Peeragogy – The Evolution of Active Learning

by Hsiao-Ting Wang, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

In a world of information overload, what is the best way to keep updated?  Other than reading through textbooks, guidelines, and journal articles, where can I learn from the wisdom of other’s real-world experiences?  Prior to starting my residency, I discovered Dr. Bryan Hayes’ twitter feed, @PharmERToxGuy, and was stunned by the abundance of knowledge shared between practitioners across the country.  One can learn about the hottest debate or the latest scientific findings in emergency medicine simply by reading 140-character tweets (aka messages)!  These are real-time conversations among experts in the field.  This is also self-directed learning conducted through peer-to-peer interaction, but without a facilitator!  The concept of peer-to-peer learning was first described in 2011 and subsequently called “Peeragogy.”^1,4  Before going further into peeragogy, I think it is necessary to take a step back to review the evolution of peer-based learning.

Traditional peer-based learning refers to the “active learning” component of instructional design where students are encouraged to formulate their own answers, participate in discussions, and engage in group work.  Teachers play the role of facilitator by selecting appropriate topics for discussions and raising questions when necessary to prompt students to think critically and deeply about the subject matter.  According to Alice Christudason, there are four common peer-learning strategies to choose from¹: buzz group, affinity group, solutions and critic group, and teach-write-discuss.  Buzz group is when students are divided into smaller groups for discussion in class and, following the small group discussion, one member of each small group presents during the whole class debrief.  Affinity group is similar to buzz group but it requires each small group to find their own time outside of the class meetings to discuss.  Solutions and critic groups work by pairing up two small groups together – one is responsible for teaching the whole class on a selected topic and the other for evaluating the presentation.  Lastly, the teach-write-discuss method utilizes a whole classroom discussion at the end of the instruction to examine how much students have learned from a lecture.

In addition, students can acquire new knowledge through other peer-to-peer instructional techniques such as role-play, debates, case studies, and group projects.  The key to successful traditional peer-based learning relies not only on students’ enthusiasm about active learning but also the teacher’s role in selecting and orchestrating the learning exercise.  In our digital world today, learning opportunity extend beyond the physical boundaries of classrooms.  One of the first peer-learning communities, Peer 2 Peer University (P2PU) was created in 2009 to provide inexpensive (free) higher education with quality content to millions of learners on the Internet.  There are many other online peer-learning communities similar to P2PU.  The newest platform is the Massive Online Open Classes (MOOCs), most notably Coursera.  These online communities still employ an instructor to facilitate learning with open forums for discussion between learners around the world.

Joe Corneli and Charles Danoff coined the term “Paragogy” to describe the self-directed learning that occurs through connections among peers.²  Literally, “para” means along side and “gogy” means leading.  Paragogy applies Knowles’ principles of androgogy (adult learning) to peer-based teaching and learning³.  There are five working principles of paragogy.  These principles along with authors’ definition of each principle are:

• Decenteralized center: Understanding the concept of shared context is more important than understanding one’s self-concept.
• Meta-learning as a source of knowledge: There is a lot to learn about learning.
• Peers have different but equal perspectives: Learners must confront and make sense of the difference among them as part of the learning experience instead of seeking to confirm what one already knew.
• Learning is distributed, not linear: It is important to learn how to work around a given social field as side-tracking is allowed.
• Realize the dream (if you can), then move one: Learners should attempt to fulfill their personal motivations but shouldn’t dwell too long.

Essentially, these working principles serve as the guidance for learners to facilitate their own learning without having a facilitator to remind them of the rules.  

To make the concept of self-driven peer-to-peer learning easily understood, Howard Rheingold coined the term “Peeragogy” in his Regent’s Lecture at the University of California, Berkeley in 2012.⁴  While parallel to paragogy, Mr. Rheingold combined social media with paragogy to describe peeragogy as the “future of high-end online learning in which motivated self-learners collaborate via a variety of social media to create, deliver, and learn an agreed curriculum.”⁵  Each learner serves in the “instructor” role and creates the syllabus and strategy to promote critical thinking and thoughtful discussions.⁶  In other words, for a peeragogical design to work, the group needs to establish a group consensus for expectations, learning objectives, media technology, and the social contract of the course.  The group needs to formulate a process for communicating with one another, how to respond to questions, give feedback in a timely manner, and evaluate performance at the completion of the course.  Last but not least, there needs to be a process to translate changes to the learning environment to be implemented in the next cycle.

