Interprofessional Education: Building a Bridge to Interprofessional Cooperation

By Susan Montenegro, Pharm.D., PGY1 Pharmacy Practice Resident, Union Memorial Hospital

Many schools boast having an “interprofessional culture,” which (apparently) they define as having more than one health professional school located on the same campus. But simply having schools across the street from each other, sharing a cafeteria, and hosting a few campus-wide social events, does not come close to building the relationships needed for optimal patient care. Many students in the health professions are taught a structured approach to managing a patient. So interprofessional education (IPE) shouldn’t be so difficult – should it? How can educators from different schools build bridges and encourage students to make the journey? How do we encourage the healthcare system to sustain these bridges?

I envision the answer to this question to be a three step process analogous to constructing a bridge to connect two places. Step 1 is putting together a blue print and building a structure.  As with any improvement process, first you need to put everything down on paper so everyone can see it. How will the bridge be built? Who will build it? Who will pay for it? Why is the bridge necessary? What are the benefits? A plan must be made and a proposal submitted to garner the support of the university, and secure the funds needed, to build the structure. Once these things are secured, those in charge of the project can begin to lay the foundations.

The American College of Clinical Pharmacy (ACCP) released a White Paper on IPE which describes considerations relevant to IPE.¹  Fundamentally, it is important for students to understand the knowledge and skills that other members of the healthcare team possess. Students must also realize that different professions take different approaches to patient problems in terms of assessment and evaluation. The paper describes several examples of IPE models.  Each approach has its strengths and future IPE programs can be optimized by building on these examples.

Creighton University Medical Center in Omaha, Nebraska has a number of IPE initiatives.² Collaborative Care Seminars are held one half-day each semester and involve students in dentisty, medicine, nursing, occupational therapy, pharmacy, physical therapy, and social work.  During these seminars, students are encouraged to reflect on what their own profession’s contributes to patient care and how to work together and understand what other professions have to offer. The Medical Center also offers a clinical conference and grand rounds series during which case-based discussions are led by panelists from the various health professions. This allows students to learn and observe how to participate in similar discussions once they start clinical training.

Step 2 is convincing the students to take the journey across the bridge. Students will only make the journey if they understand the importance of arriving at the destination. Where are they going? Why are they being asked to cross into unknown territory and away from familiar and safe ground? What are the benefits?

Another example from Kings College in London involves pairing a fourth year pharmacy student and a third year medical student to work together.³  Both students are starting their clinical year of training, so they have similar amounts of clinical experience and knowledge of therapeutics. Each student pair is assigned a patient with the objective of obtaining a medical and medication history.  The student pair is then instructed to organize the information and present it to a group of faculty and students.  They are expected to summarize the patient problems, the rationale and appropriateness of the treatment regimen, and how to monitor the patient for efficacy and adverse effects.  The results of this activity have been positive, with the medical students learning how to be more proficient at collecting the medical history of a patient and the pharmacy students being more proficient at collecting and managing the patient’s medication history. This type of activity is promising to demonstrating to health professionals early during their training how to maximize patient care by relying on the strengths of different professions.

A post-course questionnaire administered after the student pair activity found that 95% of pharmacy and medical students agreed or strongly agreed that it was useful to learn with other disciplines; 88% agreed or strongly agreed that there were equal contributions from both students; and 83% agreed or strongly agreed that more sessions were needed.³  This data shows that, given the opportunity, students are willing to meet other professions half-way and see the benefit in doing so.

Step 3 is ensuring that the destination (on the other side of the bridge) exists ... developing and continuing to foster the types of working environments where recent graduates can continue to use the skills they learned during IPE. This may require more time to develop as it will require holistic support. Not all clinicians have experienced IPE and many may feel threatened by the changes it will require. However as more programs move in the direction of IPE and as more workplaces emphasize the importance of inter-professional teams, the bridge built by educators will become stronger, producing a brighter and more promising future to optimize patient care.

In 2001, the Institute of Medicine released a report addressing the gaps in health care in the U.S. and how to redesign the health system. Titled, “Crossing the Quality Chasm: A New Health System for the 21^st Century,” this report stated that health care needs to be safe, effective, patient-centered, timely, efficient, and equitable.⁴  Included in the report were 10 general principles meant to guide improvements to meet these health care needs. One principle, stated quite simply and directly, “Cooperation among clinicians is a priority.” Thus, it is clear that our healthcare system needs to move towards interprofessional cooperation and that IPE will play an important role in making that future a reality.

References

1.  American College of Clinical Pharmacy. ACCP white paper. Interprofessional education: principles and application. A framework for clinical pharmacy. Pharmacotherapy 2009; 29: 145e-164e. [Accessed September 26, 2010].

2.  Interprofessional Education. Creighton University Medical Center. [Accessed: November 22, 2010]

3.  Greene RJ, Cavell GF, Jackson SHD. Interprofessional clinical education of medical and pharmacy students. Medical Education. 1996;30:129-133.

4.  Institute of Medicine.  Crossing the Quality Chasm: A New Health System for the Twenty-first Century.  Washington, D.C.: National Academy Press, 2001.

Taking Learning Outside the Classroom

by Olabode Ogundare, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

Do you remember those schools days when the weather was so nice outside and you wish your class was also outside so you could really enjoy the fresh outdoors as well as learn? How about those last days of spring semester when your school still had the heat on and it was unbearable for you to learn anything … but if you were outside it probably would have improved your attention span? Well, if you agree with these statements, then taking learning outside of the classroom might be just what you need to help improve your learning experience!

