Interprofessional Education: An Argument for Starting Early

by Kimberly A. Toussaint, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

When was your first professional encounter with a physician? What about a nurse? For me, it was during my fourth year of pharmacy school, on my first clinical rotation. Prior to that time, my collaborative experience with other health care professionals was merely theoretical – as abstract as the patient cases that we were given to write SOAP notes about during my therapeutics labs.  During pharmacy school, there are numerous opportunities to gain teamwork experiences.  Many schools require group journal club presentations, SOAP note write-ups, and case presentations.  However, this group experience typically involves only other student pharmacists.  Although many health professionals are educated on universities located on a academic health center that include pharmacy, medical, nursing and dental schools (within walking distance of one another), integration of the education of these various disciplines is rare.

Although health professional disciplines work together on a daily basis, at the beginning of their professional experiences they are often unsure of the extent of the other disciplines’ training and knowledge. This is likely due to the fact that health professionals have little exposure to the curriculum, knowledge base, and perspectives of other disciplines during school.  Familiarity with other disciplines typically improves after health professionals are licensed and begin practicing (and even then, misperceptions are common).  When I started my first clinical rotation, I had no frame of reference for how much instruction regarding pharmacology or pharmacokinetics the medical interns on my team had during their classes. For this reason, I was unsure of how to phrase my recommendations. Often, I was concerned that I was regurgitating information they’d heard numerous times. As it turned out, I probably wasn’t explaining things well enough because my knowledge and perspectives were different.

The “Seamless Care” model addresses the need for interprofessional practice experience during training, and has been studied in Canada and Australia.  This model prepares students in health professional schools to become collaborative practitioners by forming teams of students from different health disciplines (medicine, nursing, pharmacy, dentistry, and dental hygiene) and having them work together for eight weeks to plan one patient’s transition from acute care to home.  The primary purpose of this model is to create a unifying task and facilitate a real-life collaboration between health professionals.  The model also serves to address a disparity in the continuity of care between hospital discharge and home. The students work under the guidance of experienced preceptors that helped to facilitate the care of the patient as well as helping the student develop team work skills by serving as a role model and mentor.^1,2

This model is built on several educational theories.  It is an example of social learning theory because the students are able to observe the ways that their preceptors work collaboratively with other disciplines, and model that behavior.  Constructivist learning theory is exhibited by the students working collaboratively to share past experiences and to increase their understanding of the patients’ care and their respective roles on the team.

A study done by Coster et. al published in the International Journal of Nursing Medicine in 2008 measured the readiness of health professional students to learn together, using a survey.  This study showed that students’ readiness for interprofessional education was high at the beginning of their professional education, but declined over time. These results support the notion that interprofessional education should start from very early in health professional students’ education.³

By integrating this interdisciplinary practice model early in the advanced pharmacy school curriculum, collaborative work habits, trust, and rapport would be facilitated between various health disciplines. Additionally, each discipline would enhance the knowledgebase of the others by contributing a new perspective. This would enhance experiential learning across all disciplines, and would benefit everyone on the team, especially our patients.  Interprofessional education involving pharmacists, physicians, and nurses providing continuity of care for patients will have long term benefits - increasing the quality for years to come.

Carlisle, Cooper, and Watkins summed it up best:

Teams have a collective responsibility that necessitates even closer interprofessional working relationships.  Complementary action is not enough.  It is essential to cultivate this working relationship, beginning in school.⁴

The future of healthcare relies on increased collaboration between health care professionals.  Collaboration is frequently limited by preconceived beliefs about other disciplines, and this is exacerbated by our limited exposure during our education.  This leads to a lack of understanding and trust among health care professionals.  Incorporating interprofessional learning into the curriculum of health professional students would increase trust and enhance collaboration between disciplines, and ultimately optimize patient care.

References

Mann K, McFetridge-Durdle J, Martin-Misener R. Interprofessional education for students of the health professions: The “Seamless Care” model. Journal of Interprofessional Care. 2009 May;23(3):224-233.

Nisbet G, Hendry G, Rolls G. Interprofessional learning for pre-qualified health care students: An outcomes-based evaluation. Journal of Interprofessional Care. 2008 January;22(1):57-68.

Coster S, Normal I, Murrells T. Interprofessional attitudes amongst undergraduate students in the health professions: A longitudinal questionnaire survey. International Journal of Nursing Studies. 2008;45:1667-1681.

Carlisle C, Cooper H, Watkins C. “Do none of you talk to each other?”: the challenges facing the implementation of interprofessional education. Medical Teacher. 2004;26(6);545-552.


[Editor's Commentary:  There has been increased interest in interprofessional education at most health professional schools over the past decade - but, unfortunately, there has been limited progress despite calls by many professional organizations and the Institute of Medicine to introduce interprofessional education early (and more often) within our curricula.  Deep in our hearts, we believe patients would gain from increased interprofessional collaboration.  The data to support this belief is accumulating.  Intuitively it makes sense to harness the power of people of various knowledge and skills into a cohesive unit.   But getting people to play in the same sand box isn't always easy - particularly when everyone has had their own sandbox in the past.  The patient-centered medical home or accountable care team model is emerging under health care reform as THE health care delivery model.  Under such models of care, payment structures reward interprofessional team work and meeting quality standards.  But how to get from here (silo care) to there (interprofessional care).  Its not going to be easy and its not going to happen over night.  Certain teaching our students in an interprofessional, collaborative manner will go along way toward breakdown barriers.  Dobson and colleagues at the University of Saskatchewan describe the work of interprofessional student teams including pharmacists, nurses, dietitians, and physical therapists in a paper entitled "A Quality Improvement Activity to Promote Interprofessional Collaboration Among Health Professions Students."  During this activity, small groups of students participated in a quality improvement project following the Plan-Do-Study-Act (PDSA) model.  Through this work, the students increased their understanding of their respective roles as well as the value that each member of the team brought to the project.  It is not difficult to imagine that these kinds of "hands on" projects could be implemented at various times throughout the curricula of health professional schools.  Moreover, guided by experienced practitioners from each discipline, the groups would design and implement projects that meaningfully contribute to the care of patients in a variety of settings.  The American College of Clinical Pharmacy has a strong policy statement regarding interprofessional education and recently published a white paper on this topic that I encourage everyone to read. - S.H.]