Reflecting back on Dr. Hayes’ twitter feed, it is obvious that this online forum has provided a platform for information exchange among peers with similar interest and expertise in a particular field.  This fulfills the definition of a learning community as described by Mr. Rheingold.  To carry out peeragogy, the next step would be to establish a learning contract among followers and put it into action!

Reference:

1. Christudason, A. (2003). Peer learning. Successful Learning, Center for Development of Teaching and Learning (CDTL), National University of Singapore. (accessed 1 October 2014)
2. Corneli, J. and Danoff, C. J. (2011). Paragogy: Synergizing individual and organizational learning. (accessed 1 October 2014)
3. Knowles, M. S. (1980). The modern practice of adult education: From pedagogy to andragogy. Chicago: Follett.
4. Rheingold, H. (2012). UC Berkeley Regents' Lecture: Social Media and Peer Learning: From Mediated Pedagogy to Peeragogy. Presented by Berkeley Center for New Media. (accessed 19 September 2014)
5. Rheingold, H. (2012). Toward Peeragogy. (accessed 19 September 2014)
6. Rheingold, H, Corneli, J, Danoff, C. J. et al. (2014). The Peeragogy Handbook v. 2.0 (accessed 1 October 2014)

Stress and Anxiety: A Faculty Perspective

by Wesley Oliver, Pharm.D., PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

Anxiety, particularly related to public speaking, has been an issue I have had to deal with my entire life.  When I was younger, I would do anything to avoid speaking in public.  If speaking in front of others was unavoidable, I would reluctantly meander to the front of the group — sweating, shaking, and heart racing — mumble and stammer through my presentation, then sit down as quickly as possible.  Public speaking has never been easy for me; however, I have developed strategies to deal with my anxiety and I continue working on my public speaking skills.  Stress and anxiety are not detrimental if they are appropriately managed and I foresee the anxiety subsiding with repeated practice and become more comfortable presenting in a variety of settings.

When I explain my anxiety to others, they always give the same response: “Everyone gets nervous when speaking in front of others.”  While I have accepted this to be true based on my research on the subject, I have wondered if stress and anxiety can affect faculty in other areas of their work.

To my amazement, a quick search on the Internet reveals numerous areas where faculty experience anxiety and how it can affect them both professionally and personally.  Common themes include: maintaining heavy workloads, trying to meet unrealistic demands from administration, conducting research, applying for grants, making time for students, and creating work-life balance.^1-3  It is easy to imagine how someone experiencing excessive anxiety and stress in one area of their work life (e.g. applying for grants) can negatively affect and influence other areas (e.g. teaching).

In addition to these common themes, there are some specific areas that can cause anxiety and stress for faculty.  The first is grade anxiety.  These feelings arise as a faculty member is giving back grades to students.  It appears that the anxiety is highest in those that interact directly with students in a personal environment; however, even those teaching large groups can experience this anxiety.  The reason for this stress and anxiety is that the faculty member realizes some students worked really hard and the faculty member has invested a lot amount of time teaching these students, only to have some of them score low grades.⁴

Grade anxiety is closely related to exam anxiety.  Exam anxiety consists of faculty members experiencing stress because of the test they have created.  They are unsure of how the students will perform and whether or not they have created a “fair” test.  Anxiety also arises in faculty members questioning whether they have taught the information effectively or whether the information they taught is being tested appropriately.⁵

Finally, many faculty experience stress and anxiety at the beginning of their course every year.  Imagine having a new group of students, each with different personalities and expectations, and having to create new ways to reach them each year.  This can be very stressful.  One faculty member expressed the thoughts racing through his mind on the first of class this way: “Have them like me, Have them think I like them, Have them think I am funny, Have them think I know what I am doing so they will learn, Have them fear me because I know what will be on the exams and they do not, Not bother myself about what they think at all and just lecture.”⁶

There are many theories as to how stress and anxiety can affect performance.  The oldest theory, known as the Yerkes-Dodson or inverted-U principle, claims that a certain amount of arousal, such as stress or anxiety, is needed for a person to reach maximal performance.  However, once a person is exposed to too much stress or anxiety, performance will start to decline until the person can no longer function.⁷  Those that experience a little anxiety can perform very well, while those who experience too much are unable to perform at all.  Thus, it is important for someone to manage his/her anxiety in order to perform at a high level.

