The Perils of Clinical Pearls

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

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

Clinical Pearls: Defined

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

The Dark Side of the Pearl

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

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

Facilitating Critical Thinking with Pearls

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

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

See the Pearl in a New Light

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

References:

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

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

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

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

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

Danger Zone: Failure Ahead

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

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

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

Less is More: Learning in Small Groups

by: Yevgeniya Kogan, Pharm.D., PGY-2 Health-System and Administration Resident, University of Maryland Medical Center

College. Freshman year.  Day one.  First class. If those factors weren’t intimidating enough, imagine hurrying through a huge college campus, and locating the tucked away lecture hall.  When you enter it, before you unfold a sea of stadium-like seats occupied by about 300 hundred unfamiliar faces. You make your way all the way up to the top of the hall looking for an empty seat. Your professor is about the size of a fly from your birds-eye perspective and you are grateful for his annoyingly loud voice and 10 foot tall power point presentation.  Now, fast-forward almost 10 years and, in stark contrast, you find yourself in front of a computer (maybe in your pajamas), on your own, with faceless participants, and an unfamiliar voice permeating from the telephone leading a discussion. You are in your very first online class. Questions come to mind; which is better? What environment provides the most opportunity for growth?  Which set up will I benefit from the most? The answer might seem obvious. After all, who doesn’t love the comfort of their own pajamas over a humongous lecture hall crammed next to students, some of whom have obviously given up showering in favor of long nights of partying. Are these two extremes the only way?

Hamann¹ and colleagues took on the challenge of assessing just that question in a study where they compared discussions conducted in large face-to-face classes, online classes, and (the alternative) small face-to-face classes. Based on a survey of students who were exposed to all three environments, they found (no surprise) large class discussions were rated least favorable by the majority of students. The interesting findings emerged when they compared online and small-group discussions. While online- classes tend to yield the most satisfaction when it comes to participation and the ability to express one’s thoughts, the small-group face-to-face discussions out-perform the online environment in terms of getting to know your classmates, stimulating interest, and overall satisfaction.

The authors explore participation, which is known to enhance learning and stimulate creativity, even further by looking at gender differences. It is common knowledge that male participants tend to dominate discussions. When Hamann¹ and colleagues explored this phenomenon they saw the following. As expected, in the face-to-face classes, both large and small, males tended to participate more frequently than their female counterparts. However, in the online environment, this difference is virtually eliminated and equal participation emerged. The increased participation from the female students might be attributable to a less intimidating environment.  There is also evidence to support that smaller groups tend to level the playing field for students of different ethnic backgrounds.²

During my undergraduate years I was in many large-classrooms in a science-focused school for most of my science and math courses.  Indeed, most colleges and universities teach the  introductory science, technology, engineering and math (STEM) courses in large, stadium-like lecture halls. According to Jason Koebler³, the large classroom is a way higher-education uses a “weed-them-out” process that teaches students to sink or swim.  Luckily, I swam. During graduate school I was in both the traditional large classroom and the smaller group setting where discussions were mandated and you were held accountable for the taught content. As I reflect back, one thing stands out the most are the many faces engrossed in their laptops – such a studious bunch!   But on closer inspection, the sea of brightly lit screens were displaying social media, news, movies, and online chats.  Very few screens projected the course material.  Perhaps the large-classroom wasn’t as studious as I thought.  In contrast, my experience in small groups, while sometimes forced, yielded greater interaction, discussion, and exchange of ideas.  True, some small groups were more effective in generating discussions than others.  In larger small-groups (more than 15 people), more people took the back seat while in smaller small-groups (8 students or less) everyone was engaged. When does a small group become too large?

Class size has been a hot topic for many years.  The US Federal government allocated $12 billion (over a seven-year period) to reduce class size and states like California spent another $3.6 billion.⁴  There are some conflicting results when it comes to class size.  Maasoumi⁴ and colleagues’ analysis indicates that a reduction in class size from 20 or more students down to less than 20 students generally increases test scores for those students who initially scored below the median test score but decreases test scores for those who scored above the median.  Conversely, Konstantopoulos⁵  found that all students reap the benefit from being in small classes when they examined Stanford Achievement Test scores in  mathematics, reading, and science.  The greatest benefit was seen in students who were low achievers and those who spent the longest duration of time in a small class setting. Nye⁶ reported that when students transitioned from small classes to large ones, the academic benefits persists for two full years.