Outdoor education is relevant to educational theory and practice because it is an instructional method. Outdoor education is a type of instructional style that dates back to the early 1940s. It involves the use of outdoor learning settings to cover subject matter through hands on learning experiences. Outdoor education is still practiced in today’s educational system and can involve educational activities outside of the classroom such as field trips, field work, camping, or simple observation of the environment. What differentiates outdoor education from the more ‘traditional’ instructional methods is that it incorporates several of the different learning styles into its teaching method, thus allowing students to have an individualized learning experience that correlates with how they learn.  Outdoor education plays a significant role in shaping the education of children and may help enhance their learning.¹

In an article from Education.com titled, Environmental Education Programs Help Kids Connect to the Earth, Peter Bergstrom discussed how many adults feel that there is a steady decline of appreciation for nature in recent years. He emphasized that it is important especially for children to get in touch with nature because in his words, “fundamental to discovering who you really are, that you are not a person apart from nature, but a part of nature." If take a look at our education system, the amount of outdoor time children are allotted gradually declines overtime as they progress through their education. I think being able to connect with nature helps to develop critical skills that are not taught in the classroom setting. Outdoor educational programs similar to Bergstrom’s, help “kids recognize that they are smart in a different way from classroom smart,” which highlights that outdoor learning helps students engage beyond the norms of the classroom and enhance their learning experience.²

A study by the California Department of Education showed that six graders’ science knowledge test improved by 27% after participating in an outdoor educational program. Feedback received from the students showed that a majority of them felt that their participation in the outdoor education program actually changed them. When one student was asked whether he benefited from the program, the student responded, “Yes, because I learned more; I like science a lot because it helped me to protect the environment even more.” This demonstrates that outdoor educational programs really can enhance one’s learning experience and help students perform better academically.^3,4

The study entitled Effects of Outdoor Educational Programs on Children clearly demonstrates the potential role outdoor education may have on shaping the education system in years to come.⁴ Educators need to realize the students they encounter have different learning styles and it may not excel when traditional classroom-based methods are used.  Outdoor education is an alternative for students who seek to be engaged and have an active role in their learning experience. Most importantly, outdoor education programs have shown to improve academic performance in students.  Educators should be inclined to incorporate this instructional method as part of their teaching style to enhance their students’ learning.

References:

1.  Outdoor and Environmental Education. [Internet]. [Online: Education.com, Inc]; [Periodically updated; cited 2010 Nov 10] 

2.  Boutis, Nick.; Krisko, Beth. A Life Shaping Week: The Outdoor Education Experience [Internet]. [Online: Education.com, Inc]; [Periodically updated; cited 2010 Nov 8]

3.  What Does Environmental Education do for Children [Internet]. [Online: Education.com, Inc]; [Periodically updated; cited 2010 Nov 10]

4. Effects of Outdoor Education Programs for Children in California. American Institutes for Research. January 31^st 2005: 33-41

What is the Target?

by Angela L. Bingham, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

What is the target?  To answer this question, student pharmacists must be given a clear description of what they should be able to do after completing a learning experience.  Regardless of the field of study, instructors should give their students explicit instructional objectives.

In the “Required and Elective Educational Outcomes, Goals, and Objectives for PGY1 Pharmacy Residency Programs,” the American Society of Health-System Pharmacists (ASHP) defines educational goals, educational objectives and instructional objectives.¹  Educational goals are “broad sweeping statements of abilities.”  Achievement of educational goals is determined by assessing the learner’s ability to perform educational objectives.  Instructional objectives further narrow the focus by outlining the “knowledge and skills required for successful performance of the educational objective.”  Instructional objectives are helpful to educators and students by identifying areas for improvement to meet educational objectives.¹

Beyond providing students direction, instructional objectives help improve quality and efficiency.  According to Dr. Louis Vontver, “Instructional objectives should delineate specifically what the student is expected to do or know in terms of the student’s ability to demonstrate his skill or knowledge.”²  Objectives can only be measured effectively if they are simple.³  Measurement of complex outcomes and goals can be problematic because of the multi-factorial nature of the assessment needed.  Instructional objectives narrow the focus and help control for variables.

The Accreditation Council for Pharmacy Education (ACPE) also highlights the importance of objectives to facilitate learning.  ACPE states, “specific criteria should be developed to enable faculty and students to assess progress midway through the experience and at its completion. Students should be provided the opportunity to demonstrate achievement of stated competencies as assessed through the use of reliable, validated criteria.”⁴

When I was a student pharmacist, I was involved in a project that examined the role of self-assessment tool to evaluate the value of instructional objectives.  During this research project, a self-assessment tool was constructed using educational objective and instructional objective statements from the “Required and Elective Educational Outcomes, Goals, and Objectives for PGY1 Pharmacy Residency Programs.”⁵  Students performed self-assessments using this tool and their responses were compared to scores assigned by the preceptor for educational objectives and instructional objectives.

Twenty 3^rd-year Doctor of Pharmacy candidates participated in the study.⁵  When comparing students’ self-assessment to the preceptor’s scores on the educational objectives, students were more likely to rate themselves higher for “accurately assess the patient’s progress toward the therapeutic goal.”  A significant difference was also seen when comparing “display initiative in preventing, identifying, and resolving pharmacy-related patient-care problems.”  In contrast, using instructional objectives improved the accuracy of student self-assessment.  There was no significant difference between student and preceptor scores for any of the instructional objectives.

