The Perils of Clinical Pearls

by Kimberley Harris, PharmD, BCPS, PGY2 Critical Care Pharmacy Practice Resident, University of Maryland

Picture this situation: you’re standing on rounds listening to the attending physician relate anecdotes about patients similar to the one being discussed and something catches your attention.  So you quickly write down this pearl of wisdom hoping you’ll remember it in the future.  I’ve kept a running list of these teaching points for nearly four years and have accrued an 80-page word document filled with “interesting thoughts to remember for later.”  But what have I collected exactly?  Could some of those teaching points contradict each other?  How will I retrieve a point written years ago and reliably use it in a clinical situation if I cannot remember its source or attest to its validity?

Clinical Pearls: Defined

The term “clinical pearl” is commonly used in medicine, but what are you truly getting when a someone uses the term?  Clinical pearls have been described as brief statements that are transmitted in a “catchy delivery style”, “generalizable to many patients”, “easy to remember”, and pithy “expert opinion.”^1,2  A clinical pearl is usually expressed by someone who is respected for having great knowledge about a topic through years of experience.²  Clinical pearls summarize key concepts and learners scramble to capture them.  However, from a teaching and learning perspective, these pearls lack certain important qualities.

The Dark Side of the Pearl

If clinical pearls are based on anecdotes and derived from personal experience, many (perhaps most) aren’t backed up by evidence.  And learning how to use evidence to make decisions is critically important in healthcare today.¹  Learners who rely on (and teachers who overuse) clinical pearls may hamper the development of critical thinking skills because they foster surface learning (which focuses on memory and recall).  Moreover, clinical pearls are hard to organize in a systematic way and do not require the learner to compare this new knowledge to prior knowledge.^1,3  For example, the acronym “MONA BASS” is commonly taught as a way to remember the medications that should be used to manage patients who present with acute coronary syndromes.  While this pearl may facilitate the learner’s ability to recall the recommended medications, it does not indicate which statin or dose would most benefit the patient, which medications reduce mortality, and which medications merely relieve symptoms.  A learner might forget that the “A” in BASS stands for “ACE inhibitor” (not “aspirin”) and that the second “S” stands for “salicylate”, a reminder to use aspirin … not any salicylate … and in some cases another antiplatelet agent would be a better choice.  So while MONA BASS is a helpful mnemonic, it only provides superficial clues about what the right course of action is and can easily be misinterpreted.

While a pearl can be useful in situations when data is lacking, they ideally should be paired with evidence in order to promote deep learning.  This type of learning focuses on problem solving, comparison of new knowledge with previous knowledge, and a search for truthfulness in the information that is presented.³   The following are a few strategies that teachers can employ to promote analytical thinking and avoid using the pearl as a sole teaching strategy. 

Facilitating Critical Thinking with Pearls

The One Minute Preceptor: This model was developed to efficiently and effectively teach in an experiential environment.  It uses a strategy which combines the Socratic method of questioning with constructive feedback and one minute of didactic instruction.  During these brief encounters, the preceptor discusses the general principles (or perhaps deliver a clinical pearl).⁴  By “gaining a commitment” from the learner and “probing for supporting evidence” via directed questioning, this facilitates the development of critical thinking skills.⁴  Using this Socratic-style of questioning, the teacher guides the students’ thought process to lead them through the clinical assessment.  Moreover, students do the majority of the talking.³  Once the students have realized the “big picture”, the clinical pearl is then used to summarize the key point(s).  The clinical pearl is now linked to a thought process related to a specific situation that the learner has experienced rather than rote memorization of a fact.

Link Pearls to Evidence: Evidence Based Medicine (EBM) is perhaps the antithesis of a clinical pearl.  It relies on available scientific evidence to make decisions for an individual patient.²  Critical thinking skills are necessary when applying EBM because the clinician must determine the quality of evidence and decide if the findings apply to the patient based on the population enrolled in the study.  However, EBM is not always useful, especially when the available evidence can’t be applied to the specific clinical situation at hand.  Ideally, EBM should integrate research findings with clinical experience to arrive at a decision that applies to the patient’s unique characteristics and situation.⁵  Since pearls are based on experience, they can be useful because they summarize the collective wisdom and expert opinion.¹ This is particularly important when EBM does not exist for a specific situation.  However, analytical skills are necessary to realize when an expert opinion is appropriate.  Pearls can be used as a way to introduce the learner to the application of EBM.¹  Back to our example, after introducing the “MONA BASS” pearl, a teacher could link the acronym to the guideline recommendations.   To then facilitate deep learning, students can use this foundation to critically examine the literature that supports the guideline recommendations.  This will help develop a connection between the surface message of the pearl and the deeper meaning behind it.

See the Pearl in a New Light

Clinic pearls alone do not provide the decision-making skills necessary to take prior knowledge and apply it to new situations.  Now, four years into my career, I can take my 80-pages of teaching points and erase half of them — not because I have memorized those facts/statistics/pearls, but because I now have the deep learning and critical thinking skills that give meaning to them.

References:

1. Lorin ML, Palazzi DL, Turner TL, Ward MA. What is a clinical pearl and what is its role in medical education? Medical Teacher 2008;30:870-4.

2. Mangrulkar RS, Saint S, Chu S, Tierner LM. What is the role of the clinical “pearl”? Am J Med 2002;113:617-24.

3. Harasym PH, Tsai T, Hemmati P. Current trends in developing medical students’ critical thinking abilities.  Kaohsiung J Med Sci 2008;24:341-55. 

4. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419-424.

5. Straus SE, Richardson WS, Glasziou P, Haynes BH. Evidence-based medicine: how to practice and teach EBM, 3rd ed. Elsevier Churchill Livingstone. p. 1. 