Simulation in Health Professional Education

By Chris Shaw, Pharm.D., PGY2 Emergency Medicine Pharmacy Resident, Johns Hopkins Hospital

Passive versus active. “Chalk and talk” versus hands-on.  Educators and theorists have suggested that active learning and learner participation produce better educational outcomes than traditional, lecture-based teaching methods. Lecture, and other forms of simple information dispersion, may still be required depending on the content area and students’ prior knowledge. However, it is not until the learner is able to apply that information to a given situation, thereby linking the theory with practice that true understanding materializes. One method that can be used to achieve this linking is through the use of simulation.

Simulation training has been used for decades in military and aeronautics training with positive results. In the realm of healthcare, surgery simulation has been well described and simulation has been used extensively to train cardiopulmonary resuscitative techniques and emergency preparedness. A simple PubMed search will retrieve thousands of results for ‘simulation training.’ Formal simulation labs as well as medical and surgical simulation fellowships have been created at some of the top medical centers around the country, including The Johns Hopkins Hospital, Duke University Medical Center, Harvard, and The Mayo Clinic. The recently formed Society for Simulation in Healthcare, which publishes a peer-reviewed journal, is a forum for scholars interested in simulation technology and techniques. Simulation in the training of health professionals seems to have cemented itself in the culture of health professional education. Why is that? I believe the answer is that as health care professionals, we are always looking for ways to continually improve our knowledge and skills, with the ultimate goal of improving patient care and outcomes.

The initial and continual training of health professionals is an important factor that contributes to this goal. Human patient simulation (HPS), or “a technique to replace or amplify real patient experiences … which evoke or replicate substantial aspects of the real world in a fully interactive manner,” is one method of active learning to help build and maintain skills. HPS is able to offer a method for putting theory into practice, while maintaining a non-threatening, safe environment for students to achieve competence through repetition.  HPS can be use to reproduce a variety of clinical scenarios. This is done with a wide margin for error as real patients are not put in harm’s way, illustrating the principle of risk minimization. For a list of additional pros and cons related to the use of medical simulation training, I refer you to a previous post on this blog.

HPS has been adopted by a number of pharmacy educators at schools and colleges of pharmacy in United States. There have been publications regarding the use of patient-simulation technology such as mannequins or computer programs to teach pharmacotherapeutics, pharmacokinetics, interdisciplinary team skills, advanced cardiac life support, and other topics in the pharmacy curriculum. The benefits of these simulations vary based upon the topic and simulation.

Does effective simulation require the use of expensive technologies? Why not use real people to simulate clinical situations? HPS can and often does utilize real humans. This may be one way for pharmacy programs to incorporate simulation into their curriculum if access to the simulation technologies is not an option.

In 1997, the World Health Organization published a report entitled “Preparing the Pharmacist of the Future: curricular development.” In this report, it was stated that as a communicator, the pharmacist “must be knowledgeable and confident while interacting with other health professionals and the public… communication skills involve verbal, non-verbal, listening, and writing skills.” How does this relate to simulation? The enhancement of communication skills through simulation is commonplace in pharmacy education.

HPS using humans in lieu of available technologies is a technique that has been adopted by many schools of pharmacy, including where I graduated, Northeastern University (NU), where we frequently use simulation for patient counseling. Actors would be brought in to serve as standardized patients, and different scenarios were put forth during class sessions. Students would be required to develop and deliver educational material, counsel the patients about their diagnoses and medication regimens, and answer questions. The questions posed were a combination of what had been prepared by the facilitators of the course and provided to the actors, as well as questions the actors improvised.  This added another level of complexity to the interaction. Simulation exposed us to different scenarios, enhanced our critical thinking, and provided an opportunity to practice the management of a patient encounter.  An advanced understanding of and ability to apply all the material involved in real-time was required. But most importantly, it was a way for us to link our didactic education with practice, prior to actually stepping foot in a real practice environment during clinical rotations.

Further exploration of a variety of simulation techniques should be promoted in pharmacy education. The study of both technology and human-based simulations should evolve, with the ultimate goal of producing and identifying methods to most effectively prepare tomorrow’s pharmacy professionals. Although I’ve had only  limited personal experience with simulation training, I felt much more comfortable and confident going into the “real” clinical setting. It was still a scary prospect going in out on rotations, but it was made exponentially easier as I had my prior experiences built through simulation to fall back on.

McGahie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research. Med Educ. 2010; 44: 50-63.

Schiavenato M. Reevaluating simulation in nursing education: beyond the human patient simulator. J Nurs Educ. 2009; 48(7): 388-394.