As a result of this research project I concluded that, in order for students to understand course expectations, course syllabi must clearly outline the knowledge and skills needed to meet the educational objectives.⁵  Providing instructional objectives to students enable self-directed learners to achieve desired expectations.⁵ The learner and preceptor share a mutual understanding of the knowledge and skills required to meet an educational objective. ⁵

In addition to giving students greater clarity, instructional objectives also aid the instructor.⁵  When the learner and instructor understand the expectations, confrontation may be avoided at the time of evaluation.⁵

In an experiment conducted at the University of Washington Hospital in Seattle, Washington, medical students completing nights on obstetric call were provided with specific instructional objectives.²  Medical students were issued a document outlining objectives prior to nights on call.²  The medical students were instructed to read the document several times before each scheduled night and again during on-call period.²  The following morning, the students were expected to demonstrate fulfillment of the objectives.  Before implementation of objectives, the performance of the medical students during morning rounds were “highly erratic.”  After instructional objectives were provided as well as some instruction on how to use them, the students performed much better.  They were often able to fulfill all of the expectations after only one night in the delivery room.  Beyond guiding medical students, the instructional objectives also prevented misunderstanding by other members of the health-care team by clarifying the students’ responsibilities.²

When educators provide instructional objectives, students are more likely to find the target.  Well-written instructional objectives enable self-directed learners to achieve desired expectations.  Also, instructors may find assessment easier when clear instructional objectives are available.  Thus, instructional objectives are vital tools to both educators and students.

REFERENCES

1. Required and Elective Educational Outcomes, Goals, and Objectives for PGY1 Pharmacy Residency Programs. American Society of Health-System Pharmacists. 2008.  Available at: http://www.ashp.org/s_ashp/docs/files/

RTP_PGY1GoalsObjectives.doc. Accessed November 15, 2010.  

2.  Vontver LA. A Use of Instructional Objectives To Increase Learning Efficiency. Journal of Medical Education. 1974;49:453-454. 

3.  Norman HG. Schmidt GR. Effectiveness of Problem-Based Learning Curricula: Theory, Practice, and Paper Darts. Medical Education. 2000; 34(9):721-728.

4.  Accreditation Council for Pharmacy Education: Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Available at: http://www.acpeaccredit.org/pdf/ACPE_ Revised_ PharmD_ Standards_ Adopted_Jan152006.pdf. Accessed November 15, 2010.

5.  Bingham AL, Hess MM. Self Assessment as a Tool to Evaluate the Value of Instructional Objectives. ACCP Annual Meeting. Anaheim, CA. October 18, 2009.

Pay Attention to the External Realities

by Kathleen Fuller, Pharm.D., PGY2 Pharmacotherapy Resident, University of Maryland

With the recent midterm elections, public education reform has again been the center of much media buzz. The documentary Waiting for Superman¹, directed by Academy Award-winning director Davis Guggenheim, identifies some of the major problems with the current American public education system, while also offering a glimpse of possible solutions. The film highlights the success of public charter school programs including the Harlem Children Zone (HCZ)² and the Knowledge is Power Program (KIPP)³. These programs are built on the concept that education must extend beyond the school day to correct for the external factors that influence how learning occurs in the classroom. While these programs have been developed for primary education, they offer lessons that are applicable to both adult and patient education.

The Knowledge is Power Program

"Every day KIPP students across the nation
 are proving that demographics do not define destiny."³

Started as single school in 1994 by Mike Feinberg and Dave Levin, the KIPP network now consists of 99 schools in underprivileged areas of 20 cities nationwide enrolling 26,000 students. The program is based on five pillars: high expectations, choice and commitment, more time, power to lead and focus on results. The programs are rigorous and both the school days and the academic years are extended. Curriculum is built around character, leadership and community involvement, as well as traditional subjects. But what may be most important, high expectations are placed on children who may otherwise not be expected to graduate high school or attend college.³

Over 85% of KIPP students enroll in college, compared to less than 40% of low-income students nationally. And 100% of KIPP 8^th grade classes do better on state tests for math and language arts than their district averages.³

The Harlem Children’s Zone

"A child is more than just the test scores they get inside a classroom.
They live in families and communities. And where those families
and communities are struggling we have a responsibility
to help those children."² – Geoffrey Canada

Recognizing that the unique struggles the children of Harlem, NY faced were contributing factors to the poor performance of the schools in that district, Geoffrey Canada founded the HCZ in 1997. The HCZ targets a 100 block area and serves over 10,000 children. Using a community based approach the program aims to "give poor children the things middle-class children take for granted".⁴ This includes programs that educate expectant and new mothers, pre-K programs, after school programs, fitness and nutrition education, internship placement, college preparatory programs with one-on-one counseling sessions, and public health initiatives.²

One of the public health initiatives provided free asthma screening in the HCZ and then deployed case managers to visit the homes of children identified as having asthma to educate on medical assistance programs and environmental trigger control. Counselors went as far as to assist tenants in contacting the building managers of apartment buildings to demand necessary repairs and rodent extermination.⁵ Far-reaching, all-encompassing interventions, such as this, characterize the work of the HCZ and impact every aspect of life for the children enrolled in this program.

An independent study compared winners of the HCZ enrollment lottery to those that entered the lottery but did not win. They concluded that "the effects in middle school are enough to reverse the black-white achievement gap in mathematics."⁶

Application to Adult and Health Education

While adult learners may not be as impressionable as the students targeted by the HCZ and KIPP programs, external factors certainly impact their educational performance.  The theories applied in these programs can be extended to adult education.

How many of the students in your program are the primary caregiver for children or parents? How many have jobs outside of your program? How many do not have the technological literacy or access to the technology necessary for your program? Ask adult learners to reflect on their experiences to identify perceived barriers to achievement.