There are two methods to combat stress and anxiety as a teacher.  First, is to prepare for stressful situations and address them before beginning teaching.  The other is to identify those affected by stress and anxiety and institute programs to help them.  Both can be instituted simultaneously.  Faculty should go through training to teach them to effectively assign grades, administer exams, prepare for classes, and manage the demands of faculty life.  While this instruction will help diminish the stress and anxiety, programs will still be needed for those that need more help.  Given the risk of isolation for faculty members experiencing stress and anxiety, proactive methods to identify those that might need more help should be implemented.  These individuals can then be referred to receive cognitive behavioral therapy to help them deal with excessive stress and anxiety.⁷  A recent blog series focused on mental health issues in academia.  The author states that it is easy for those in academia to feel isolated.  Most do not feel comfortable approaching colleagues about their feelings.^8,9  Thus, it is very important to recognize stress in colleagues and strive to create an appropriate work-life balance to keep from becoming too stressed.

Stress and anxiety not only affects students but also those that teach them.  The best way to address faculty stress and anxiety is to implement programs to assist in preparing for and deal with these emotions.

References:

1. Kraus MW.  Do Professors Live a Stress-Free Life? [Internet].  Psychology Today; July 2013 [cited 2014 Sep 30].
2. Shaw C. Overworked and isolated-work pressure fuels mental illness in academia [Internet]. United Kingdom: The Guardian; May 2014 [cited 2014 Sep 30].
3. Smith D. Dealing with anxiety as a professor [Internet]. University Affairs; May 2014 [cited 2014 Sep 30].
4. Grade anxiety for professors [Internet]. Science Professor: The questionable life of a science professor; October 2010 [cited 2014 Sep 30].
5. Gabriel ME. Exam jitters? Professors battle test anxiety, too [Internet]. Madison (WI): University of Wisconsin-Madison College of Letters and Science News; December 2013 [cited 2014 Sep 30].
6. Kakela P. Start-up Anxiety: Professor shares his fears as a new semester begins [Internet]. Faculty Focus; December 2013 [cited 2014 Sep 30].
7. Staal MA. Stress, Cognition, and Human Performance: A literature review and conceptual framework [Internet]. Hanover, MD: NASA Center for Aerospace Information; August 2004 [cited 2014 Oct 11].
8. Blog + Mental health: a university crisis [Internet]. United Kingdom: The Guardian; July 2014 [cited 2014 Sep 30].
9. Shaw C, Ward L. Dark thoughts: why mental illness is on the rise in academia [Internet]. United Kingdom: The Guardian; March 2014 [cited 2014 Sep 30].

Using Reflective Writing to Teach Empathy

by Rachel Coleman Drury, Pharm.D., PGY2 Ambulatory Care Pharmacy Practice Resident, University of Maryland School of Pharmacy

Can empathy be taught? Some would argue that empathy is an inherent personality trait.  Others believe it’s a developed skill.  The literature suggests that empathy can be cultivated.^1,2 Many health professional schools are incorporating fine arts and empathy building exercises into their curricula to develop well-rounded practitioners.  The Accreditation Council for Pharmacy Education (ACPE) references empathy five times within the Accreditation Standards and Guidelines for the Doctor of Pharmacy Degree.³  Pharmacy practitioners must be empathetic in order to competently deliver effective patient care.³

As a pharmacy resident practicing in the ambulatory care setting, I could not agree with ACPE more.  “They don’t care what you know, until you show them that you care” is something I frequently say to students on rotation. To achieve optimal health outcomes, the provider must first understand the patient’s problems from the patient’s perspective. This is how a trusting relationship is built.  Without empathy, a provider cannot make patient-specific recommendations.

Empathy is a higher-level skill that requires the practitioner to quickly process information from the patient interaction to make a purposeful response that conveys understanding.  Like empathy, reflective writing requires the learner to process information and respond.  Given these similarities, reflective writing has often been used as one method to develop empathy. Universities, residency programs, and even hospital systems have successfully used reflective writing exercises to develop a practitioner’s empathy.¹ At the Cleveland Clinic, participating physicians attended training sessions that included reflective writing and small group discussions. Topics included the patient experience of pain and suffering, empathy across cultural barriers, and empathetic communication. This study found that facilitated small group sessions, which included sharing thoughts from reflective writing exercises, was effective in increasing self-reported empathy.¹

The Columbia University College of Physicians and Surgeons used a similar method of reflective writing to foster empathy development in an elective course that was structured to allow participants to deeply explore their personal experiences of illness. Throughout the course, students were asked to write about the cultural context of the illness as well as how the ill person was perceived by others. Similar to the Cleveland Clinic exercise, students were given the opportunity to share and discuss their reflective writing. Students in the course indicated that they had a better awareness of their own personal illness and this awareness brought them closer to the experiences of patients.²