Mesquita AR, Lyra Jr DP, Brito GC, Balisa-Rocha BJ, Aguiar PM, Neto ACA. Developing communication skills in pharmacy: a systematic review of the use of simulated patient methods. Patient Educ Couns. 2010; 78: 143-148.

Haidar E. Clinical simulation: a better way of learning? Nurs Manag. 2009; 16(5): 22-23.

Learning Through Teaching

By Rachel M. Kruer, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

As pharmacy students and residents we often wonder why we are required to give frequent presentations and lead numerous topic discussions.  I have found myself wondering why it is that I am presenting a topic to my preceptor on subject matter for which she is viewed as the house-wide expert.  She obviously already knows the material.  For example, why lead a topic discussion on rapid sequence intubation to an audience of emergency department pharmacists?  Then it hit me!  After reading the material, I had a basic understanding of the mechanisms of pre-induction and induction agents.  I understood the kinetics of neuromuscular blockers.  However, it was not until I was asked to explain the sequence of drug administration and answer questions regarding the most appropriate agents for a patient with a specific injury, that I truly understood rapid sequence intubation. 

Heidi G. Elmendorf explained this phenomena quite nicely in her essay entitled “Learning through Teaching:  A New Perspective on Entering a Discipline.”   In her essay, Elmendorf describes an introductory level biology course she taught at Georgetown University targeted to non-science majors.   During a volunteer project, one of Elmendorf’s students found herself in charge of an elementary class.  The student did a quick mental scan for topics she could present to these children that would peak their interest.  In Elmendorf’s course, the student had been learning about childhood vaccinations, so she decided to lead a discussion with the elementary class on the basic scientific principles of vaccines and their use.  While teaching the subject matter she had recently learned, the student became more engaged in the material of her biology course.  When returning to Elmendorf’s course, she asked thoughtful questions so that she would be better prepared to answer the questions of others, including her elementary class students.  Elmendorf writes of her student, “Her experience spoke to the educational power of the intersection between the metacognitive engagement stimulated by the creative construction of knowledge and the affective impact of communicating that knowledge to a group eager to learn.”¹    

The essay reminds us of a supposition previously proposed by David Perkins, that learning facts is not equivalent to learning for understanding.²  Elmendorf describes a three-fold theory of understanding.  The first step is basal understanding of fundamentals. Next is structured understanding of the organization of ideas into a larger conceptual framework and how ideas from other disciplines are connected.  The final step is translational understanding in which the learner is able to move fluidly between organizational levels of information.  It is not until the third step is reached that one becomes fluent in a content area.  These steps in understanding correlate with the educational theories discussed in our course.  Behaviorists help us to understand the formation of a solid foundation of knowledge, while constructivists describe the mechanisms by which knowledge is internalized and organized.

Elmendorf believes that by teaching, students re-learn basic concepts in a way that deepens previous superficial understanding.  Learning through teaching has certainly been helpful in my practice thus far.  I often feel that my knowledge of a topic is superficial at best, until I really dig in and prepare a presentation or topic discussion in such a manner that I feel comfortable (well, as comfortable as possible) answering questions from the content experts.  It seems as though this concept of teaching through learning is used widely in the development of pharmacy residents.  It is also employed when we counsel patients.  We often ask patients to repeat back how they are going to take a given medication.  This model may be further utilized by asking patients to teach us how to take a medication, or use an inhaler, for example. 

Additionally, this model could be explored to a greater extent in formal pharmacy education.  Students are often asked to prepare presentations and topic discussions during their experiential rotations, however, this model could prove to be beneficial as a part of didactic teaching and learning.  Perhaps students would have a deeper knowledge of disease states after being required to teach the topic to others, whether that be students or content experts, prior to going on advanced experiential rotations.   The take home message from the Elmendorf essay reveals “that casting students in the role of teacher is a remarkably powerful way of making visible, to both the students and their instructors, some invisible shortcomings of traditional educational approaches.”

1. Elmendorf, Heidi G. “Learning Through Teaching: A New Perspective on Entering a Discipline”, Change: The Magazine of Higher Learning 2006; 38: 6, 36 — 41.

2. Perkins, David, “What is Understanding,” in Teaching for Understanding: Linking Research with Practice, M. Wiske, ed., San Francisco: Jossey-Bass, 1997.

[Editor's Commentary:  Research has shown that deep learning is facilitated when the learner articulates and expresses his / her understanding of the material.  This can be accomplished through writing about the subject, answering questions about the subject, or giving an oral presentation about the subject.  Teaching others typically requires the learner to do all three.  It is through these forms of expression - by explaining one's thoughts -  that a learner begins to solidify mental schema, organizational structures, and inter-relationships with prior knowledge.  Teaching requires thoughtful preparation.  The learner has to decide what information is most critical to convey, how to organize and sequence the material, as well as create visuals (or stories or analogies) that convey important concepts.  Moreover, teaching is a public activity - one that has potential consequences for those being taught.  So the incentives are strong and the stakes are high.  A learner who is teaching others is highly motivated to do a "good job" explaining the material.  The old adage "see one, do one, teach one" rings true.  So rather than giving your students a dull lecture on some topic ... ask them to teach you instead! - S.H.]