Develop a technology primer course. Distribute literature regarding child or elder care services in your area. Create flexible deadlines that can accommodate rigorous work schedules. And finally the strategies need to be implemented and assessed.

The principles are even more important when educating patients. Patients present from tremendously varied backgrounds and living situations. It may be easy to tell your patient with heart failure to avoid prepackaged foods with high salt content. But it is harder to walk down the aisles at the discount grocery store and find such foods in the same price range. As the HCZ asthma program illustrates, educating patients to recognize environmental triggers is different than walking through their homes and coaching them on strategies to realistically modify these triggers.

While you or I may not be in a position to implement the types of sweeping change we have seen from Geoffrey Canada, Mike Feinberg and Dave Levin, each of us can start small by analyzing the students and patients we teach to identify how their external lives affect our educational efforts.

1. Guggenheim D (director). Waiting for Superman [Movie]. Paramount Pictures; 2010.

2. Harlem Children’s Zone [Internet]. New York (NY): Harlem Children’s Zone. Updated 2009.

3. Knowledge is Power Program [Internet]. San Francisco (CA): KIPP Foundation.

4. Sayles M. Geoffrey Canada [Internet]. New York (NY): The New York Times; 2010 Oct 12.

5. Perez-Pena R. An Everyday Struggle for Breath; Childhood Asthma Project Reaches out in Harlem. New York (NY): The New York Times; 2003 May 1.

6. Whitehurst GJ, Croft M. The Harlem Children’s Zone, Promise Neighborhoods and the Broader, Bolder Approach to Education. Washington (DC): The Brookings Institution; 2010 Jul 20.

Inspiring Students - My Path Towards Nuclear Pharmacy

by Amber Mae Todd, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

If someone had told me in my first year of school that I was going to choose nuclear pharmacy for my career, I would not have believed them. I would have never guessed that I would spend the next two summers learning how to elute technetium from a generator at 2 am, or discussing the properties of medronate while watching the sunrise. What could have happened that changed my perspective so much. I went from having no clue about where I wanted to go, to falling in love with any drug that sets off a Geiger counter. There had to be one very inspiring teacher in my life for this to transpire.

I have often wondered what qualities an inspiring teacher possesses. What does it take to inspire a student? One study by van der Zee and de Jung entitled “Teachers as a Source of Inspiration in Catholic Schools”, defines inspiration in the following way:

… inspiration may be regarded as mental causation of perlocutionary effects that, through the outstanding qualities of the source of inspiration, may motivate people, on the basis of suitable aptitudes, to have certain thoughts and desires and to perform certain actions.¹

In other words, inspiring teachers, using the special qualities that they possess, can change the actions and perceptions of their student(s). In my opinion, this is the definition of what it means to teach. A teacher should always leave a lasting impression on their students' perceptions. I believe the student should walk away from the experience changed in some positive and profound way. It was certainly the case for me; I was never the same after crossing paths with my teacher.

What qualities make a teacher inspiring? Certainly enthusiasm, patience, empathy, and the ability to explain a subject proficiently are important qualities.¹  van der Zee and Jung describe the teacher as a leader. They contend that a teacher must inspire their students in the same way a leader of an organization would inspire their followers.  Some of the leadership qualities that they point out include: vision, charisma, promoting intellectual stimulation (challenging a student), and being a role model. I do not believe a teacher must have all these attributes to inspire. However, having a few of these characteristics are probably necessary. In my case, my teacher was enthusiastic, patient, and proficient at explaining details. He challenged me and he was an excellent role model. His enthusiasm helped me to see the significance and life-changing nature of every radiopharmaceutical we made.

There are other factors that can affect the inspiration process. In Barbara Davis’ chapter entitled “Motivating Students” in the book Tools for Teaching, she points out several classroom strategies that can help motivate learning and inspire students.² These include: making students active participants in learning, hold high but realistic expectations of your students, help students set goals for themselves, and explaining to students what they need to do to succeed.  These methods can help boost student confidence and help students to begin working and thinking independently.

My teacher inspired me. His proficiency at explaining concepts was amazing; this included his patience in repeating points where I was confused. A teacher who can explain things clearly is easier to follow. This will provide a greater understanding that leads to confidence and the ability to complete tasks successfully. Challenging a student can help increase that student’s confidence, as well as teach them to “work outside the box.” Challenges can show them that they can apply their understanding to new and stressful situations.  Lastly, my teacher was a role model.  The purpose of a role model is “to trigger a thought, an assurance, a vision, a character and a way of life, which can serve as the impetus for a students' personal and professional growth.”³ My teacher did that.  He showed me night after night what a great nuclear pharmacist could look like. It’s an image I took to heart.

It is no small thing to change a student’s perceptions.  Often, an inspired student will remember the lessons the teacher bestowed on them for the rest of his/her life. It takes a unique set of attributes to inspire someone.  I was lucky to find a teacher who had so many of them. He inspired me to take the path to nuclear pharmacy. When we become teachers, we must try to inspire our students … and change the path they take in their lives.

Sources:

1. van der Zee T, de Jong A. Teachers as a source of inspiration in catholic schools. Journal of Empirical Theology 2009 06;22(1):7-29. 

2. Gross Davis Barbara. Tools for Teaching. Hoboken: Joey-Bass, An Imprint of Wiley. c1999. Motivating Students.

3. Meetu. Teachers as Role Models. [Internet] BrightHub. 2010 Apr 5. [cited 2010 Oct 29] Available from: http://www.brighthub.com/education/special/articles/17266.aspx

Application of the Socratic Method in Health Professionals Education

by Stacy Elder, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

The Socratic Method is a widely used term for teaching via question and answer dialogue between a teacher and a student. However, the Socratic Method has undergone many changes since its first documentation by Plato, a student of Socrates.  Health professional instructors frequently employ various forms of this style of teaching in order to explore the critical thinking of their students and trainees. Analysis of the Socratic Method in the healthcare setting is a prime example of the evolution and contemporary utility of this mode of teaching.

