Assisting Students with Disabilities During Experiential Education

by George Lamare Haines, PharmD, PGY1 Community Pharmacy Resident, The University of Mississippi School of Pharmacy

There is only one way to look at things until someone shows us how to look at them with different eyes.

—Pablo Picasso

At times it is hard to see problems that face others. Often, when a problem doesn’t affect a person, they don’t perceive it as a problem or that it exists because they don’t have to deal with it. This is certainly true when it comes to people with disabilities. There are many things that an able-bodied person takes for granted and never even considers. When it comes to students in college, title II of the Americans with Disabilities Act (ADA) protects people with disabilities from discrimination by universities, community colleges, and vocational schools.¹ Most of us are at least somewhat familiar with accommodations for students with disabilities in the classroom setting, but it is far less common to see these considerations in experiential learning environments.

Every educator tries their best to determine the most appropriate teaching methods for the largest number of students. For most programs, there are special accommodations made for students with learning disabilities in the classroom, like providing extra time during testing or having someone read the exam questions aloud. When students with disabilities enter professional programs, they will be required to participate in experiential education that places them in environments similar to those that they will work in after completion of their program. These “non-academic” settings, which are not under the control of the university or college/school, can be challenging for students with disabilities.

When the University of Colorado School of Medicine was faced with this, they took steps to ensure that their students were set up for success. To illustrate, the school made special accommodations for a third-year medical (M3) student who uses a wheelchair. The student was scheduled to start an Operative/Perioperative clerkship. Before the start of the student’s M3 year, the student met with the medical school dean to discuss requirements, barriers, and reasonable accommodations for the clerkship. The dean then met with preceptors for the clerkship to inform them of the student’s disabilities and to develop a plan for an optimal experience, which included selecting clerkships that would allow for maximal physical access and participation. By putting in this extra effort, the student was able to fully participate in all required clerkships and went on to complete the degree with honors.²

Due to the student’s proactive behavior, there was effective communication and reasonable accommodations made so that they could complete their clerkship. Early communication is the key here. As with most issues, if they are addressed as early as possible, the issue can be addressed before it causes real problems. Often administrators have to do the groundwork to ensure that learners with disabilities are able to complete the requirements of an experience. These steps are important for both physical and learning disabilities. Students with learning disabilities are often hesitant to report these since there is often stigma and shame. Or they may not understand the impact of their disability and the potential benefits of sharing the information with their preceptors.³

Preceptors and faculty in experiential education administration can determine reasonable accommodations for students if they are given adequate time, resources, and knowledge of the disability.⁴ There are five basic principles that should guide institutions to ensure that reasonable accommodations are provided. The accommodations should be based on a reliable diagnosis; they must mitigate factors of the disability that affect student competencies; it should be tailored to each experiential site; they must ensure collaboration and communication occurs between the students, staff, preceptors, and administration; and most importantly, it must uphold privacy. If the accommodation takes away from any of these, it can not be considered reasonable.⁴ Often, accommodations for a student with a learning disability can be made by minor adjustments to the environments, policies, and procedures. Students with physical disabilities may require significant adjustments in the environment.  By having proactive policies and procedures in place, preparing preceptors for what to expect, and monitoring student learning outcomes, students with disabilities have the best chance for success during experiential education.⁴

A recent commentary published in the American Journal of Pharmaceutical Education provides a stepwise approach to addressing these needs.⁵ The first step is to create a system for students to submit a request when entering the experiential program. Once the student has submitted the request, the program is then responsible for exploring accommodation options and sites that either already meet the requirments of the accommodation or that can reasonably accommodate the request. The next step would be applying and fully implementing these accommodations. This will look different for different locations and will depend on the needs of the student. For example, a student who does not have sufficient strength may be accommodated by shortening the length of the rotation day but extending the total number of days in order to meet the required number of experiential hours. Another example would be to avoid rapid-fire questioning for a student that struggles with processing information.⁴ A practice walkthrough by both the student and preceptor may also be useful before the start of the rotation to allow the student to familiarize themselves with the environment and what to expect when they start the experience. The final, and possibly most important, step is to monitor the effectiveness of the accommodation. Continued communication between the preceptor, student, and experiential program director is essential to quickly address oversights and ensuring the accommodation is effective.⁵

When we start looking at these required experiences from the student with a disability perspective, we see problems that we didn’t know were there. It takes students with courage to tell you what their needs are. Open, honest communication seems to be the key to addressing the needs of students with disabilities, especially in experiential education.