Engaging the Whole Mind

by Samantha Lee, Pharm.D., Clinical Toxicology Fellow, Maryland Poison Center/University of Maryland School of Pharmacy

Let’s begin with a simple exercise.  It doesn’t require a calculator to solve a kinetics problem or a reference book to look up a drug fact.  This only requires one thing: your brain.  Actually, the right side of your brain.  See that cartoon on the left side of the page?  Your task is to come up with a humorous caption to go with it.  Easy, right?

by Leo Cullum
Published in The New Yorker 8/21/2006
Available from the Cartoon Bank

This may seem like a fun activity that a middle school student might do, but it’s really a sample test question created for the Rainbow Project at Yale University.  As part of the project, they are developing an alternative scholastic aptitude test (SAT) designed to measure whole-minded abilities.  Concepts such as the Rainbow Project stemmed from the question: is our education system designed to help students to think creatively and express their true aptitudes, or are we just preparing them to survive rounds of multiple-choice exams that may not truly capture what they know and have learned?  Do we only place emphasis on standardization, routine performance and compliance?

In his book entitled A Whole New Mind: Why Right-Brainers Will Rule the Future, author Daniel Pink makes a case for the end of the “left-brain” era with a transition to the “Conceptual Age,” where the right brainers will flourish with their highly valued traits such as creativity, imagination and innovation.  While left brain thinkers have thrived over the past several decades in the Information Age, the once dominating traits of logics, functions, and linearity are no longer sufficient to meet the demands of a new world that values a more holistic and empathic big-picture view. 

Pink recognizes three factors that are causing this shift in change and which will impact the nature of our future employment: Asia (can jobs be done cheaper overseas?  We are seeing this in medical practice, such as radiology), Automation (can a computer do it faster?  We are definitely seeing automation in pharmacy with the use of robotics.  We don't have robot teachers . . . yet.) and Abundance (The world is awash in plentiful and cheap material goods.  Are we overloading the workforce with an abundance of pharmacy graduates as more schools are opening?)

Now the author isn’t saying we should only care about right brain thinking and let’s ditch the left, but rather it should be using both hemispheres of the brain to successfully navigate through this new era.  How can we capitalize on “r-directed thinking” in our classrooms?  Daniel Pink introduces his “six senses” to help develop the whole mind needed to meet the demands of the future.

1.     Not just function but also DESIGN – Function and significance should balance.  Basically, we want things that work, but it’s even better to have functional things that are pretty and engaging to the eyes.  For educators, this can be seen in the way we present our content - are we focusing solely on the content or can we balance it with an attractive presentation that would capture the students’ attention? 

2.     Not just argument but also STORY – Communication is as important as the story that it is told through.  Our minds gravitate better toward stories since many of our experiences and knowledge can be told through a narrative.  When I was in my third year of pharmacy school, I had to create a digital story to tell my leadership story by using video, pictures, music and audio. 

3.     Not just focus but also SYMPHONY – This is the ability to put the pieces together, connect the relationships and see the big picture.  In healthcare, it’s all about the symphonic interaction of the different professionals-the pharmacists working with the physicians, nurses and other staff ... and let's not forget THE PATIENT.   Many programs are now integrating interprofessional coursework into their curricula to ensure graduates are capable of working together ... and seeing the big picture.

4.     Not just logic but also EMPATHY – We all know this one. It’s the ability to put yourself in someone else’s shoes.  It’s essential for healthcare professionals to not just look at patient’s vitals, drug regimen, and physical exam, but get to understand the whole person.  How can we do this in pharmacy school?  As educators, are we exposing the students to activities and interactions that will bring out the humanistic side?

5.     Not just seriousness but also PLAY – “When you are playing, you are activating the right side of your brain.  The logical brain is a limited brain.  The right side is unlimited.  You can be anything you want.”  Using games as learning activities is one way for an educator to add the fun to learning.  Learning is about the content, but playing while learning is soul food for the brain. 

6.     Not just accumulation but also MEANING – “Man’s main concern is not to gain pleasure or to avoid pain but rather to see a meaning in his life.”  Educating students is an opportunity to make a difference in the world.  We can impact those students ... and our students impact patients.  We need to help students connect with the meaning of our work as pharmacists - not just the content.

As Dr. Seuss once said, “Think left and think right and think low and think high.  Oh, the thinks you can think up if only you try!”  As we embark on our path to academia, let’s rethink what we’re doing in the classroom to develop this whole new mind. 

P.S.  What was your cartoon caption?

[Editor's Commentary:  Left-brain thinking is logical, sequential, analytical. And there is little question that you need to be pretty good at that stuff to be a pharmacist.  But I think most of us would agree that being logical, sequential, and analytical isn't sufficient.  Our right-brain thinking abilities - creativity, sensitivity to design and aesthetics, empathy, and contextual awareness - are equally important.  Perhaps MORE important today because computers and other forms of automation are able to do the logical, sequential, analytical stuff far better than we humans could ever hope to do.  But computers have not yet mastered right brain thinking.  So, its time to flex some right brain muscle.  We need to spend more time teaching our students how to be creative, think holistically, and relate to people in an authentic manner. - S.H.]

Empowering Patients - Social Learning and Health Outcomes

By Whitney Redding, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins University Hospital

Social learning is defined, in the simplest terms, as the process by which a person learns from observing others. The belief is that we are most likely to model our behavior based on what we have learned from watching those around us.  The best models are those to whom we relate the most – often our peers.¹ Learning in a social setting plays a critical role in how we gather information and adapt successfully to our environment, but it can also be how we pick up less effective, less healthy habits.