As the pressures on academia increases to produce competent and confident students, it is important to consider the benefits of small groups and the impact they have on student satisfaction, understanding of concepts, and ability to work together.  Learning in small, face-to-face groups seems to have many advantages over large, content driven, sink or swim classrooms and independent, self-directed, lonely cyberspace classes.

Reference:

1. Hamann K, Pollock P, Wilson B. Assessing Student Perceptions of the Benefits of Discussion in Small-Group, Large-Class, and Online Learning Contexts. College Teaching [serial online]. Spring 2012; 60(2):65-75. Accessed December 15, 2013.

2. Pollock P, Hamann K, Wilson B. Learning through Discussions: Comparing the Benefits of Small-Group and Large-Class Settings. Journal of Political Science Education [serial online]. January 1, 2011;7(1):48-64. Available from: ERIC, Ipswitch, MA. Accessed December 17, 2013.

3. Koebler J. Experts: 'Weed Out' Classes Are Killing STEM Achievement. US News & World Report.  April 19, 2012. Online. Accessed December 14, 2013.

4. Maasoumi E, Milliment D, Rangaprasad V. Class Size and Educational Policy: Who Benefits from Smaller Classes? Econometric Review [serial online]. November 2005;24(4):33-68. Accessed December 17, 2013.

5. Konstantopoulos S, Chung V. What are the Long-Term Effects of Small Classes on the Achievement Gap? Evidence from the Lasting Beneftis Study. American Journal of Education [serial online]. November 1, 2009;116(1):125-54. Accessed December 14, 2013.

6. Nye B, Tennessee State Univ.  Small is Far Better. A Report on Three Class-Size Initiatives: Tennessee’s Student Teacher Achievement Ration (STAR) Project (8/85-8/89), Lasting Benefits Study (LBS:9/89-7/92) and Project CHALLENGE (7-89-7/29) as a Policy Application (Perliminary Results). Pager No. 5. [serial online]. November 13, 1992.  Accessed December 14, 2013.

Tips for Teaching Non-Native English Speakers

By Ittiporn Chuatrisorn, PGY-1 Pharmacy Practice Resident at the University of Maryland Medical Center

The non-native English speaking adult population in the United States is large and diverse.  Educational programs serve learners from very different backgrounds and with very different needs.^1,2  From my experience as an international student, I have found some teachers to be more understandable and have more effective techniques for teaching non-native English speakers (NNES) than others. This blog essay has been assembled as a resource for you - the instructors and preceptors who are encountering more and more NNES students.  I hope to provide you with some ideas on how to teach lectures and lead small groups in a manner that improves listening comprehension for NNES and ways to get your non-native speakers more involved in class discussions.

Monitor how you speak and what you say.^2-6  Pause for a couple of extra beats between sentences.  By reducing the speed of your speaking, even just alittle, you are giving the audience (NNES and English speakers alike) a chance to absorb what you say.  You do not have to cut your rate of speech in half; simply become aware of your speech and slow down! When a professor speaks slowly and clearly this helps NNES understand the concepts and, later, they do not have spent extra hours trying to find the concept in the textbooks or other resources.

Avoid idiomatic expressions and slang.^3-6 If you use idioms, slang, or long series of adjectives, define them and repeat the concept in more formal terms.  For example, one professor, when explaining how to approach a job interview, said “Do not shake hands like a wet fish when you greet the interviewer.” I had absolutely no idea what the professor meant until the idiomatic expression was explained to me!

Clarify examples that refer to cultural events or norms that may be unfamiliar to people from another country.^6-7 Some professors use “Ameri-centric” examples to explain concepts (e.g. references to U.S. history or popular culture). NNES who are unfamiliar with the examples may not understand the concept. You should take a few minutes to provide brief background information.  During one lecture regarding drug therapy reimbursement, for example, a professor talked about Blue Cross and Blue Shield, Aetna, and Humana. I had no idea that these were health insurance companies! At the end of that lecture, I did not understand anything. What may seem everyday and commonplace to the lecturer may be alien to the NNES student.  Of course, this is not unique to NNES students.  English speakers who are not from the US would have similar difficulties – but NNES students likely face even greater challenges when Ameri-centric examples are used.

