Beware! Teacher’s Bias and Favoritism

by Mariah Cole, PharmD, PGY1 Community Pharmacy Practice Resident, Mississippi Department of Public Health

“Ugh, ____ is such a teacher’s pet.”

Does this ring a bell for you? The teacher’s pet was a title given to any student who had a “preferential” relationship with the teacher. What does the teacher’s pet relationship look like? The teacher's pet could be the child who was consistently picked to pass out papers or lead the lunch line. It wasn’t just the most helpful students but the “smart” students as well. The “smart” students seemed to know the answers to all the questions asked during class or were consistently recognized by the teacher for scoring the highest on quizzes or tests. Not every student called a “teacher’s pet” was actually given any form of favoritism. None-the-less, such preferential treatment can have a positive effect on students. But just as importantly, favoritism impacts the rest of the students in class.  Thus, teachers need to be mindful of how their relationships with students are perceived.

Teachers and students are human and subject to bias, whether intentional and/or unintentional.  This trickles into their interactions with and among each other.¹ Bias arises from both positive and negative attitudes towards people based on their socio-cultural and economic background, gender, and many other factors. For example, students or teachers from differing geographical regions may experience bias due to beliefs about regional dialects or accents. And bias can lead to barriers to effectively working together.¹ In addition, teachers and students may have interfering dynamics that arise during interactions such as approval seeking, competition, excessive dependency, and psychological withdrawal or reactance.¹ Thus bias and interfering dynamics culminate in favoritism, neglect, or prejudicial actions towards others.

Teacher favoritism may be defined as “the act of giving preferential treatment to someone or something; the tendency to favor a person or group for factors “such as a characteristic they possess, or their personal contacts, or merely out of personal preferences”.¹ Thus, the “teacher pet” relationship is a type of teacher favoritism. It may be noted that there are various definitions within the literature for the “teacher pet” relationship. One author defines it as, “a phenomenon of a special emotional relationship (often a love relationship) between the teacher and a particular student (or two) in the classroom.”¹ Meanwhile, another author defines the concept as “student favored by teachers because they have actual and/or alleged characteristics that are highly valued by teachers but not necessarily by classmates.”¹ Favoritism may also manifest from teachers’ affectionate ties to a student, which derive from the pleasure that the student brings to the teachers’ work.² One study characterized teacher’s pets are more likely to be girls who come from higher socioeconomic backgrounds but may not be considered the best academic students.²

While overt favoritism toward particular students may not be seen in the same way in college and professional degree programs, the mentoring relationship has the potential to be interpreted as a teacher’s pet or favoritism relationship. A few students, by virtue of their background or preferential characteristics, are given more access to the instructor or professor and are given opportunities not afforded to other students.  The development of a friendship may complicate or compromise the mentoring relationship. One author notes that a professional mentor is a position of power. Thus, a hierarchy should predominate and the mentor should not be considered equal to the mentee. For this reason, a friendship-type relationship should never be established during the mentorship period.³  This is not to say that mentors should not act in a friendly, helpful manner to mentees and that these relationships should not have a personal dimension.⁴ Befriending mentees increases the psychosocial support provided to students. However, befriending is not equivalent to friendship. Befriending is about building a positive relationship that is collegial.  Thus, the mentoring relationship can still be cordial, personal, and enjoyable.

As the mentoring relationship progresses, the relationship should evolve. Setting clear expectations of the relationship at the beginning may increase the effectiveness of the mentoring relationship. Heidrun Stoegar explains “effective mentoring relies on mentors and mentees having clear ideas about what mentoring entails, how it is distinct from other support measures, and what expectations for a given mentoring experience are realistic”.⁵ One method of setting expectations includes creating a mentoring contract which would include “defining relationship’s boundaries, reduce confusion about roles and expectations, clarifies commitments including time, and defines relationship’s objectives. However, making formal contracts may stifle informal support”.^6,7 Thus, a conversation about expectations, rather than a written contract, is probably more appropriate.