As a freshman, I lived in a dormitory on a special floor designed for pre-pharmacy students, called a “Pharmacy Learning Community.” Our neighbors became our colleagues and we learned from each other not only the material taught in our classes, but also how to study and adapt to college life. I would say that I learned many good behaviors from those with good study habits on my floor, and I learned what not to do from those with poor study habits. I also picked up some very poor eating habits from my college peers, which differed from the environment in which I was raised.

For my sophomore year, I enrolled in Organic Chemistry. Our professor divided us into study groups the first week based on our previous GPAs. Together we discussed problems during class, completed extra credit assignments, studied and took exams. In addition to the active learning strategies used in the classroom this course created an atmosphere that embraced social learning among peers.  Groups that collaborated outside the classroom learned more and performed better than the groups that spent less quality time together.²

When it comes to our health, social learning is also a key element to success. Patients, as the learners, adopt habits from their friends and family that impact their risk of disease.  In a study published in the New England Journal of Medicine by Christakis and Fowler, it was found that among groups of friends, if one friend developed obesity, the other friend(s) was 171% more likely to become obese.³  And this increased risk of obesity was correlated to social closeness (rather than geographic closeness). In another study, smoking cessation was increased when a spouse or family member quit smoking. Moreover, smoking cessation tended to occur in clusters of people (not single individuals, one at a time) and in those with larger social networks.⁴ This research provides evidence that the impact of social networks on health cannot be ignored.

I wonder how effective it would be to create health learning communities for our patients, or health study groups. This has already been done in the setting of Alcoholics Anonymous, diabetes education and cancer support networks, but could also be expanded to smoking cessation, obesity and any number of other health-related behaviors. Research has been expanding in the areas of online health networks, and their impact on social learning.  Even television has tried to take advantage of observational learning in such shows as The Biggest Loser. The trend towards not only patient-centered care, but also family-centered care, is another example of ways the healthcare system should embrace social learning to improve health outcomes.

It is important to look at the big picture of health. How successful will a patient be at losing weight … when his or her closest friend is gaining weight? How easy will it be to quit smoking, when one’s social network continues to smoke?  How reliably will one take his or her medication, when his or her spouse has difficulty (or doesn’t believe in) taking medications? It seems to me a patient’s social environment and the role of social learning must be considered when implementing patient interventions.  How do we learn to use the power of social learning? Our patients may help us gain a better understanding of how to encourage healthy behavior.  Perhaps pharmacy education could provide opportunities for us to utilize this theory of learning to advance patient care. Both patients and healthcare workers alike would benefit from discussing the impact of how society and our own social networks impact our health.

¹Schunk DH, Hanson AR. Peer models: Influence on children’s self-efficacy and achievement. Journal of Educational Psychology 1985;77:313-322.

²Loudon GM. What happens when we change the way we teach organic chemistry?

³Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357:370-9.

⁴Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. N Engl J Med 2008;358:249-58.

[Editor's Commentary:  Clearly the social context in which we learn has a powerful impact on our behaviors.  Cultural norms of behavior are generally acquired through modeling ... not through explicit instruction.  While teachers and health care practitioners do have some influence on behaviors, we need to face the (sad) truth that our influence is rather small.  Very small.  Direct instruction - lecturing and/or counselling people on what they should (or should not) do - is ineffectual.  Active engagement improves the odds that someone will adopt a behavior ... and social engagement with influential peers improves the odds further still.  The risk of disease and the management of chronic illness is far more dependent on the social context than any "traditional" intervention that health professional "prescribe" or "counsel" patients to do.  And yet, our expectations as a society (and our payment systems) are built around one-on-one interactions between a patient and a health care provider ... rather than working with families and communities.  Public health practitioners have known for a long time the power of family and community on health outcomes.  Perhaps under a reformed healthcare system in the United States we'll learn how to PAY FOR best practices that harness the power of social learning.  To see what the University of Maryland School of Pharmacy is doing to improve the health of our community and to be a role model for social learning, check out our Rx for Health Habits website. - S.H.]

The Power of Praise ... Use it Wisely

by Brian L’Heureux, Pharm.D., PGY1 Pharmacy Practice Resident, Suburban Hospital

I’m sure you’ve been in the same situation.  The big presentation is finally over, and now it’s time for the evaluation.  Hoping for some valuable feedback to further improve your presentation content or hone your presentation skills, all you get is a “good job, great presentation” or maybe a “keep up the good work.”

In today’s culture, feedback always seems to come heavy on the praise and light on the criticism, for fear of hurting the student’s self-esteem.  While no student or teacher would enjoy outright criticism, praise can be equally damaging by not affording students opportunity to better themselves intellectually. In trying not to trample on a person’s self-esteem, feedback is falling flat and teachers are often not giving enough content to enable students to better their skills.  Is the problem the lack of constructive criticism?  Or is it the type or the amount of praise given?

In “How Not to Talk to Your Kids,” an article that appeared in the New York Magazine, Po Bronson writes about the inverse power of praise, and how too much praise may actually hinder intellectual growth.  Although the research presented was primarily done in elementary school-aged children, there is a definite connection with learners of any age.  The article outlines what characteristics of praise produce negative outcomes and the kind of praise that promotes the best results.  Praise should emphasize the student’s effort, be specific by highlighting the behaviors that are desirable, and be genuine.  Research by Dr. Carol Dweck indicates that when students were continuously praised on their intelligence, which is a quality that is outside of students’ control, they are more likely to underestimate their skills and only attempt easy tasks for fear of showing their intellectual vulnerabilities.  Dweck also demonstrated that when students are praised on their effort, which is something they can control, the children were more likely to try harder tasks and therefore have the opportunity to learn and improve their skills.  Secondly, praising specific behaviors, not issuing general platitudes, has been shown in many studies to be most effective.  One study described the effects of selective and specific praise on a losing hockey team.  The team started winning when they were given self-esteem boosting praise that was specifically directed at the number of checks each player gave during games.  Lastly, the article points out that by the age of 7, children become suspicious of praise.  If the child determines that the praise is disingenuous, the student may feel patronized and that the praise signifies that they’ve reached the limit of their capabilities.  Constructive criticism on the other hand, can signify to a student that they still have the ability to improve their skills.