The classic Socratic Method involves dismantling prior ideas in order to free the mind to think about a topic without the constraints of preconceived notions. By definition, this method deconstructs all prior thoughts on a topic and leaves the learner without a satisfactory answer to the primary question. Socrates taught that the only person who cannot learn, is the person who thinks he already knows the answer, so it is logical to remove prior beliefs in order to make way for the creation of new ideas. An example of the classic Socratic Method is observed in Meno, where Socrates asks Meno to define virtue. They discovered that they could not define virtue and, furthermore, virtue could not be taught. Meno learned that even this common term, when broken down to its fundamental parts, was actually not definable. As you might imagine, it was an Earth-shattering revelation for Meno to realize that it was impossible to trust even the most basic beliefs. The abolishment of prior beliefs on a subject is the deconstructive phase of the Socratic Method.

Once the student’s mind is freed from the constraints of prior beliefs, the teacher is free to bring forth new ideas during the constructive phase.  Notably, the teacher’s role in this scenario is to help the student clear away previous ideas in the deconstructive phase so that he may build new ideas in the constructive phase. Socrates stressed the importance of humility on the part of the teacher, due to the need to create a safe environment for the student to have these revelations. He believed that the teacher served to help the student do his own learning and asking questions was his method to facilitate that goal.

The classic definition of the Socratic Method is not always practical for teaching health professionals.  After the abolishment of the definition of virtue during Meno’s lesson with Socrates, Meno suggested a paradox that no one could ever question anything if definitions are impossible. Science, in general, does not accept the impossibility of defined answers, making the classic Socratic Method incompatible with the field of science. Also, healthcare does not generally involve discussion of abstract ideas. Established definitions of terms used to describe conditions and disease states are a critical part of healthcare learning. Standard, well-accepted “truths” in medicine make it possible to advance patient care by using the outcomes from research in a specific subset of patients in order to apply the highest level of decision making to patient care. However, the Socratic Method is still utilized in healthcare teaching, in a modified form.

The modern Socratic Method differs from the classic method by establishing that knowledge is recollection. Another of Socrates’ theories was that a student can only learn that which he already knows. Therefore, the teacher’s role is to facilitate the production of a constant progression of defined knowledge from the students pre-existing stores. In general, the teacher asks direct questions that have a predefined range of answers, allowing the student to answer correctly before moving on to the next step in the construction of an idea. If the student is unable to answer the question at hand, the teacher is responsible for guiding the student to a point where he/she can conquer the question.  This is accomplished by helping in the student/trainee recollection prior knowledge required to answer the question.  The modern Socratic Method is compatible with the training of health professionals, and it remains within the scope of Socrates’ belief that a student can only learn things that he already knows.

Using the Socratic Method is more than asking a lot of questions. In contrast to “pimping,” the Socratic Method requires the teacher to create a nurturing environment and ask helpful questions to achieve the desired lessons for the student.  Teachers must recognize that these probing questions can expose ignorance … and this can invoke fear in the student.  But Socrates described the role of the teacher as similar to a midwife, in that they facilitate by clearing the way for the student to bring forth new knowledge without intimidation. In any setting, finding the balance between using progressive questions to provoke deep thought while maintaining a comfortable environment for learning is the key to using the Socratic Method of teaching.

References

1    Maxwell, M. Introduction to the Socratic Method and its Effect on Critical Thinking. [Accessed on 9/30/10].

2    Fritts, HW. Are We Socratic Teachers? Trans Am Clin Climatol Assoc 1979;90:109–115.

3    Gordon, LA. Is the Socratic Method Illegal? Am Surg 2003;69:181-182.

4    Oh, RC. The Socratic Method in Medicine-The Labor of Delivering Medical Truths. Fam Med 2005;37:537-539.

I Finally Earned My Doctorate!!! Wait…Can I Find a Job?

by Mina Kim, Pharm.D., PGY2 Pain and Palliative Care Resident, University of Maryland School of Pharmacy

By Jeff Parker
Available from floridatoday.com

This cartoon depicts an unfortunate reality over the past 2 years.  Due to the economic recession, many graduates have found themselves without jobs or having to take positions outside of their career choices.  Many people who were employed found themselves jobless with no promising options for re-employment.  The once abundant pharmacist employment market diminished as well due to a number of factors:  1) the recession, 2) increasing number of pharmacy graduates, and 3) delayed retirements.  Just a few years ago, every pharmacy student walked across their graduation stage with a diploma in one hand and a few employment offers in the other.  Now, finding employment after graduation has become a daunting challenge due to the tight market in all fields, including pharmacy practice.

A solution that many adults have turned to during times of economic recession has been more education. With the increased competitiveness for jobs, the need for additional education to boost one’s resume and career has become a necessary measure.  An article about continuing education (post-secondary education) in the New York Times, stated that most college graduates will experience five to seven job changes during their career and thus need more education to remain competitive.   Continuing education institutions also follow the job market to create programs in fields that are growing and will have job opportunities.  Some career counselors no longer encourage adults to simply follow their passion but to take into consideration practical values such as the availability and salary of jobs when making career decisions.