Favoritism is cultivated by our conscious and unconscious biases. Bias may lead to positive and negative attitudes toward various groups of students and differences in the way they are treated. Favoritism may manifest within undergraduate, professional, and graduate education in the form of mentoring. If the boundaries of the mentoring relationship cross into friendship, students may interpret this relationship as favoritism. Setting boundaries and expectations can help prevent perceptions of favoritism and maintain a professional relationship with all learners.

References

1. Cheng E. Teacher Bias and Its Impact on Teacher-Student Relationships: The Example of Favoritism [Internet]. [cited 2021Mar8].
2. Tal Z, Babad E. The teacher’s pet phenomenon: Rate of occurrence, correlates, and psychological costs. Journal of Educational Psychology. 1990;82(4):637–45.
3. Detsky AS, Baerlocher MO. Academic mentoring--how to give it and how to get it. JAMA. 2007;297(19):2134–6.
4. Mullen CA, Klimaitis CC. Defining mentoring: a literature review of issues, types, and applications. Annals of the New York Academy of Sciences. 2021;1483(1):19–35.
5. Stoeger H, Balestrini DP, Ziegler A. Key issues in professionalizing mentoring practices. Annals of the New York Academy of Sciences. 2021 Jan 1;1483(1):5–18.
6. MacLeod S. The challenge of providing mentorship in primary care. Postgrad Med J. 2007 May;83(979):317-9.
7. Burgess A, van Diggele C, Mellis C. Mentorship in the health professions: a review. Clin Teach. 2018 Jun;15(3):197-202.

Should Standardized Patients Score Student Performance?

by Ashley Miller, PharmD, PGY1 Community Pharmacy Resident, University of Mississippi School of Pharmacy

It's the end of the semester, and the last thing standing between you and your summer break is the objective structured clinical examination (OSCE). You know that you’ll be entering multiple interactive stations that will assess your ability to perform patient care-related activities. Who do you hope will be grading your performance – a teacher you’ve had, or a stranger — a standardized patient (SP)? I know what I preferred when I was the one undergoing these evaluations, but I was curious to learn more about what other professional students, faculty, and researchers had to say about who is the best person to evaluate and score a student’s performance.

OSCEs date back to the 1960s and were first used as assessments in medical schools.  Each OSCE station is intended to represent a realistic clinical scenario during the student interacts with a “patient.”^1,2  At many schools, the patient role is played by an experienced actor known as a standardized patient (SP).  An OSCE allows students to "practice" in an environment safe for both them and patients.¹ OSCEs are reliable and valid assessment tools and predict students' future success.^1,2  Their use was expanded to other health professional programs including dentistry, pharmacy, and nursing.^1,2 They were designed to comprehensively evaluate clinical, interpersonal, and problem-solving skills and consistently portray the clinical scenario so that every student has the same experience (and opportunities).^1,3 While preparing and delivering an OSCE is very time-consuming, both educators and students alike agree that OSCEs are a valuable learning and assessment tool.³

One thing not always agreed upon when considering OSCEs is whether a faculty member or SP should grade performance. In some instances, an SP may interact with the student while a faculty member grades the interaction while observing the encounter either remotely or in the same room. Some argue that having faculty graders introduces additional bias and negatively influences students' performance when compared to a more neutral grader.³ Others claim SPs do not have the skillset or training needed to properly assess students.³ Previous studies involving faculty versus SP graders have not provided a clear answer as to who makes the “best” grader.

Different evaluator factors contribute to variability when scoring OSCE encounters, including lack of defined criteria, lack of training, and the number of items to be assessed.⁴  One study looked at factors that affected student scores during an OSCE when evaluated by faculty versus SPs.⁴ Before grading began, all examiners were first put through a series of training on the OSCE process and the criteria they were to use for scoring students.⁴ The researchers found that the scores given by SPs were higher than those given by faculty members, suggesting that the type of grader does influence scores.⁴ Another interesting finding was that the faculty evaluators assessed technical skills more strictly, yet were not as strict when grading communication skills when compared to SP evaluators.⁴ The technical skills assessed included history-taking, physical examination, and patient education.⁴ Communication skills that were graded include the attitude of the student, active listening, ability to build rapport, and effective questioning.⁴ Notably, faculty members who were scoring items related to their specialty tended to assign lower grades.⁴ The authors hypothesized that these differences are seen because faculty graders are more familiar with assessing the technical skills (particularly if it was relevant in their specialty) and have higher expectations for performance, while SPs are not as comfortable giving lower scores on technical matters.⁴

