants to see all medication options and then determine which one he/she would want to take depending upon the information presented. A watcher may be a patient who would benefit from listening to a short lecture on diabetes and how he/she can decrease his/her risk factors. A thinker may be a patient who would try a medication, think about how it made him/her feel, and then approach the health educator to discuss different options. A feeler may be a patient who takes the medication information home to read it on his/her own time and formulate his/her own opinion. No matter which learning style a patient possesses, he/she is going to benefit from a variety of teaching styles.

I believe that if we approach each patient with a fresh mindset, we can take into account our audience (i.e. the patient), the learning content (i.e. medication information/disease state information), the learning style of the patient (i.e. if the patient is a more hands-on learner and requires pictures; if the patient cannot read/understand English and requires a translator; if the patient prefers to read the information him/her self, etc.) and adapt our teaching style to fit that patient. From personal experience, I know that the patients I see in geriatrics clinic differ from my younger patients in the diabetes clinic, who differ from the patients I serve in the mental health clinic. I am constantly adapting my teaching and educating styles to fit whichever patient population I’m working with that day. I truly believe that all teachers and learners/patients are not created equal, and to truly benefit our patients, we must adapt to each situation.

[Editor's Commentary: Health literacy can significantly impact health outcomes and its an issue that every clinician should have a working knowledge about. Health literacy is NOT synonymous with literacy. While they are related concepts, patients can be literate - indeed, well educated - and have relatively poor HEALTH literacy. Clinicians often make assumptions about patients who are articulate and well educate. Some fully understand health terminology and complex health concepts. But many don't. That's why its so critically important to know your learners - to figure out what they already know, what they need to know, and how they learn best. S.H.]

Student Absenteeism

by Lauren Hynicka - Assistant Professor, University of Maryland School of Pharmacy

The branch campus is becoming ever more popular in higher education. As a result, lectures are recorded for students at the distance campus to view asynchronously and often students on the "main" campus also have access. The University of Maryland School of Pharmacy recently started its own branch campus at Shady Grove. I have heard during my short time here that there has been a decline in student attendance since the adoption of the recorded lecture. [Editor's Note: Dr. Hynicka joined our faculty in August 2009]

Over the past several weeks, we have been discussing teaching and learning styles. I was curious to see if I could find any information that might give me a clue as to the types of students who would be more apt to be absent from lectures and what if anything could be done to encourage attendance. In my search I found an article by Westrick and colleagues entitled, “Factors influencing pharmacy students’ attendance decisions in large lectures.” (Citation: Westrick SC, Helms KL, McDonough SK, Breland ML. Am J Pharm Educ 2009; 73: 1-9).

The authors introduce the topic by identifying the reasons why educators should be concerned about absenteeism in the classroom. Negative impacts on both academic performance as well as professional development were identified as two major consequences of student absenteeism. In order to better delineate strategies to improve student attendance at classes, a study was conducted at the Auburn University School of Pharmacy. The study consisted of a two step process - the first step was to develop a survey instrument. All students were invited to participate in a discussion on student absenteeism. They were asked to identify reasons to attend and not to attend classes. Following the generation of this list, the students ranked the reasons based on how much they agreed or disagreed. In addition to student generated ideas about absenteeism, a literature search revealed two research studies evaluating similar research questions. A compilation of these sources lead to the generation of the survey instrument.

A cross-sectional survey was disseminated to 131 second-year pharmacy students via email. Students were asked to identify the number of times they were absent from 3 courses: integrated pharmaceutical sciences, management, and pharmaceutics. Demographic information was also collected. Finally, students were asked rate 14 reasons to attend class and 22 reasons not to attend class. Students were asked to use the following scale: main reason, moderately important reason, minor reason, or not a reason.

A total of 98 (75%) students responded. Three-quarters of the students were female and unmarried. Prior education was split down the middle, with half of the students earning prior college degrees. The majority of the students was not working during school and lived less than 10 minutes from campus. The average age was 23 with a cumulative GPA of 3.0. Student reports of absenteeism were highest in the pharmaceutics course with 38% of students reporting 11 or more absences and lowest in the management course with 100% of student reporting ≤ 2 absences. When analyzing the effect of student characteristics on absenteeism there were no statistically significant differences in the pharmaceutics or management courses. In the integrated pharmaceutical sciences course students were more likely to miss more classes if they lived more than 10 minutes from campus (p=0.04) and paid for their own education (p=0.04).

The main reasons to attend or not to attend class varied based on the course. A resounding reason to attend class (common to all courses) was the desire to take notes and to hear what the instructor considered important to know. In the management course a strong motivator for student attendance was the implementation of pop quizzes and activities that would impact student grades, with 97.7% of students reporting this as a reason to attend class. In terms of reasons not to attend class, students stated they would skip class if they were sick, they were studying or working on an assignment for another course, and the material was available from another source. These reasons were common to all three courses.

One thing I have gleaned from this article is that awarding credit (or points toward the student’s grade) for attending class is a strong incentive. I also think one of the students' justification for not attending class - the need to study or work for other courses - is an interesting one. In pharmacy education we have the unique advantage in that our students are taking essentially the same classes and we (the teachers and administrators) have access to their schedules. While I recognize that developing time management skills is important, perhaps we (the faculty and administration) are doing a disservice to ourselves and our students by not exploring better ways to schedule course-related activities that would enable more students to complete assignments, study for tests, and attend class.

Relative to the student reasons to attend class it is interesting to note that one is an intrinsic characteristic of the learner (a desire to take notes) and the other is a quality related to how the teacher presents the material (emphasizing what’s important). While the authors were not able to delineate which students were more likely to miss class based on demographic characteristics, I would argue that the authors failed to collect some important information. I believe information about the students’ learning style, perhaps by using an inventory such as Kolb’s learning style indicator, would have been helpful . This might have provided additional insight into student responses to the survey and may be helpful for instructors to design learning activities for large groups that would entice more students to attend. Instructors are the other piece to the equation of classroom attendance and yet this crucial stakeholder was not surveyed in this study.

I think that this study could be used as a tool for faculty development. Having faculty members participate in a similar survey to see what biases / beliefs they have as it relates to student absenteeism would add an interesting dimension. Taking this a step further I would like to see faculty members complete an inventory to identify their teaching style. A better understanding of their own teaching tendencies will allow faculty members to see what areas they should strive to develop to better meet the needs of their students.

[Editor’s Commentary: Should we force, coerce, or bribe students to attend lectures (e.g. take attendance, administer pop quizzes, give attendance points)? Is there any evidence that attendance (per se) improves outcomes? If students perform equally well (or perhaps better) on assessments and exams when they skip class, what is the incentive to attend? From the student’s perspective, if the benefits of not attending outweigh the potential consequences, being absent is a simple benefit-risk decision. Does absenteeism bother us (the faculty) because it reflects badly on us (the faculty)? Does it annoy us because its boring talking to a bunch of empty seats? Are we failing to measure and assess important aspects of learning that best occur during face-to-face encounters with and between students? Or are students simply making rational decisions about how best to use their time? Food for thought. S.H.]