When looking at the profession of pharmacy, the economy has prompted many changes.  Numerous graduating students now choose to take one or two years to complete a residency and boost their Curriculum Vitae (C.V.).  The hope is that with additional training and experience will make them more qualified/marketable and be able to obtain the position they desire.  Of note, in 2006, ACCP stated that by year 2020, a residency should be mandatory for pharmacists involved in direct patient care.  Direct patient care was defined as pharmacist’s observation of the patient and contributions to the selection, modification and monitoring of patient-specific drug therapy.  Whether or not this is feasible or necessary is a separate issue; but there is no doubt of the increasing demand for residency training – both among employers and graduating students.  As the job market remains competitive, having a residency for many clinical positions is becoming a minimum requirement.  Paradoxically, while the poor economic conditions incentivize more students and pharmacists to pursue residency training, institutions have a limited ability to increase the number of residency positions due to financial constraints.

Pharmacists who already have a position in clinical practice feel additional pressure to obtain board certification through the Board of Pharmacy Specialties.  In a recently published article by Connor et. al in the American Journal of Health System Pharmacists, the benefits of board certification include “increased therapeutics knowledge, enhanced professional and clinical opportunities…greater marketability and monetary compensation.”  Although it has not been common for pharmacists to lose their jobs in this recession, as they look towards promotions, new career opportunities, and even tenure, experience is no longer sufficient.  To supplement their C.V.s, board certification is one avenue for pharmacists to demonstrate that they have attained (and are maintaining their) advanced knowledge.

Compensation (monetary and other rewards) has always played a role in influencing career choices and goals.  The economic recession has had a key role in the encouraging continuing education.  A struggling economy serves as a stimulus for people to pursue further education to remain competitive in their profession and pharmacy is no exception.  A Pharm.D.alone is no longer enough for pharmacists to secure a satisfying position or get promoted.

I fear (and this fear is possibly shared by other residents) that all the effort, energy and time exerted into my education and training (8+ years of post-secondary education and training!) will still not be enough for me to secure my “dream job.”  But I can only keep my fingers crossed – and demonstrate that I’m qualified, ready, willing, and able to make substantial contributions.

References:

Greenhouse S.  Learning Curves on the Career Path.  The New York Times [Internet]. 2010 Aug 25  Education.  [cited 2010 Oct 17]

Connor KA, Hamilton LA.  Pursuing Board of Pharmacy Specialties Certification.  Am J Health Syst Pharm 2010;67:1146-1151.

Bright DR, Adams AJ, Black CD, Powers MF.  The Mandatory Residency Dilemma: Parallels to Historical Transitions in Pharmacy Education.  Ann Pharmacother 2010;44.  Epub  2010 Oct 5.

[Editor's Commentary:  Dr. Kim's essay expresses the fears of many graduates today - not only in pharmacy but nursing, medicine, and other health professional fields too.  While a significant shortage of health professionals remains and will continue to grow as our population ages, the short term impact of the worse economic downturn in over 75 years has had ripple effects that has impacted even the most stable areas of employment.  According to some experts the current pharmacy job market has grown tight due to two competing factors:  1) increased number of graduates (which we need to meet future demand!) and 2) a very significant delay in retirements.  In other words, people who normally would have left the workforce aren't (and this is a moral dilemma the profession must address if the over-abundance of highly qualified practitioners continues for very long).  Of course the employment prospects for Dr. Kim and her well-trained brothers and sisters is far brighter than most ... but still, its all a bit unsettling when compared to the prospects just two or three short years ago.  There is little question that medication use is more problematic (and costly) than ever and the need for caring and well-qualified professionals, like Dr. Kim, is greater than ever. However, Dr. Kim's essay points to an important adult learning principle.  Adults are motivated to learn by relevancy and applicability.  The economic downturn has made training and credentials (like residencies and board certification) more relevant and applicable!  The motivations to learn often vary at different stages of life.  In the early stages of one's career, acquiring the "right" credentials for the "dream job" is often most important.  In mid-career, the desire to expand one's skill set beyond the core professional domains is often motivated by changes in responsibility.  In the later stages of one's career, cultivating deeply personal qualities (e.g. mentoring skills, religious faith) or engaging in new pursuits (e.g. playing the fiddle, photography) begin to emerge as motivations to learn and change.  So while a recession and the poor job market may seem like it has little to do with educational theory and practice, the motivation to learn is driven by many factors.  Needless to say, the prospects of unemployment and a mountain of debt is a strong motivator!  -S.H.]

Psychological Safety - A Key Component to Students’ Motivation

by Kimberly Still, Pharm.D., PGY1 Pharmacy Practice Resident, Baltimore VA Medical Center

Have you ever had a truly stellar professor? The kind who made you feel like no question was a dumb question?  Who made you energized about the subject and confident that you would succeed? Ever had the complete opposite? A professor so intimidating and negative you’d rather bite your tongue (literally) than ask a question for fear of looking stupid? What’s the main difference between these two extreme cases? The answer: the presence/absence of psychological safety.

So what does this term mean exactly? Psychological safety basically endorses the concept that students learn better when they feel safe. Embracing this idea means creating an environment where students feel comfortable enough to acknowledge their own weaknesses, voice their gaps in knowledge, and ask for help when they need it.  The importance of this concept lies in its link to student motivation. However, in order to understand how the two are related, we must first take a look at what creates motivation.
Though there are many theories surrounding student motivation, it is pretty well summarized by the following equation from Barron and Hulleman:¹

motivation = expectancy x value

“Expectancy” in this case means the extent to which a student believes that he/she can perform a particular task. “Value” means the level of interest and degree of importance the student places on a task. Psychological safety ties into this equation in a number of ways. Creating a positive and safe learning environment can be empowering for students, giving them the confidence to take on the challenge presented to them, which translates to a high level of expectancy. Furthermore, allowing students to feel safe asking questions prevents the suppression of any innate interest they might already have for a particular topic, which helps preserve perceived value.