While some faculty members believe that their presence does not impact student performance, students often report that knowing teachers are grading OSCEs increases testing anxiety.³ The increased stress then impacts performance which, in turn, affects students’ grades.^3,4 In a study conducted using student questionnaires to survey the use of SP versus faculty graders, McLaughlin et al. found that the majority of students felt SPs helped create a less stressful testing environment, were as good at giving feedback as faculty graders, and felt they were adequately equipped to assess their skills.² The findings of this study demonstrate that students generally prefer to be graded by an SP and believe that an SP can competently assess their performance.²

So, who should grade a student’s performance during an OSCE? It likely depends on who you are asking. Overall, it seems that most students feel SPs are equipped for the task, are fair graders, and help them to feel more at ease. Much like how I felt when I was a student, it seems students would prefer an SP in these encounters since it is a more realistic experience — similar to interacting with patients in the “real world.”³  However, some may contend that, while students may not be as comfortable, having professors performing the assessment is in the student's best interest long-term because they can more accurately assess the student’s technical skill. One point made for this argument is that some studies have shown that grades given by faculty are predictive of future performance.² Another point made by researchers and those in academia for having faculty graders is that they are content experts and may be able to identify students who have only surface-level knowledge but appear confident and skillful to a non-expert.² It is also possible to have SPs interact with the students while faculty members observe and grade the encounter synchronously or asynchronously.  In this way, the student performance is scored by both the SP and faculty members.  However, this would cost more time and money as both SPs and faculty would need to be trained. Research shows SPs focus more on communication while faculty focus more on technical skills in an encounter, thus, it may come down to the most important skill being assessed in a particular OSCE station when choosing who should score it.

^References 

1. Alsaid A, Al-Sheikh M. Student and Faculty Perception of Objective Structured Clinical Examination: A Teaching Hospital Experience. Saudi J Med Med Sci [Internet]. 2017;5 (1):49-55.

2. McLaughlin K, Gregor L, Jones A, et al. Can SPs Replace Physicians as OSCE Examiners? BMC Med Educ [Internet]. 2006;6: Article 12. 

3. Salinitri FD, O’Connell MB, Garwood CL, et al. An Objective Structured Clinical Examination to Assess Problem-Based Learning. Am J Pharm Educ [Internet]. 2012;76(3): Article 44. 

4. Park YS, Chun KH, Lee KS, et al. A Study on Evaluator Factors Affecting Physician-Patient Interaction Scores in Clinical Performance Examinations: A Single Medical School Experience. Yeungnam Univ J Med 2021;38(2):118-126.

Facilitating Student Success in Remediation Programs

by Madison Gray, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Some colleges of pharmacy and other professional schools have programs in place to identify students early who are underperforming so that they can provide additional help and coaching before they fail a course.¹ Many of these strategies focus on tutoring and supplemental academic assistance to address underperformance and, ultimately, prevent failure.^1,2  Course failure is not only associated with a significant financial burden but also psychological and social consequences.¹ So, what is the most appropriate approach to remediation? Should remediation programs focus on course/content review or strategies for success? Several remediation approaches have been described in the literature for various professional schools and range from course repetition to developing individual remediation plans.² Individualized remediation that focuses on helping students become self-regulated learners is, in my opinion, a more effective approach to ensuring a student’s long-term success.^1-3

Years of research have identified self-regulated learning to be a differentiating factor separating high and low-performing students.³ Three key factors underly the success of self-regulated learning including preparation, performance, and self-reflection.³ Self-regulated learning requires the identification of barriers, appropriate time management skills, motivation, and strategic study habits.³

Many factors affect student performance and individual barriers often exist that impact each student’s ability to develop a self-regulated learning behavior.^1,3 Sansgiry and colleagues evaluated the effect of these factors on both high and low-performing students.  They found that test competence (which includes test anxiety) was one differentiating factor between the two groups.¹ They defined test competence as a “student’s ability to manage and cope with the amount of study material for examinations and/or tests.”¹ Many students (69.3%) reported feeling some type of anxiety during testing and some students even report experiencing physical symptoms.¹ Some other barriers affecting student performance include access to learning materials and technological barriers.¹ Identifying barriers for students is the first step in addressing issues that may hinder their success. Strategies to identify and address these barriers should be a routine part of the remediation process and could include interviews, surveys, and student self-reflection.