Shapiro and colleagues proposed a two-stage conceptual model that uses reflective writing to cultivate empathy in health professional students. The first stage is writing and the second is reading and listening.  It is during the writing phase that learners think about the patient’s situation and contemplate their own subjective and personal reactions to the patient.  Learners should also be aware of their voice (or point of view) in the reflective writing – is it the voice of the provider or patient? The learners should also be encouraged to express emotions, use imagination, and think creativity when writing. In this manner students may begin to see the psychological and spiritual dimensions of many clinical dilemmas as well as find creative solutions.⁴  During the writing stage prompts should be given to guide the learner. Prompts may include: thinking about a time when it was challenging to be empathic; reflect on an experience that gave you insight into patient suffering; and reflect on a personal illness.^1,2

During the second stage learners read and listen.  By reading out load and listening to the experiences of others, learners have the opportunity to empathize and sympathize with one another other. Shapiro defines this as witnessing – an act that creates responsibility in those who hear the testimony of suffering to not turn away, but rather to accept and acknowledge. Witnessing allows students to release their own helplessness and fears. Witnessing only occurs through mindfulness — excluding thoughts of past problems or future obligations and accurately and attentively listening and observing.  Sharing personal experiences often makes students feel vulnerable — which in turn allows them to understand their patients’ feeling of vulnerability.⁴  When students share their reflections, ground rules must be established. It is important that students feel safe.  Strict confidentially must be established.  All participants must listen to each other without judgment and offer support.⁴

The scoring of reflective writing can be challenging. Should student’s reflection be “graded” or should the student be awarded points merely for completing the assignment? When evaluating reflective writing, it is important to remember that the exercise is intended to foster and develop empathy. Therefore, any evaluation should ensure that students are truly growing from the experience. One validated evaluation rubric is the Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT). The rubric examines several elements of the writing process including spectrum, presence, description of conflict, attending to emotions, and analysis and meaning.  The performance on each element is assessed based the following ratings: habitual action (nonreflective), thoughtful action or introspection, reflection, and critical reflection. In addition, the evaluator rates the narrative as a whole as either transformative reflection and learning or confirmatory learning.⁵

Reflective writing is an effective method to teach and develop empathy in health professional students.  These activities can be easily facilitated and there is a validated grading rubric.  Learners can continue to use reflective writing throughout their careers.   But reflective writing does have some drawbacks.  For learners, reflective writing is difficult and requires considerable time to reflect and compose ones thoughts.  For teachers, there is a lack of evidence confirming its benefits in terms of actually increasing practitioner empathy applied to patient care. None-the-less, the literature shows that reflective writing can be successfully incorporated into any curriculum and formally evaluated.

References:

1. Misra-Hebert A, Isaacson JH, Kohn M, et al. Improved empathy of physicians through guided reflective writing. International Journal of Medical Education [Internet]. 2012 Apr 9 [cited 2014 Oct 1]; 3:71-77.
2. DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Academic Medicine [Internet]. 2004 Apr [cited 2014 Oct 1]; 79(4):351-356.
3. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree [Internet]. [Chicago]: Accreditation Council for Pharmacy Education; 2011 Jan 2006 [cited 2014 Oct 1]. 35, ix, xxvi, ps.
4. Shapiro J, Kasman D, Shafer A. Words and wards: a model of reflective writing and its uses in medical education. Journal of Medical Humanities [Internet]. 2006 Sep 26 [Cited 2014 Sep 29]; 27:231-244.
5. Wald HS, Borkan JM, Taylor JS et al. Fostering and evaluating reflective capacity in medical education: developing the REFLECT rubric for assessing reflective writing. Academic Medicine [Internet]. 2012 Mar [Cited 2014 Oct 4]; 87(3): 355.
6. Peterkin A, Roberts M, Havey T. Narrative means to professional ends. Canadian Family Physician [Internet]. 2012 Oct [Cited 2014 Sep 30]; 58(10): e563-e569.
7. Wald HS, Reis S. Beyond the margins: reflective writing and development of reflective capacity in medical education. Journal of General Internal Medicine [Internet]. 2010 Jul [Cited 2014 Sep 30]; 25(7): 746-749.

