Advancing Community Pharmacy Practice Through Integrated Course Design

by Joseph Nosser, Pharm.D., PGY-1 Community Pharmacy Resident, University of Mississippi School of Pharmacy and Tyson Drug Company

A wise person once told me, “everyone wants progress, but no one likes change.” In recent years, pharmacy benefit managers (PBMs) have repeatedly reduced reimbursement rates to pharmacies.  For many independent community pharmacies, the traditional dispensing-prescriptions-only service model is no longer viable. Clinical services, such as medication therapy management (MTM), chronic care management (CCM), wellness visits, and immunizations can be (and successfully have been) implemented in community pharmacies to diversify revenue streams. Pharmacy students learn about community pharmacy practice through introductory and advanced practice experiences, as required in the 2016 ACPE educational standards.⁴

A wealth of research supports the effectiveness of experiential learning. However, a call to action has been issued to increase community pharmacy practice exposure in the didactic classroom. A 2011 study found that less than 40% of pharmacy students strongly agreed that they received the necessary education to provide clinical services and only 35% felt strongly confident in their abilities to provide these services in a community pharmacy.⁵ While many community pharmacy advanced pharmacy practice experiences expose students to the delivery of quality clinical service, these results suggest that pharmacy students would benefit from additional didactic instruction through an integrated-curricular design.

James Beane, the author of Towards a Coherent Curriculum, compared a traditional curriculum-based education to a jigsaw puzzle.^1,2 Students have traditionally learned in “disciplinary silos”, moving “from one classroom to another, one time-block to another, one textbook to another, and one teacher to another”.^1,2 Like puzzle pieces, each foundational knowledge course and each practical skill that is learned in a practice lab or experiential course contributes, only partially, to the final outcome. No single learning outcome or “puzzle piece” creates the entire picture needed to become an effective health professional. However, when those “puzzle pieces” in a curriculum are connected-together (in a thoughtful way), it can produce the picturesque mosaic that can truly impact real-world practice. Unfortunately, in most curricula, students gather the pieces of knowledge and skills in a “disconnected, fragmented” manner, and often have difficulty connecting those pieces.^1,2 Moreover, learning in this manner can be like assembling an intricate, 1,000-piece puzzle without the container’s display image.^1,2

In recent years, pharmacy schools have worked toward creating integrated learning experiences and facilitating their students’ assembly of the “puzzle pieces”.¹ Pharmacy education has experienced a paradigm shift to this integrated curricular model away from the traditional disciplinary model where each student was responsible for correlating classroom learning with pharmacy practice.¹ For example, pharmacy students are trained to administer immunizations in their first or second year, while learning about the pathophysiology and pharmacotherapy of diabetes mellitus in their second or third year. However, do students connect their knowledge about immunizations and diabetes mellitus when conducting MTM visits at a community pharmacy? An integrated curriculum intentionally creates a learning environment for students to make meaningful connections between their foundational knowledge and real-world practice.¹

Integrated course design generally includes a careful examination of learning goals, learning activities, and assessment/feedback methods. ³ Instructors for an integrated course must account for situational factors, such as class size, students’ knowledge level, and available resources, which can influence each component. Initially, the team of instructors must develop learning goals that define what students should be able to do in order to achieve success. The instructors use the course goals and resources to create activities and learning experiences that correlate with real-world pharmacy practice. Active learning strategies should be emphasized, which may include facilitated group discussions, group projects, and case-based simulations. Instructors use authentic assessments to measure and evaluate student performance, while also allowing students to provide course feedback for continuous improvement.³