Self-regulated learning is a behavior that requires well-developed time management skills.³ Students who try to learn course material in a short amount of time tend not to perform as well as those who develop study plans whereby the learning effort is distributed over an extended period of time.^3,4 Appropriate time management skills that allow for more time for studying may also help decrease test anxiety and increase the student’s confidence in their preparation.^3,4 A study by Hartwig and colleagues assessed the study habits of college students in correlation with their grade point averages (GPAs).⁵ Students who reported scheduling study times over an extended period rather than cramming the day (or two) before an exam trended toward higher GPAs although the results were not statistically significant⁵. Remediation programs that encourage students to set goals, create tasks, and use schedules will help teach time-management skills that can be used in and out of the classroom.⁴ Effective time-management skills are necessary for both academic and career success.⁴ Once a student has good time management skills, learning how to use other study strategies may be helpful.^4,5

Students who use a variety of strategies to study, such as re-reading material, summarizing, note-taking, flashcards, and self-testing, are more likely to be successful.⁵ These different strategies have been studied and some of these strategies are used by high performing students more often when compared to low performing students.^3,5 In the study by Hartwig and colleagues, a survey administered to college students included questions about study strategies, self-testing, and study schedules.⁵ Self-testing correlated with higher GPAs versus other study strategies.⁵ The majority of students who reported using self-testing as a study strategy also reported that they did so to test themselves on how well they learned the material.⁵ Notably, re-reading was also associated with higher GPAs among the surveyed students; however, other studies have not found this association.⁵ These are just a few positive study strategies that can be utilized by college students to promote self-regulated learning.^3,5 Having students reflect back on their study habits to determine what works and what doesn’t work is one strategy that can be utilized during remediation programs.^3,5 Some students are not accustomed to having to study and this creates a challenge when they get to college.¹ They may go from previously not having to study (at all!) to learning how to study.^1,2 An individualized remediation program is an opportunity to address some of these challenges.^1,2

Course repetition is used by many schools and colleges of pharmacy.² This approach to remediation focuses on academic competence by requiring students to simply repeat the course they have failed.^1,2 Course repetition aims to re-expose students to the same course material in the hopes they achieve higher performance.^1,2 Some programs allow students to continue in the program and repeat the course once it is offered again while other programs require that the course be successfully passed prior to moving forward within the program.^1,2 The later strategy often involves students sitting out for a year and this obviously has significant financial implications.^1,2 Course repetition is not individualized and often does not address the underlying issues that contributed to the failure. This approach to remediation fails to address the non-cognitive barriers to students’ success.

Programs that focus on individualized remediation allow students to actively participate in the remediation process and help set them up for success both in the classroom and their careers. In an individualized remediation program, students must identify their barriers (with guidance) and engage in self-reflection. Such programs help students develop plans to address their identified barriers. Additionally, individualized programs should aim to promote self-regulated learning behaviors by giving students experience creating goals, formulating learning tasks, and developing time-management skills. Individualized programs should also focus on helping students develop new study strategies such as self-testing and summarizing. By identifying and addressing the non-cognitive barriers that often cause students to fail, remediation programs can foster the development of self-directed behaviors that enable students to be successful in subsequent coursework … and life.