To bring into the context of the issues we are discussing in this course, the “praise” described in the article is feedback, and the students are adults.  As pharmacists, we can appreciate the fact that learning continues throughout our lives.  Thinking back on the feedback that I’ve received in the past, I’m starting to see how I was impacted – positively and negatively.  The author also alludes to the fact that great feedback requires a good deal of effort.  The next time that you have the opportunity and responsibility of providing feedback to someone, consider the potential impact you can have on their development.  The effort can certainly be worth it.

Bronson, P.  “How Not to Talk to Your Kids.”  New York Magaine. 2007: Feb 19.


[Editor's Commentary:  Feedback is a critical component of the learning process.  Feedback from teachers can be especially powerful.  Feedback not only helps students focus on the things they did well and points out the things they can (should) improve ... but it also impacts students' motivation to learn.  Most of us think of feedback as a dichotomy - its either praise (uplifting, positive speak) or criticism (disheartening, negative speak).  Praise is believed to affirm a person's self-esteem.  While criticism is generally believed to be (potentially) destructive or harmful.  While there is little doubt that criticism can be a used (intentionally or unintentionally) like a weapon to breakdown and diminish people, praise can have a corrosive effect too.  In the book "Punished by Rewards," Alfie Kohn describes how the use of carrots (and sticks) has inadvertent and negative consequences in our schools, the workplace, and at home.  The judicious use of "praise" in the form of describing specific behaviors that the teacher feels is desirable can help students (children or adults) know what they are doing well.  But growth can only come when the teacher is willing to point out what could be done better.  Striving for better does not imply that the performance was "bad" or "poor."  It simply means there is room for growth.  And frankly, isn't there ALWAYS room for growth?  Constructive criticism, delivered in a manner that suits the individual's learning style and judiciously applied at the right time, is perhaps a teacher's most powerful tool.  Dr. Dweck's research demonstrates that our job is to help student develop a positive (growth) mindset toward learning ... and this can't be accomplished through the indiscriminate use of praise.  -S.H.]

E-Learning and Health Professional Education

by Nicholas Fusco, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

“Everyone take your seats. Let’s get started. We have a lot to cover today.”

As the lecturer quickly goes through their outline and objectives for the class, you frantically try to organize your mind for the impending deluge of information. Physiology, biochemistry, pathology, pharmacology, clinical guidelines, monitoring parameters, adverse effects and the list goes on. The lecturer unflaggingly presses forward as your wrist begins to cramp from scribbling down each bit of seemingly invaluable information. Soon, you realize you may have missed something and turn to your neighbor for help. You look to the left and find your best friend in Stage 1 of non-REM sleep. You turn to your right and find another classmate starring helplessly at the board, jaw slightly dropped, eyes glazed and you wonder if you should check his vital signs. While all this has transpired, the lecturer has moved on. No time for stragglers. Every student for themselves! Before you know it, the lecture is over. You’re left floating in a sea of new information. I hope you can swim (or at least brought a raft).

Sound familiar? Traditional, instructor-centered teaching placed the teacher in control of the learning experience. Increasing demands on academic faculty to accommodate the ever-expanding field of biomedical science and to incorporate new fields of practice has challenged the way in which they deliver this information. Emerging from these challenges is a new, learner-centered model that allows the student to be in control of their learning experience. One vehicle by which information can be delivered that supports the learner-centered model is that of “E-learning” or Web-based learning. E-learning is the use of any Internet or computer-based technology as a source of instruction. It can be broken in to two broad categories of distance learning and computer-assisted instruction. Distance learning describes those technologies that allow for the delivery of information to remote sites from a central location. Computer-assisted instruction utilizes one or more sources of multimedia to aid in the delivery of information. These terms are not mutually exclusive, nor do they need to be separated from traditional, instructor-led learning. In fact, most instructors already take a blended approach, supplementing a traditional lecture with online or computer-based aids.

The advantages of E-learning can be summarized in two main categories, learning delivery and learning enhancement. For the student, well-designed E-learning scenarios increase their accessibility to the content, allows them to customize their learning experience and control the pace, time and even the media by which the instruction is delivered. For the instructor, the ease by which online multimedia can be updated, distributed and standardized sets it apart from traditional print media. Learning enhancement is less well described, but is just as important as learning delivery. As more institutions embrace competency-based curricula, a greater emphasis is being placed on learning outcomes. By allowing the student greater accessibility and customization of online multimedia, E-learning supports a more efficient learning process. Based on it’s interactive nature and the degree of control that the student exhibits over the delivery of the content, E-learning can potentially motivate the student to become more engaged with the content and through this increase retention rates.