A great example of an integrated course was implemented at the University of North Texas College of Pharmacy.  The goal of the course was to improve second and third-year pharmacy students’ knowledge about clinical and business management skills related to community pharmacy practice. This elective course was created by community pharmacy-trained faculty in collaboration with the university’s Center for Innovative Learning, which supports integrated course design in the classroom. The instructors created course learning goals based on the 2012 NACDS and NCPA competencies for community pharmacists.⁴ Moreover, feedback from community pharmacy residency programs guided their focus to emphasize certain clinical services (i.e., MTMs, CCM, immunizations, wellness visits) in the course content.^4,6 Instructors accounted for situational factors (i.e., class size, student’s prior knowledge) to create meaningful learning experiences. This course was offered to students who had previously completed training in point-of-care testing, patient assessment, and counseling during their first-year. The small class-size enabled student engagement and facilitated discussion.⁴ The course activities included a behavioral change assignment, topic discussions with guest lecturers, quizzes, and a group-based business plan proposal.⁴ The instructors used a pre/post survey to measure changes in the students’ knowledge and confidence. There were statistically significant improvements in student knowledge related to the course learning goals.  Moreover, there was a significant improvement in student confidence to perform these clinical services.⁴ Student feedback identified the guest-lecturing community pharmacists as one of the most valuable components of the course, as they shared real-world experiences that connected clinical knowledge and skills with the clinical services provided in their practices. Students also believed that the business plan proposal and behavioral change assignment helped them to develop the skills needed to implement clinical services and motivate patients towards behavioral change.⁴

The integrated course design model is an intentional process that promotes active learning, connecting students’ foundational knowledge from various disciplines with real-life applications.¹ Instructors should assess students’ abilities to connect and use clinical knowledge and skills across disciplinary boundaries, while also using previous knowledge to make new associations.¹ For example, an assessment could include a case-based, simulated MTM activity with a standardized patient.

While integrated course design has many advantages, several limitations for implementing this model have been identified, including the lack of research evidence regarding its effectiveness and the amount of time and resources required to create course content.¹ However, this model offers a promising alternative method bridging foundation knowledge acquisition to real-world applications.  This form of instruction may be especially when teaching students about community-pharmacy-based clinical services. As the scope of community pharmacy practice evolves, pharmacy programs should use integrated course design to prepare students to effectively implement and perform clinical services in the communities they will serve.

References

1. Pearson ML, Hubball HT. Curricular integration in pharmacy education. Am J Pharm Educ. 2012; 76(10): Article 204. Accessed March 7, 2020.
2. Beane JA. Towards a Coherent Curriculum. Association for Supervision and Curriculum Development. 1995. Accessed March 7, 2020.
3. Mantell A, Moore CS, Barnett A, et al. Composing a course for significant learning. Temple University, Center for the Advancement of Teaching. Accessed March 7, 2020.
4. Bullock KC, Horne S. A didactic community pharmacy course to improve pharmacy students’ clinical skills and business management knowledge. Am J Pharm Educ. 2019; 83(3): 6581. Accessed March 7, 2020.
5. Maynard RA, Wagner ME, Winkler SR, et al. Assessment of student pharmacists’ perceptions on participating in clinical services in the community pharmacy setting. Curr Pharm Teach Learn. 2011; 3: 123–136. Accessed March 8, 2020.
6. Schommer JC, Owen JA, Scime GM, et al. Patient care services provided at primary community pharmacy residency sites J Am Pharm Assoc 2013;53:e125–e131. Accessed March 8, 2020.

Rethinking Assessment Strategies

by Ben Carroll, PharmD, PGY-1 Pharmacy Practice Resident, North Mississippi Medical Center

Since making the transition from a student pharmacist to pharmacy resident, I have contemplated my four years in pharmacy school and whether the assessment strategies the instructors used were ideal. I graduated with almost two-hundred classmates. With such a large class size, my pharmacy school’s ability to provide individually tailored and personalized learning was limited. I feel that not only the school I attended but likely most others across the country, commonly fall short when it comes to using assessment strategies that accurately reflect the extent of a student’s learning.

Recently, I read the book Grading Smarter, Not Harder: Assessment Strategies That Motivate Kids and Help Them Learn by Myron Dueck.¹ In the book, Dueck contends that many of the assessment strategies teachers implement are detrimental to student motivation and achievement. He discusses ways educators can tailor assessment practices that really determine what matters most: student understanding and application of content.

The book challenges the traditional use of the grading policies related to late assignments and awarding zeroes for assignments not submitted. Dueck argues that the use of a grading scale from one to one-hundred does not make sense mathematically. Ten points separate an A, B, C, and D. However, if a student fails to turn in an assignment and is given a zero then 60 points separate that student’s grade between a D and an F. This scale can make missing a single assignment the “academic death penalty” and is mathematically inaccurate. It might be a better strategy to grade all assignments on the GPA scale of zero through 4 in which A=4, B=3, C=2, D=1, and F=0.