 

References:

1. David M, Fuller S, Hritcko P, et al. A Review of Remediation Programs in Pharmacy and Other Health Professions. Am J Pharm Educ [Internet]. 2010;74(2): Article 25.
2. Sansgiry S, Bhosle M, Sail K. Factors That Affect Academic Performance Among Pharmacy Students. Am J Pharm Educ [Internet]. 2006;70(5): Article 105.
3. McKeirnan K, Colorafi K, Kim A, et al. Study Behaviors Associated with Student Pharmacists’ Academic Success in an Active Classroom Pharmacy Curriculum. Am J Pharm Educ [Internet]. 2020;84(7):Article 7695
4. Britton B, Tesser A. Effects of Time-Management Practices on College Grades. J Educ Psychol [Internet]. 1991 [cited 2021 Jan 10];83(3):401-10.
5. Hartwig M, Dunlosky. Study strategies of college students: Are self-testing and scheduling related to achievement? Psychon Bull Rev [Internet]. 2012;19:126-34.

Mindfully Teaching and Learning

by Alisha S. Nicks, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Before you clicked on the link to read this blog post, were you thinking about your to-do list? Or perhaps you were reflecting on a decision you made last week that you wish you could change? While our physical bodies are in the present moment, our minds often drift to thinking about mistakes of the past or planning for the future. Mindfulness, as defined by Jon Kabat-Zinn, Ph.D., is purposefully paying attention to the present moment in a non-judgmental manner.¹ Psychological and educational research shows that Dr. Kabat-Zinn’s mindfulness-based stress reduction (MBSR) program teaches individuals the power of paying attention to the present, models a conscious way of living, and provides healthy coping mechanisms for stress.²

MBSR is an eight-week training program centered around formal mindfulness practices, including mindful attention to breathing through sitting meditation and body awareness through Hatha yoga. MBSR also teaches participants to informally practice mindfulness through attentiveness in everyday activities, such as walking, talking, driving, and eating. In a systematic review assessing the efficacy of MBSR on stress management, MBSR interventions positively impacted both psychological and physiological measures of stress. Although an eight-week MBSR course may not be feasible for most schools to provide to their students, faculty, and staff, instructors can create “mindfulness moments” throughout the curriculum. Including mindfulness techniques in one’s instruction can motivate students to become more self-aware as well as build positive relationships.³ The results of one study in an early childhood education program showed that students who participated in an “awareness of the breath” activity at school also engaged in mindfulness-based conflict resolution strategies with friends and family.⁴

What if instead of telling students to focus on some end result, we encouraged them to focus on the actual pursuit itself?
– Amy Burke: Mindfulness in Education, Learning from the Inside Out

Health professional students often struggle with stress from challenging coursework, extracurricular activities, and personal responsibilities. Moreover, they often struggle with internal pressure to meet personal expectations of perfection and a fear of failure.⁵ After a case discussion I facilitated with students at the University of Mississippi School of Pharmacy, a few third-year students asked me for advice on how to prepare for pharmacy licensure exam. They seemed anxious about an exam that is more than 18 months away. After sharing a few recommendations, I encouraged them to focus on the materials they are learning now, taking action now to really understand what they are currently learning, rather than worrying about the exam or life post-graduation. Mindfulness is not turning a blind eye to present difficulties or future responsibilities. It involves conscious acceptance and intentional responses to current circumstances.

Mindfulness begins by observing one’s internal state (emotions and thoughts) as well as external environment (sensations) but without judgment or automatically reacting.  The five facets of mindfulness are described below (see Table 1).

Table 1: Five Facet Mindfulness Questionnaire⁷

Scales	Definition	Sample Item
Observe	Tendency to observe, notice, or attend to internal and external phenomena	I intentionally stay aware of my feelings.
Describe	Tendency to describe or label sensations, perceptions, thoughts, emotions, etc. with words	My natural tendency is to put my experiences into words.
Accept without judgment	Tendency to accept without making judgments or evaluations	I disapprove of myself when I have irrational ideas.
Nonreactive	Tendency not to react to one’s experience	I watch my feelings without getting lost in them.
Act with Awareness	Tendency to focus undivided attention on the current activity or avoiding automatic pilot; concentration	I easily get lost in my thoughts and feelings.