Use visual aids.  Write key words on the board, slides, or otherwise provide visual cues to help NNES process meaning more readily.  This can include gestures, pictures, and concrete objects.^2-4 I think it is better to start early with visual cues in the class.  When the professor repeated key terms, wrote key terms on the board, and prepared a handouts in advance, this really helped me follow the lecture.  One of my pharmacy professors had a section of the blackboard site set aside for key terms and an outline of the day’s lesson plan.  He posted this information on board prior class. This gave me a refer to if I lost the thread of the discussion.

Provide written instructions about homework assignments and examinations.^2,6  Asking if everyone understands the assignment or knows when it is due may not be enough. NNES may be too embarrassed to speak up or may not even understand that you are discussing an assignment.^7-8 When I studied in pharmacy school, the professor asked if everyone understood the assignment, no one said a word. However, a Chinese colleague, who had only been in the country for 2 months, did not understand.  She misunderstood and presented a wrong topic. As you can imagine, she was very embarrassed!  Thus, oral explanations, without written support, could create problems for NNES.

Allow NNES students to record lectures.² They can listen as often as necessary to fill in their notes. Moreover, they can concentrate solely on trying to understand what the professor is saying during class, knowing that they can make notes later from the recording. In my first semester of school, I was shocked to discover that the professor did not begin at chapter one and continued through the textbook in a step-wise manner, chapter by chapter.  And they use a lot of materials outside the textbook. This can create confusion and obstacles for NNESstudents. Access to notes, class recordings, and a list of helpful outside sources helps NNES keep up the class.

Provide NNES students more opportunities to talk about the material.  Give NNES time to reflect before asking them to speak.^7-8 Many Americans think aloud, but people from many other cultures do not. What this means is that NNES rarely have time to reflect and respond before a native English speaking student (or, worse, the professor) has answered the question and taken over the conversation.  In some parts of the world, students are taught to be deferential, never challenging the teacher’s point of view or offering innovative ideas.⁸ For example, many Asian student would prefer to conform to tradition without trying to present novel ideas. Furthermore, you may experience difficulty-eliciting opinions from Korean, Japanese, Chinese, Thailand, and other students who come from educational systems where rote learning is the rule. Thus, you should give NNES a few minutes to write in response to a question before asking students to participate in the discussion.

Some NNES are very self-conscious about their imperfect English.^7,8 They may be frustrated by not being able to accurately articulate their complex thoughts. They may be concerned that their native English-speaking peers will think less highly of them. If the response is slightly off, try to do something positive with it. You should rephrase the response but don’t point out grammatical errors.²  Ask clarifying questions and elaborate on their response.

To summarize, NNES students are just as smart as native English speakers and will learn from you if you employ a few simple techniques. These students face many challenges navigating a new academic setting with different expectations, studying in a new language, and adapting to a new culture.  These techniques will help you to make your lectures and small group discussions more accessible to them, improve their listening comprehension, and enhance the learning experience for everyone.

Check out these additional resources:

1)   Responding to non-native speakers of English (University of Minnesota)

2)   Teaching Nonnative Speakers (Baruch College)

3)   ESL Instructional Resources (University of Washington)

References

1.   National Center for Education Statistics. Participation of adults in English as a second language classes: 1994-1995. Washington DC. Assessed 1 December 2013.

2.   Stevens LP, Jefferies J, Brisk ME, Kaczmarek S. Linguistics and Science Learning for Diverse Population: An Agenda for Teacher Education. In: Bruna KR and Gomez K, editors. The Work of Language in Multicultural Classrooms – Talking Science, Writing Science. 2^nd ed. New York: Taylor and Francis Publishers; 2009. p291.

3.   Wright WE. Foundations for Teaching English Language Learners: Research, Theory, Policy, and Practice. 1^st ed. Philadelphia. Caslon Inc. Publisher; 2010.

4.   Common Classroom Practices for All English Language Learner Educators. In: Wagner S, King T. Implementing Effective Instruction for English Language Learners: 12 Key Practices for Administrators, Teachers, and Leadership Teams. Philadelphia. 1^st ed. Caslon Inc. Publisher; 2012. p107.

5.   Tapia AT. Non-Native English Speakers Setting New Standard. New America Media Commentary. Assessed 1 December 2013.

6.   Lee DS. What Teachers Can Do to Relieve Problems Identified by International Students. New Directions for Teaching and Learning. 1997; 70: 40-51.