A unique challenge of E-learning is in its evaluation. As more learning becomes student-based, the instructor’s role will evolve from a transmitter of information to a facilitator / evaluator of learning. The process of E-learning must be closely evaluated to determine whether the experience was appropriate, well designed, and met the needs of the students that it was intended for. Likewise, outcomes must be measured to determine how efficiently E-learning was able to alter a student’s knowledge or skills. It is important to make a distinction at this point between learner satisfaction and efficacy. E-learning should be interacting and engaging, which certainly will provide some degree of entertainment to the learner. Subjective evaluations of E-learning may yield high levels of learner satisfaction if the experience was fun or entertaining, and may falsely lead the instructor to believe the learning experience was efficient or effective. Poor content can be masked by an entertaining design and may lead to ineffective learning. It is therefore important to develop effective, instructor-mediated strategies for the evaluation of outcomes of E-learning. In many health care professions, the preferred technique for evaluation of skills is direct observation. This can be time consuming, costly and inefficient. A combination of web-based competency evaluations combined with direct observation may allow the instructors to perform a more thorough evaluation of the student’s knowledge, while still engaging the student in traditional, face-to-face assessments. Further development of this area is needed and may potentially be a source of scholarship to academic faculty in the future.

E-learning offers several advantages to both the student and the instructor. Wouldn’t it have been nice to be able to press “Pause” during some lectures to recollect your thoughts before moving on to the next, big idea? Customization of learning experiences may better accommodate different learning styles, which can simultaneously enhance the learning process and improve outcomes. As E-learning becomes a more integral part of health professional education, students and instructors will benefit from this vehicle to navigate the great sea of knowledge.

References:

Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med 2006;81:207-12.

Leung WC. Competency based medical training: review. BMJ 2002;325:693-6.

Ward JP, Gordon J, Field MJ, Lehmann HP. Communication and information technology in medical education. Lancet 2001;357:792-6.

[Editor's Commentary:  E-learning includes a range of electronic tools (hardware and software) that are employed in the learning process. When most people think about e-learning, they immediately think of computers connected to the Internet but it also includes mobile devices like cell phones and MP3 players … as well as a range of software tools, increasingly web-based applications.  Mobile computing devices and the Internet have revolutionized the way we can deliver instructional materials.  But is this new delivery method better or worse than older methods of deliver (namely, oral expository in a classroom and written materials in the form of books, journals, and handouts)?  This dichotomous question, is e-learning better or worse than traditional methods of learning, forces us to think in terms of either/or rather than examining things in a more holistic manner.  Most instruction delivered through an e-learning conduit is no better or worse than the face-to-face methods it is attempting to “replace.”  Indeed, most instruction delivered online is merely a replica of what would have been delivered had the learner been seated a few feet in front of the teacher. Perhaps the biggest advantage of e-learning is that it often can increase availability and access.  Most e-learning materials are available to students in an enduring way – and accessible from any computer 24/7 anywhere in the world.  Face-to-face instruction often enjoys an advantage with regard to greater social connection and interactivity – thus the transactional distance between the teacher and learners (and among learners) is smaller.  Clearly an important benefit.  Thus institutions and instructors who have embraced “blended learning” have an opportunity to maximize student learning by using a variety of instructional tools and methods, online and in the classroom, exploiting the advantages that each has to offer.  So the decision to use e-learning should not be a yes or no proposition, but rather a who, what, why, when, and how analysis. –SH]

Early Practice Experiences & Curricular Reform

by Liana Mark, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

Standard number 11 of the 2006 ACPE Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree states that “the pharmacy school must use and integrate teaching and learning methods that produce graduates who become competent pharmacists by fostering the development and maturation of critical thinking and problem skills.”  The Standards also go on to say that “the pharmacy school must enable students to transition from dependent to active, self-directed lifelong learners.”  This lofty goal is easier said than done, and I am not entirely convinced that the majority of pharmacy school curriculums enable students to achieve these objectives upon graduation.

My school of pharmacy implemented early (i.e. pre-P4) experiential learning into its curriculum after the 2006 Standards were published.  As such, I participated in both introductory and intermediate pharmacy practice experiences during the summers after my P1 and P2 years in addition to P4 advanced pharmacy practice rotations (APPEs).  During the school year, most learning was passive via didactic lectures and, in some cases, active through laboratory experiences and discussions.  Looking back, it seems as though I grew as a professional and as a learner at an exponential rate during my P4 APPEs, compared to the rather modest growth in the first few years of professional schooling.  My capacity to learn and apply resembles a J-curve, with a significant upswing towards the end of my student years.  However, now that I have the ability to look at pharmacy education from a bird’s eye view, I must say that I would have preferred my learning curve to resemble first-order kinetics during those years; with a steady, progressive increase that would have allowed me to build upon my prior knowledge and learn how to problem solve and critically think through problems early on, rather than just retaining factual knowledge and finally having a number of “a-ha!” moments at the end of my student career when everything suddenly fell into place.

So, the question is, how can first-order learning be promoted?  First, we must identify the barriers.  Passive learning techniques employed in the didactic portion of the Pharm.D. program provide limited opportunity for the development of problem solving and critical thinking skills.  This obstacle is mainly due to the factual nature and the sheer volume of information that pharmacy students must learn in order to create a substantial knowledge base.  A student can manage to pass via “cramming” and regurgitating the information on an exam, but this method of retention (because it is clearly not learning) benefits neither the learner nor his/her future patients.  Additionally, factual information, especially in the field of pharmacy, changes from year to year.  Taking this into account, treatment guidelines learned in the P1 year may not be applicable by the time the student reaches APPE rotations.  Thus, honing the skills of critical thinking and problem solving is absolutely necessary to prepare the student pharmacist for independent practice and satisfactory patient care.