Anticipating Difficult Situations in Experiential Learning

by Kaitlin Pruskowski, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Bayview Medical Center

Inevitably, all preceptors will be faced with difficult teaching situations in the experiential learning setting.  Both the teacher’s and the student’s skills and expectations can contribute to these difficult situations.  Lack of motivation, either on the student’s or preceptor’s part, can play a big part in a difficult teaching situation.  In addition, not understanding generational differences and expectations can lead to problems.

Teacher-specific factors that can make teaching difficult include poor teaching skills, lack of experience, and not being well-prepared to supervise students.¹  Student-specific factors include lack of effective communication skills, poor baseline-knowledge, and lack of ‘real world’ skills.  Because students lack real-world experience, they may question a preceptor’s recommendations.  When this occurs, it may be helpful to direct the student toward the evidence on which the recommendation is based.  Additionally, mismatched teaching and learning styles, personal insecurities, and life events may contribute to difficult teaching situations.¹

Lack of motivation may also be a significant contributor.  A student may lack internal motivation and is only motivated by external factors (i.e., grades).  Because the learner may not be interested in the subject matter, she may only be willing to do the minimum work required.  Her actions and body language may reflect this.  The student may be tardy, not prepared, or not willing to participate during patient care rounds or group meetings.  Similarly, a preceptor may not be motivated to teach his student.  The preceptor may not make time to meet with students and may not provide clear instructions about what is required.

Generational differences can also play a role in difficult learning situations.  Today, there can be up to three or four generations sharing a common workplace.²  Each generation has its own unique attitudes with regard to work, work-life balance, and respecting authority.  The ‘Baby Boomers’ tend to be ‘workaholics’ and work until they achieve the goals they have set for themselves.  They usually work to please their managers and coworkers.  Members of ‘Generation X’ tend to be self-reliant and are focused on building their resume.  Most are usually very knowledgeable about technology and how it can be used to improve the workplace.  ‘Generation Y’ value life-long learning and like problems-solving.  They are often dependent on technology and are comfortable participating in virtual meetings and communities.  With all of the technology available to them, they expect their preceptors to be available 24/7 to address questions or concerns.  If a preceptor and learner are of different generations, issues may arise due to these differences in values and expectations.²

So how can you prevent difficult teaching situations?  During the orientation period, teachers need to clearly define their expectations, including rotation schedule, workload, and interactions with the medical team.  The teacher/preceptor should know the school or program’s expectations of its learners; chances are that the learner has already received some instruction about these expectations – but it is up to the teacher to reiterate these to the student or resident, along with any rotation-specific requirements the teacher may have.³

Despite clearly stating the expectations in the beginning of the rotation, teachers may face problems as the rotation progresses.  Be sure to address these issues early! If the teacher ignores them, they will worsen with time.  Ask the student about what is going on.  When talking with the learner, it is important to stay calm and give objective feedback.  Be specific about what was observed and what the student can do to improve.

Hewson and Little conducted a survey of medical residents to see which feedback techniques were the most and least helpful.⁴  Feedback that was non-judgmental and based on observations was found to be significantly more helpful than disparaging comments that were not tied to specific events.  It is important to elicit the learners’ ideas and to offered suggestions for improvement.

Based on their findings, the authors developed a model for giving effective feedback.⁴  First, the learner should be given some ‘warning’ that the teacher like to give some feedback and to schedule a time to talk about it.  Next, the learner should be asked to do a self-assessment.  The student should identify what he does well and the areas in which he should improve.  Then, the teacher/preceptor can give feedback as to what the learner is doing well and what he can do to improve.  As a team, the teacher and learner should develop a plan for improvement.  The session should end with a follow-up plan developed by both the teacher and the student.

After meeting with a student and discussing difficult learning issues, the situation may not improve or may get worse.  When this happens, it is time to contact the school or program director.  Program administrators know that not every student is ‘perfect’ and that the teacher may encounter an especially difficult student from time to time.  The school needs to get involve and they are prepared to help if an especially difficult situation arises.

References

1. Langlois JP and Thach S. Managing the difficult learning situation. Family Medicine. 2000;32:307-309.
2. Ginsburg DB. Teaching across the generations: Challenges and opportunities for preceptors. Presentation given at The University of Texas at Austin College of Pharmacy. Austin, TX.
3. Langlois JP and Thach S. Preventing the difficult learning situation. Family Medicine. 2000;32:232-234.
4. Hewson MG and Little ML. Giving feedback in medical education: Verification of recommended techniques. J Gen Intern Med. 1998;13:111-116.