While most instructors are unlikely to fall into the extreme category of the negative and demeaning persona presented at the beginning of this discussion, evidence suggests that many teachers have lost sight of the importance of psychological safety, specifically as it relates to student-teacher rapport. One survey of teachers and undergraduates revealed only 7% of professors ranked rapport in the list of top 10 master teaching qualities, compared to 42% of students.² Another student survey by Benson, et al, examined the association of rapport with student attitudes and motivation. They found a positive relationship between rapport and many proacademic behaviors such as “attending class, paying attention during class, and studying.” When asked to identify the characteristics needed to establish rapport, among the most common responses included open-mindedness, accessibility, approachability, and concern for students.³

So how does one go about establishing a rapport and promoting psychological safety in the classroom? The possibilities are numerous. Here are just a few suggestions:⁴

• Address students by name. With a large class size this can be an arduous task, but it can go a long way with letting your students know that you care about them.
• Set your students up for early success. Start off easy and gradually increase the level of difficulty in content. Such a strategy will help build their confidence and their comfort level with the subject.
• Provide positive feedback early and often.
• Avoid demeaning comments.
• Don’t be afraid to admit “I don’t know.”  This will help increase your students’ comfort level in voicing their own gaps in knowledge.
• Never underestimate the utility of the compliment sandwich!
• When providing individualized negative feedback, identify with your student if possible.  At a minimum encourage him/her by expressing a sincere belief that he/she can improve (Ex. “I noticed you had some difficulty putting things into layman’s terms for the patient. I had trouble with that as well when I was first starting out. Here are some tips that I find handy… Don’t stress, I know you’ll get the hang of it, it just takes practice.”)

These suggestions may sound fairly simple, but attempting to utilize such strategies while still maintaining focus on the successful implementation of the course/rotation can be quite challenging. Nonetheless, adhering to these principles is vital in order to maintain a positive learning experience and cultivate each student’s motivation to succeed.

References:

1. Barron KE and Hulleman CS. Is there a formula to help understand and improve student motivation? Essays from e-xcellence in teaching. 2006 ;8:33-8.  [cited 2010 Oct 18]

2. Buskist W, Sikorski J, Buckley T, & Saville BK. The teaching of psychology: Essays in honor of Wilbert J. McKeachie and Charles L. Brewer. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2002. Elements of master teaching; p. 27-39.

3. Benson TA and Cohen AL. Rapport: its relation to student abilities and behaviors toward teachers and classes. Teach Psychol 2005;32:237-9. [cited 2010 Oct 18]

4. Davis BG. Tools for teaching. 2^nd ed. San Francisco: Jossey-Bass; 2009. Chapter 31, Motivating Students; p. 278-87.

Embracing Social Media in Teaching

by Leah Sera, Pharm.D., PGY1 Pharmacy Practice Resident, Suburban Hospital

OK, I admit it – I’ve been suckered into social media. Not at the crest of the wave, mind you. In my case it’s more like being pulled in by the undertow.  But the end result is the same: I have a Twitter account, I spend lots of time on Facebook, I’m an occasional contributor to various discussion boards and listservs.  And I’m really, truly, going to start a blog as soon as I have the time to do so. We’ve been using social media from the beginning in this class as a teaching and learning tool – this blog, for instance, and our discussion board. I think these techniques have been useful in our online class, but are they being used elsewhere? How successful are they?

Media consultant Fred Cavazza breaks the term “social media” into ten categories: publication tools, sharing tools, discussion tools, social networks, micropublication, social aggregation, platforms for livecast hosting, virtual worlds, social gaming platforms, and massively multiplayer online games. ¹ Most of what has been written about higher education and social media addresses recruitment efforts, but there is some information available about its use in the classroom – and I found most of the information on discussion boards and in blogs!

Social media is apparently a more widely used instructional technique than I might have guessed from my own experience. A survey of about a thousand professors conducted by the Babson Survey Research Group reported that over half of those surveyed used video, podcasts, blogs, and wikis as part of their classes (online videos and podcasts were most commonly used), and about a third used social networks to communicate with students.²

It’s intriguing to imagine what things might be like if classroom techniques moved beyond BlackBoard and online lecture tools. How about creating a virtual classroom using a tool like Second Life? Using Facebook groups to increase communication between classmates, and between faculty and students? One educator has stopped using physical textbooks completely; instead she uses a social bookmarking tool to share current articles, websites, and other online content. She also requires the students to use the bookmarking tool to collect and share materials relevant to their field, as well as keep a blog. She even created a synchronous chat (e.g. instant messaging board) which allowed students to anonymously pass virtual notes during her class sessions so that they could “add their own voice to the lecture, as well as…have the agency to multitask while listening.”³

The use of social media may be a way to mitigate some of the problems with traditional education in today’s tech saavy society. Often traditional lectures fail to capture students’ attention, especially when there are so many distractions. Teachers who inadequately attempt to bridge the gap between traditional classroom teaching and modern technology often seem to end up reading lecture notes verbatim from a set of PowerPoint slides. As a student, that experience is supremely boring, and a bit of an insult to student capabilities. I’ve been known to remark to my classmates that it doesn’t seem likely that I would have been accepted into a doctoral program if I wasn’t capable of reading the slides on my own. I can be snarky like that sometimes.