Danger Zone: Failure Ahead

by Elaine Yip, Pharm.D., PGY1 Pharmacy Practice Resident, Kaiser Permanente Mid-Atlantic

John is a student in your class.  He has several unexplained absences, is unable to follow along during topic discussions, and has not turned in several assignments.  The end of the semester is approaching.  What should you do?  Wait for John to approach you for help? Give him a grade that is just enough to pass at the end of the year?  Fail him?

Luckily, I have not yet been confronted with this situation. However, as I engage in more teaching and supervise students during advanced practice experiences, I know that, sooner or later, I will be faced with this unfortunate and uncomfortable situation.  I am afraid that when that moment comes, I will not be prepared to handle it appropriately and will ultimately end up doing a great disservice to the student. I know that I am not alone in this fear.  In a survey of nursing student preceptors, approximately 18% reported a lack of confidence when dealing with and failing a student who was not performing well.¹  I have often wondered, what is the best course of action when it seems that a student is headed in the wrong direction or faces a real danger of failing?

In order to appropriately address the situation, we must differentiate between the types of failing students we may encounter. There are “actively” failing students who usually attend class, take notes, complete assignments, and participate in learning activities.² Despite this, they are still having a difficult time with the material. Thankfully, these are the students you tend to proactively seek assistance. The story can be quite different when dealing with “passively” failing students, like John. These are the students who skip class, don’t turn in assignments, and are not engaged in the learning process.  Most often, these are the more difficult students to work with as they may not be as receptive towards efforts to help.

Once you have identified which category the student falls into, it is important to understand the specifics about why that student is struggling. Whether it may be poor study habits, difficulty juggling multiple priorities, test anxiety, or other extenuating circumstances (such a learning disability or a mental health problem), each student should be evaluated on a case by case basis. In her study looking at nursing students who failed their clinical experiences, Duffy identifies common reasons including poor communication, lack of interest in the learning experience, persistent lateness, and lack of insight into professional boundaries.³

What strategies may be helpful in preventing students from falling into that danger zone in the first place^2,3,4? Course design, clarity of communication, and including more active learning in a course seems to be helpful. One study looking at failure rates in introductory science courses showed that highly structured course a that incorporated active learning activities had lower failure rates when compared to a less structured course that was taught primarily by lecturing.⁴  The failure rate dropped from 18.2% in the low-structure course to 6.3% in the high-structure course.  Here are some things you can do:

• Create a syllabus and set clear objectives: This conveys expectations and helps students understand exactly what they are held accountable for.
• Perform an audience analysis: Identify the needs of the students. Take into consideration how far along they are in their training.  Is your level of expectations consistent with what they should reasonably be expected to do?
• Use the Socratic Method:  Students are regularly engaged in answering questions and learn from the resulting discussion rather than simply being handed the information.
• Use ungraded, active learning exercises: Ungraded sample exam questions, case studies and in-class demonstrations can help students digest and discuss what they have just learned. It allows room for error and the discovery of weaknesses without the pressure of a grade.
• Use clicker/polling questions: These provide a helpful way to gauge audience understanding throughout the learning process. It enables the teacher to identify knowledge gaps early on that need extra review rather than wait until exam time.
• Implement a weekly class summary assignment: Have students write down what they think was the most important concept introduced that week and at least one question they have about the material.
• Provide frequent quizzes: This forces students to pace themselves and keep up with course content over the course of the semester rather than falling victim to procrastination.  Start quizzing early to identify students who are struggling and at risk for failing.

What if a student is already heading into the danger zone, like John? What can be done to get them back on track^2,5,6

• Talk to the student and do it early! Note your concerns and ask them if there is anything that can be done to help.
• Develop an action plan. Include the student’s input. The plan should include the instructor and the student’s roles to resolve the situation. Together, decide what reasonable and measurable outcomes would represent improvement.
• Schedule times for regular and constructive feedback.  The “sandwich method” can be used to help deliver negative feedback by first highlighting something the student has done well, then moving on to areas of improvement, and then ending with more positive feedback.  Feedback should not only occur when something is wrong.  Positive feedback will improve the student’s confidence and encourage continuation of that specific behavior.
• Perform regular self-assessments. This can be done formally in writing or as a discussion. The student should be asked to evaluate themselves on their performance and progress.
• Document, document, document. Make note of all of these interactions with the student and efforts made so far to resolve the situation.

Unfortunately, there will be some students who will not make any effort to acknowledge and act on your feedback. In these circumstances, you will need to make that difficult decision to fail a student.  Hopefully, by implementing these strategies, failures will be a rare occurrence.  If I’m ever faced with that decision, I will know that I have given it my best effort.

References:

1.  Heaslip V, Scammell JM. Failing underperforming students: the role of grading in practice assessment. Nurse Educ Pract. 2012 Mar;12(2):95-100.

2.  Buskist, W., & Howard, C. Helping Failing Students: Part 1. Association for Psychological Science RSS.  Accessed on January 24, 2014.

3.  Duffy, K. Failing students: a qualitative study of factors that influence the decisions regarding assessment of students’ competence in practice. University of Ulster. Accessed on January 24, 2014.

4.  Freeman, S, Haak D, Wenderoth M.  Increased Course Structure Improves Performance in Introductory Biology. CBE-Life Sciences Education. 2001:10:175-186.

5.  Buskist, W., & Howard, C.  Helping Failing Students: Part 2. Association for Psychological Science RSS.  Accessed on January 25, 2014.
6.  Ideas When a Student Has Difficulty: Understanding the Failing or Weak Student. Philadelphia University. Accessed on January 24, 2014.