Dueck argues that it is unfair to assign a grade of zero to an assignment that was never submitted because this does not accurately reflect how much the student learned. In the book, he proposes giving uncompleted assignments an incomplete and implementing an intervention rather than handing out zeroes. There is a stepwise approach to this tactic. In the first step, the educator sets a timespan when each assignment should be completed rather than a due date. By communicating to students, that they have a certain window of time to turn in their assignment, they are given more flexibility and choice. The actual due date would be the final day in the timespan, but by setting a window of time for work to be completed, students may be less likely to procrastinate. This technique also helps prevent a flood of assignments from being submitted on a single day – making it more difficult for the teacher to grade them all in a timely manner. In the second step to this approach, Dueck suggests using a late or incomplete assignment form. Using this form, the student has the opportunity to explain why his or her assignment was not turned in. The form could include a section in which the student is asked to select potential interventions that might help him or her to complete the assignment. Dueck described examples of how this approach improved student success in his classrooms. One student in particular completed a form explaining that she failed to complete an assignment because of recent bouts of anxiety and panic attacks. This student was introduced to counseling resources at the school that she was not aware were available. Subsequently, her grades steadily improved.

This strategy of using incompletes and interventions rather than zeroes argues against a one-size-fits-all approach to assessing students. Conversely, when using grading and assessment strategies that are individualized, some students may feel they aren’t being treated fairly and others might take advantage of these lenient grading policies. None-the-less, I believe the benefits outweigh the risks. A fellow classmate of mine in pharmacy school was the mother of a child with a chronic illness that required frequent hospital admissions. I know that our school tried to accommodate her in certain ways, but there were times in which more leniency should have been provided in terms of extending deadlines and excusing absences. I don’t believe anyone in my class would have taken issue with a more flexible approach given her situation.

In the book, Dueck also argues that teachers should be more focused on finding ways to promote learning through creativity. In my opinion, pharmacy schools do not emphasize the importance of creativity enough. We take case-based multiple-choice exams with clear-cut, one correct answers. However, when we practice pharmacy in the real-world, we are frequently called to think creativity to solve complex patient issues. I spent countless hours in pharmacy school using notecards, highlighters, and acronyms attempting to memorize every detail about a medication in order to be prepared for tests. While I believe that a certain amount of this type of learning is necessary, I do think we should spend more time practicing “how to think” rather than memorizing. This can be done by setting up more project-based activities which require students to integrate knowledge across a range of disciplines. Perhaps students should not be assessed on their performance during these activities. Removing assessments for these activities may alleviate some stress and students may feel more freedom to think outside the box. They may also be more inclined to ask questions knowing every word isn’t being critiqued. Creativity promotes curiosity and requires students to think on a deeper level about concepts and ideas.

When thinking back on some of my best teachers, I realize that they all shared one common attribute: the ability to motivate. In the book, Dueck states, the best teachers are “often better coaches than teachers” and highlights the value of applying coaching skills learned on the playing field in the classroom. I believe that, in general, coaches are more likely to develop personal relationships with their players than teachers are with their students. Coaches often share personal stories about how they overcame adversity to improve to motivate their players. I feel many students would benefit from their teacher adopting this approach. Coaches also promote the importance of team unity whereas in the classroom it sometimes feels like every-man-for-himself. Teachers can promote more unity in the classroom by not grading on a curve. Grading on a curve encourages students to constantly think about how their grade compares to their classmates. Studies have shown that students in competitive class environments do not learn or retain information as well as students in more cooperative class environments.² Also, the use of a curve is based on the idea that the aptitudes of a single class represent a sample of the general population which is rarely the case.

I think we should rethink the assessment strategies commonly used in pharmacy and other health professional schools.  By adopting coaching techniques and giving students more flexible opportunities to demonstrate what they have learned, they will be more motivated to achieve success, and would, in turn, begin their careers as better clinicians.

References

1. Dueck M. Grading Smarter, Not Harder. Assessment Strategies That Motivate Kids and Help Them Learn.  ASCD; Alexandria, VA., 2014,
2. Humphreys B, Johnson RT, Johnson DW. Effects of cooperative, competitive, and individualistic learning on students’ achievement in science class. Journal of Research in Science Teaching. 1982;19:351–356.