In the case of Educational Theory and Practice [the course for which this blog essay was written], social media makes the class much more accessible.  Since one of the instructors lives in Florida, I’d say social media makes this course possible. For those of us who also live outside the Baltimore area [this course is offered through the University of Maryland School of Pharmacy Baltimore campus], online discussions cut down on travel time (and gas money).  Indeed, it seems likely there are a few participants taking advantage of this class who otherwise would not have been able to do so. It takes some adjustment, particularly with regard to student participation. It’s much easier to be distracted when you’re not sitting in a classroom, and there isn’t as much pressure to participate because you can easily avoid eye contact with the professor (indeed, there is no eye contact!). However, my mother once told me that when she was in grad school, before Gmail and Facebook, and lectures were primarily accompanied by a set of slides, that the lights would go down and so would student eyelids. So maybe student participation is more about student attitude and engagement than the mode of delivery. As someone interested in a career in academia, I think social media has a lot to offer and represents a new and creative way to engage students in the learning process.

¹ Cavazza F. Social Media Landscape [internet]. Accessed 2010 Sept 27. Available from http://www.fredcavazza.net/2008/06/09/social-media-landscape/

² Pearson Social Media Survey 2010 (online presentation). 2010. Accessed 2010 Sept 27. Available from http://www.slideshare.net/PearsonLearningSolutions/pearson-socialmediasurvey2010

³ Manfield L. Effectively using media in social education: a college educator on the advantage of Web 2.0 Classroom [internet]. Published 2008 Dec 30. Accessed 2010 Oct 5. Available from http://www.suite101.com/content/using-social-media-in-education-a87365

You Can’t Teach an Old Dog New Tricks. Or Can You?

by Brian Timberlake, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

We all know the age old adage “You can’t teach an old dog new tricks.”  You’ve probably heard this phrase so often you might think its true.  However, research today shows that this is an outdated notion.  Until recently, many people, including scientists, believed that the brain deteriorated over time through loss of neurotransmitters, decreased blood flow, and a diminishing oxygen supply.  However, now, it seems these “facts” are not true, and that learning occurs throughout one’s life.

People can learn at any age.  Prior to the 1960's, it was considered nonsensical for people to seek education in midlife.  Not only was the brain slowly starting to “shut down,” but the working years left in one’s life were slowly coming to an end.  With the baby boomer generation and longer life spans, middle aged people seeking education has gained wide spread acceptance. 

Even though acceptance has been gained for adult education, there is still that small problem of the deteriorating brain.  Science has come to show that as we age, the possibility of learning does not deteriorate.  While the middle-aged brain is slower at recalling facts, it gets much better at other tasks.  As people age, their brain actually gets sharper, due to myelination.  Myelination basically protects brain cells and increases conductivity in the brain.  Improved interconnections in the brain leads to improved reasoning skills.  Science has shown us that “life and learning doesn’t end at 50.”

Of course, disease is more prevalent in older people and diseases of the brain can change the brain drastically.  The most notable brain disease is Alzheimer’s, which is a form of dementia.  It is estimated that by 2050, 1 in 85 persons will suffer from Alzheimer’s Disease. The disease causes a significant loss of memory and the ability to learn.  Alzheimer’s disease usually presents around sixty-five, but can have early onset in some people.  It usually presents as difficulty in acquiring new memory or trouble recalling facts.  Since these symptoms are common as we age, it is hard to diagnose, and can lead into intense mood swings, extreme forgetfulness, and episodes of rage.

Even though the physiological aspect plays a huge role in learning, there is still the aspect of outside influences.  The differences in learning between children and adults has been a hot topic for the past few decades, and those differences are discussed in theory in the book, “The Modern Practice of Adult Education: Andragogy vs. Pedagogy,” written by the American educator Malcolm Knowles.  Knowles’ theory claims that there are five key differences in the learning processes between adults and children.  The theory describes key differences in the learner, experience, readiness, orientation to learning, and motivation.

The theory postulates that adults are independent and evaluate themselves and their surroundings while children need instruction from a teacher and must be told what to focus on.  Adults bring the experience factor to the table and can incorporate life lessons into what they learn, while children have very little or no experience.  In terms of readiness, adults usually learn based on their current needs and often with a sense of urgency and necessity, while children are guided by a teacher and only advance when they are told they are ready.  In the last part of the theory, Knowles described differences in motivation.  Adults are driven by emotions and personal goals, whereas children are usually affected by factors such as rewards and peer pressure.

The true mystery behind all of this research is the brain itself.  Nothing can unlock the intricacies and depth of this most fragile organ.  In the end, it all comes down to the individual.  Just like no two people are alike, no two brains are the same.  The best we can do as individuals is to keep using our brains and presenting ourselves with the new challenges.  Because of life’s uncertainties, you can’t teach every old dog a new trick, but age does bring new opportunities and possibilities.

References

Crawford, David.  The Role of Aging in Adult Learning: Implications for Instructors in Higher Education.  New Horizons for Learning [Internet].  December 2004.  [cited 2010 September 28].  Available at  http://www.newhorizons.org/lifelong/higher_ed/crawford.htm

Flatlow, Ira and Strauch, Barbara.  Brains, like Red Wine, Gets Better with Age.  NPR radio broadcast.  2010.  [cited September 28, 2010].  Available at  http://www.npr.org/templates/story/story.php?storyId=127771662

Trudeau, Michelle.  The Aging Brain Is Less Quick, But More Shrewd.  NPR radio broadcast, morning edition.  2010.  [cited September 28, 2010].  Available at http://www.npr.org/templates/story/story.php?storyId=124118077

Knowles, M. S. The Modern Practice of Adult Education. Andragogy versus pedagogy, Englewood Cliffs: Prentice Hall/Cambridge. 1970, 1980.