Active learning is a more effective learning method for long term retention.  This method of learning includes discussion, practicing by doing, and teaching others.  Experiential learning is employed in many healthcare professions to prepare the student for independent practice, pharmacy included.  However, pharmacy experiential learning comes much later in the student pharmacist education as compared to other healthcare professions, and the experiential learning we do get early on is sparse and, in my experience, not fully maximized.  Students of dentistry, optometry, medicine, and physical therapy all have active, hands-on learning placed very early on in their curricula.  As such, by the time these students graduate, they have a strong fundamental, and, more importantly, applicable, knowledge base.  Individuals in these professions are well-equipped upon graduation to walk into a real-life setting, given that they have been in the setting as an apprentice for years.

A potential solution for student pharmacists is to incorporate weekly practice experience starting in the first few days of the Pharm.D. curriculum.  This integration would allow the student to apply facts learned in the classroom to a real situation, thus enabling him or her to critically think, problem solve, and retain the information in a different way than strictly classroom-based learning allows.  Weekly practice experiences may not be feasible due to course load.  Thus, another solution, which is employed at a number of pharmacy schools, is co-operative experiential learning, wherein the student pharmacist alternates classroom learning and experiential training from one semester to the next.  The experiential training, of course, must be coordinated with the classroom learning of the student.  My school’s current format that consists of IPPEs and APPEs could be maximized by ensuring that preceptors have a better understanding about their responsibility to the pharmacy student and to their profession.

It is clear that pharmacy education lags behind other professions in its active learning experiences.  Pharmacists need to be exposed to real-life situations earlier in their careers in order to meet the ACPE Standard that encourages the development of critical thinking and problem solving capabilities in the Pharm.D. curriculum.  Through active learning techniques, student pharmacists will be able to retain knowledge and create for themselves usable, applicable databases that will serve to improve their clinical abilities as practitioners and, additionally, encourage the pursuit of lifelong learning.

DiPiro JT. Making the most of pharmacy school. Am J Pharm Educ 2008; 72(1) Article 15. 

DiPiro JT. Why do we still lecture?  Am J Pharm Educ 2009; 73(8) Article 137. 

Duncan-Hewitt W and Austin Z. Pharmacy schools as expert communities of practice? A proposal to radically restructure pharmacy education to optimize learning. Am J Pharm Educ 2005; 69 (3) Article 54.

[Editor's Commentary:  Is the typical pharmacy curriculum backward ... based on outdated, unproven notions about how people learn?  Should we provide students with experiences first and then talk about the theory and science that supports the practice of pharmacy afterward?  There are perhaps practical reasons why pharmacy schools (and most other professional schools) have elected to front load their curricula with didactic course work and save the practical experiences for the end. But most of the reasons have more to do with scheduling and resource allocation, not pedagogy or instructional design. Let's examine how one would go about teaching people to play a guitar (and to be good enough to make money playing it).  Now, learning how to play a guitar is complicated stuff.  To get really good at it you have to learn new terminology (e.g. adagio, allegro, forte), read (and perhaps even write) an entirely new form of communication (e.g. music notations), play different styles of music, and coordinate your actions with other people who are simultaneously playing their musical instruments or singing. If we approached learning how to play a guitar the same way we approach pharmacy education, we'd have the students sit through a series of didactic lectures about the guitar and its history, about guitar playing techniques, how to select a guitar, how to read music, and how to be a member of a band.  We'd probably have students watch an instructor (or better yet, a resident!) play a guitar in front of the class.  And then we'd have everyone watch videos of Eric Clapton and John Scofield playing guitars - and then debrief about it for 30 minutes.  In addition, we'd have the students participate in 3 or 4 "guitar labs" each semester where three or four students would use the school-provided XBox or PS3 and play "Guitar Hero" (or something like that) - and watch each other play - for a couple of hours.  And then, we'd have a one week observation (P1) and a one-month (P2 and P3) "guitar playing" rotation with a preceptor.  The student probably wouldn't be assigned his or her own guitar to play - but would rather "assist" the preceptor with some guitar playing activities (like, for example, handing the preceptor the right pick to use).  In the fourth year of our "guitar school,"  each of the students would be sent off into the field and would be asked to start playing guitars - 40 hours a week!  This would probably overwhelm our students, who haven't yet built the skills to play guitar very well on their own nor the stamina.  But, during the last year of the curriculum, most of our students would, indeed, get pretty good at it.  Most would become competent guitar players (good enough to be street musicians) and a few would become stars (acclaimed by their audience and peers as truly great musicians).  Many of our students would arrive at our fictitious guitar school with some guitar playing experience - and nearly all of them would be innately interested in guitar playing.  But we wouldn't let them touch a guitar until they've completed a least 16 credit hours of instruction about the latest statistics regarding guitar playing in the US, music theory, and (of course) the physics of sound.

Seems a bit absurd, doesn't it?  If you wanted to learn how to play guitar, the first thing you'd do is pick a guitar and try to make some sounds with it (not take a series of didactic lectures about it).  And a good teacher would encourage you to do so.  In fact, you probably wouldn't be allowed into "guitar school" unless you had access to a guitar and could get practice using it several hours a week.

I encourage you to read a provocative article by Wendy Duncan-Hewitt and Zubin Austin published in AJPE.  I think the traditional pharmacy curriculum is a relic of the past.  Its time to rethink and radically restructure things. -SH]