7. Nelson GL. How Culture Differences affect Written and Oral Communication; The Case of Peer Response Groups. New Directions for Teaching and Learning. 1997; 70: 77-84.

8. Hodne BD. Please Speak Up: Asian Immigrant Students in American College Classrooms. New Directions for Teaching and Learning. 1997; 70: 85-92.

Patients Counseling: Applying Gagne’s Nine Events of Instruction

by Chris Dobroth, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

“Excuse me. Where are the paper towels? Oh, and I have a prescription to pick up.” Or "Really? We have to talk to another person before we can be discharged?” Not an auspicious start to a conversation, much less one regarding someone’s health. This indifference by many patients combined with the many demands for the pharmacist’s time calls for counseling sessions that are quick and efficient. What makes these sessions both quick and efficient as opposed to just quick?

The American Society of Health System Pharmacists (ASHP) in Guidelines on Pharmacist-Conducted Patient Education and Counseling states that patient counseling and education should be approached by pharmacists as “interrelated activities.”¹  According to the American psychologist Robert Gagne, there are nine events that should be included in every instructional activity to maximize its effectiveness.²  These events are the “why” behind the “how” of ASHP’s four steps to patient interaction.  Examining them more closely will help us develop a more complete understanding of what needs to happen during a patient counseling session. After all, at its core, effective patient counseling is a form of instruction.

Here are AHSP’s four step of patient counseling and how Gagne’s nine events of instruction related to each:^1,2

Step 1. Establish caring relationship, explain pharmacist role, and ask for permission to counsel. Gagne’s first and second event of instruction are to gain the learner’s attention and inform them of the objectives.

Step 2. Assess the patient’s knowledge and capabilities. Gagne’s third event is to stimulate recall of prior learning.

Step 3. Provide information to fill in the gaps in the patient’s knowledge. Gagne’s fourth and fifth events are to present content and provide learning guidance.

Step 4. Verify patient’s knowledge and understanding. Here Gagne’s sixth through ninth events are to elicit performance, provide feedback, assess performance, and enhance retention and transfer.

Notice how efficiently ASHP’s four steps contain all of Gagne’s nine events of instruction?

Let’s consider the Indian Health Services Three-Prime Questions:³ 

1. What did the doctor tell you this medication was for?
2. How did the doctor tell you to take this medication?
3. What did the doctor tell you to expect?

Gagne’s nine events show that these questions are an integral part of the learning process.² Here the use of opened questions serve to grab learners’ attention and engage them in conversation.  Now that you’ve got their brain running and you’re stimulating prior learning through the three questions, it’s your turn to assess their “knowledge and capabilities” as Gagne suggests and then to present the content and provide guidance.  You have already elicited the patient’s understanding, so now the holes can be filled in based on their level of health literacy. While the Indian Health Service’s Three-Prime questions lay the groundwork for an effective counseling session, they do not offer guidance from start to finish the way ASHP’s Four-Steps do.  Understanding Gagne’s nine events of instruction allows for an effective closer to the counseling session by utilizing the sixth through ninth steps: eliciting performance, providing feedback, assess performance, and enhance retention, and finally transfer to future situations.  Without these final steps, the patient will have endured a deluge of information but you won’t know if they really understood. While your intentions were good and the information thorough, the “teach back” technique is the only way to ensure the patient is truly ready to use their medication in an appropriate manner.

As the demands on our time increase, we must seek ways to be more efficient. By reminding ourselves that patient counseling sessions are a form of instruction, we can use Gagne’s nine events of instruction to master these techniques. Effective patient counseling leads to better outcomes and may decrease the amount of time spent re-answering the same questions at a later encounter.  So before your next patient encounter, take a few minutes to reflect on how you would approach it and remember Gagne’s nine events of instruction.

References:

1.  American Society of Health Systems Pharmacists. ASHP Guidelines on pharmacist-conducted patient education and counseling. Am J Health-Sys Pharm. 1997; 54:431-434. [accessed 2013 Sept 22].
2.  Buscombe, C. Using Gagne’s theory to teach procedural skills. The Clinical Teacher. 2013; 10: 302-307. [Accessed 2013 Nov 16^th].

3.  Indian Health Services: The Federal Program for American Indians and Alaska Natives [Internet]. Patient-Provider Communication Toolkit. Tool 9.  Pharmacist Consultation.  Rockville: Indian Health Services. [accessed 2013 Nov 16^th].