References:

1. Americans with Disabilities Act of 1990; 42, USC §§ 12101 et seq.
2. Malloy-Post R, Jones TS, Montero P, et al. Perioperative Clerkship Design for Students With Physical Disabilities: A Model for Implementation. Journal of Surgical Education. 2022; 79(2): 290-94.
3. Vos S, Kooyman C, Feudo D, et al. When Experiential Education Intersects with Learning Disabilities. Am J Pharm Educ 2019; 83(8): Article 7468.
4. Vos S, Sandler L, Chavez R, et al. Help! Accommodating learners with disabilities during practice-based activities. J Am Coll Clin Pharm; 2021; 4(6): 730-37.
5. Kieser M, Feudo D, Legg J, et al. Accommodating Pharmacy Students with Physical Disabilities During the Experiential Learning Curricula. Am J Pharm Educ 2022; 86(1): Article 8426.

Should We Adopt a Two-tier Grading System in Health Professions Education? Benefits and Practical Considerations

by Mary Kathryn Vance, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Grades have long been a cornerstone of educational systems, giving students and educators a way to measure the achievement of learning objectives within courses. Grades were first instituted in the 1700s in Europe to assign a rank order among students. By the late 1800s, several American universities had adopted a grading system with “passing” rates ranging from 26-75%. Eventually, this transitioned to the tiered grading system we recognize today, where an A generally means the student has scored at least 90% on the assessment (or received >90% of available points in the course), a B means 80-90%, a C means someone scored in the 70s, and so forth. Grades typically are attached to a descriptor.  For instance, an A might signify an exceptional level of achievement, a B good but not outstanding level of performance, a C a fair level, and a D signifies significant performance deficiencies but still passing.¹ While this is still the system widely employed by the majority of Doctor of Pharmacy programs in the United States, some programs have adopted a pass/fail or two-level grading system.

Several studies have shown that students in health professions programs, including pharmacy students, experience anxiety, depression, and stress at higher rates than their peers. This places students at a higher risk of developing burnout, which is characterized by exhaustion and a diminished sense of accomplishment.^2,3 Moreover, multitiered grading systems can foster unhealthy competitive environments among students. Two-level grading systems have been proposed as a potential way to mitigate stress, reduce competition, and increase students’ well-being. A survey with nearly 1200 first- and second-year medical student respondents found that students in schools using grading scales with three or more categories had higher levels of stress, emotional exhaustion, and depersonalization when compared to students in schools using two-level grading systems. Students in schools with multi-tier grades were also more likely to have seriously considered dropping out of school.⁴ Another study conducted at Mayo Medical School compared students from classes before and after implementation of a two-level grading system. Students graded with the two-level system had less perceived stress and greater group cohesion than their multilevel peers.⁵

One concern that educators express about two-level grading systems is that they can negatively impact academic performance. Students’ motivation to learn the material might be decreased because they may not have to understand the concepts as deeply to get a passing grade. Some evidence suggests this concern is more theoretical than true. At the University of Virginia School of Medicine, the first two years of the curriculum were changed from graded to pass/fail. When student performance was compared before and after the change, no differences were observed in subsequent course grads, grades during clerkships, or scores on the United States Medical Licensing Examination (USMLE) Steps 1 and 2 Clinical Knowledge boards.⁶ Similar results were seen at the Mayo Medical School — there was no difference in USMLE Step 1 board scores before and after changing from a multilevel to a two-tier grading system.⁵

While they do not appear to reduce students’ achievement during school, two-level systems may better position students to become self-regulated learners. Health professionals are expected to engage in a process of continuous learning throughout their careers. This may be difficult for some students after transitioning from a system with strong extrinsic motivators (i.e. grades) to professional life where the individual must muster the internal motivation to figure out what, how, and when to learn. Helping students develop into self-regulated learners while still in school lays the foundation for this to continue throughout their careers and ultimately increases their knowledge and skills to provide better patient care.⁷

Another potential disadvantage of two-level systems is a decreased probability for students to match with residency programs. The American Society of Health-System Pharmacists (ASHP), the organization that is responsible for pharmacy residency program accreditation, will soon be requiring that all accredited pharmacy residency programs develop procedures on how to evaluate the academic performance of applicants from pass/fail (two-tier grading) institutions.⁸ There is still the potential that students from institutions that have two-tier grading systems could be seen as less desirable or competitive. However, this effect was not seen in a study that examined the effect pass/fail grading on advanced pharmacy practice experiences (APPEs) had on residency match rates at 100 pharmacy schools in the United States over the course of 3 years.⁹ Unadjusted analyses showed that there was no difference in match rates between students from schools with multilevel and two-level grading systems. After adjusting for potential confounders, two-level grading was actually associated with higher match rates during one of the three years.⁹ Similar rates of success in residency placement were also seen in the study conducted at the University of Virginia School of Medicine before and after their transition to a two-tier grading system.⁶

Despite the potential benefits, two-tier grading systems have not been widely implemented in pharmacy education and when it has been implemented, they are some inconsistencies. A study examining the implementation of two-tier grading systems within Doctor of Pharmacy programs found that the programs varied in the terminology used to describe student achievement levels, minimum pass levels, and whether a class rank or GPA was calculated, among other factors.¹⁰ This lack of uniformity leads to questions as to how best to implement two-tier grading systems.

Experiential courses such as introductory and advanced pharmacy practice experiences would seem to lend themselves well to a two-tier grading system. These types of courses tend to vary in their rigor and requirements based on the practice site. This can make interpreting and interpreting letter grades assigned to a student’s performance is already difficult. There are a variety of labels that could be used in a two-tier system, such as pass/fail, pass/no pass, or satisfactory/unsatisfactory. These labels haven’t been evaluated, but the connotations with “fail” and “unsatisfactory” would seem to be more negative than “no pass.”

Converting non-experiential courses to a two-level system is controversial. In schools where this has been done, numerical grades given to assignments and assessments are used to calculate a student’s class rank. This could allow high achievers to be rewarded and give residency programs a way to compare applicants. We clearly need additional studies about two-tier grading systems to determine their benefits and risks and how to best execute them.

References

1. Cain J, Medina M, Romanelli F, Persky A. Deficiencies of Traditional Grading Systems and Recommendations for the Future. Am J Pharm Educ 2022; 86 (2): Article 8850.
2. Brazeau CMLR, Shanafelt T, Durning SJ, et al. Distress Among Matriculating Medical Students Relative to the General Population. Academic Medicine. 2014;89(11):1520-1525.
3. Geslani GP, Gaebelein CJ. Perceived Stress, Stressors, and Mental Distress Among Doctor of Pharmacy Students. Social Behavior and Personality: an international journal. 2013;41(9):1457-1468.
4. Reed DA, Shanafelt TD, Satele DW, et al. Relationship of Pass/Fail Grading and Curriculum Structure With Well-Being Among Preclinical Medical Students: A Multi-Institutional Study. Academic Medicine. 2011;86(11):1367-1373.
5. Rohe DE, Barrier PA, Clark MM, et al. The Benefits of Pass-Fail Grading on Stress, Mood, and Group Cohesion in Medical Students. Mayo Clinic Proceedings. 2006;81(11):1443-1448.
6. Bloodgood RA, Short JG, Jackson JM, Martindale JR. A Change to Pass/Fail Grading in the First Two Years at One Medical School Results in Improved Psychological Well-Being. Academic Medicine. 2009;84(5):655-662.
7. White CB, Fantone JC. Pass–fail grading: laying the foundation for self-regulated learning. Adv in Health Sci Educ. 2010;15(4):469-477.
8. American Society of Health-System Pharmacists. (2021). ASHP Accreditation Standard for Prost Graduate Residency Programs Draft Guidance.
9. Pincus K, Hammond AD, Reed BN, Feemster AA. Effect of Advanced Pharmacy Practice Experience Grading Scheme on Residency Match Rates. Am J Pharm Educ 2019; 83(4): Article 6735
10. Spiess JP, Walcheske E, MacKinnon GE, MacKinnon KJ. Survey of Pass/Fail Grading Systems in US Doctor of Pharmacy Degree Programs. Am J Pharm Educ. 2022;86(1): April 8520.