Instructors play a critical role in setting the tone of the learning environment and engaging students in the learning process. In a commentary exploring the lessons that teachers can learn from actors about living in the present moment, Daniel R. Malcom reflects on his lectures as a junior faculty member that focused on information delivery but neglected to fully engage learners.⁶ Dr. Malcom suggests being reliably in the present moment with learners as a key strategy for creating learner-centered environments and strengthening relationships between teacher and learner.

In a study conducted in Ireland regarding stress and stress management, student pharmacists were interviewed in a series of focus groups. Students who did not have strong and regular interactions with instructors felt a lack connectedness and this hindered their access to support systems and resources. Focus group participants recommended integrating mindfulness practices into the curriculum instead of didactic lectures on stress management to encourage active learning. In a clinical trial evaluating the impact of a four-week mindfulness course, student pharmacists experienced improvements in stress and became more skillful at the observing facet of mindfulness.⁷ Although additional evidence is needed to assess the impact of mindfulness on learning outcomes, techniques listed in Table 2 have shown to reduce stress and increase wellbeing. 

Table 2: Mindfulness Strategies and Practices for Educational Settings³

 

Setting/ Audience	Learning Objective	Mindfulness Strategies	Example of Practice	Benefits
Educators	Understand how to treat students with respect, fairness, and non-judgment	Cultivate self-awareness to identify preconceived notions or judgments that may stand in the way of treating students equitably	Practice moment-by-moment awareness of your thoughts and feelings by focusing on bodily sensations or taking deep breaths	Educators become more reflective, thoughtful, and culturally responsive in their language and actions toward students
Educators	Proactively manage the stresses of teaching and leading	Educators recognize triggers of their own stress and emotional reactions	Pause and take several deep breaths whenever a strong emotional reaction is triggered, to cultivate self-awareness rather than reactivity	Educators can manage stress, personal hardship, and trauma
Elementary & Secondary Education Students	Cultivate focus and attention	Integrate a deliberate pause to help students settle their minds and bodies in preparation for learning	Begin class with a “mindful moment” where students are guided through either (1) sitting and noticing their bodily sensations or (2) slow and deliberate movement (e.g., deep breaths with movements such as raising their arms over their heads and down to their sides in repetition)	Students learn to slow down, quiet down their nervous systems, and check in with themselves and any feelings or thoughts that might need attention as they get ready to learn
Elementary & Secondary Education Student	Increase academic confidence, reduce stress, and manage anxiety	Use mindful breathing to help students self-regulate when under stress	Teach students to recognize the symptoms of anxiety in the body (e.g., elevated heart rate, fast-moving thoughts) and to practice taking several slow, deep, and full breaths to signal ease to the body when they feel these symptoms	Students are better able to manage stress and anxiety by practicing a healthy behavior

The highest function of education is to bring about an integrated individual who is capable of dealing with life as a whole.
– Krishnamurti: Education and the Significance of Life

Being more aware of the present moment is a healthy coping mechanism as students navigate virtual learning environments which have been required due to restrictions during the COVID-19 pandemic. Studies show that virtual learning settings create new challenges for students and many feel less confident in their ability to master the material.⁸ Mindfulness can serve as a constructive way to support student and faculty resilience during these unprecedented times. Incorporating techniques such as mindful breathing before exams and mindful appreciation of positive moments during instructional activities can inspire perseverance and reduce burnout. While mindfulness has proven to enhance emotional regulation, some people do not respond to these practices as there is no one-size-fits-all wellness model. Therefore, institutions should provide mindfulness activities and courses as an option to help teachers and learners become skilled in responding intentionally rather than reacting irrationally to life’s circumstances. Mindfulness can create meaningful connections between students and teachers both in and out of the classroom.

References

1. O’Driscoll M, Byrne S, Kelly M, et al. A Thematic Analysis of Pharmacy Students’ Experiences of the Undergraduate Pharmacy Degree in Ireland and the Role of Mindfulness. AJPE [Internet]. 2019;83:6457.
2. Sharma M, Rush SE. Mindfulness-Based Stress Reduction as a Stress Management Intervention for Healthy Individuals. J Evid Based Complementary Altern Med [Internet]. 2014;19:271–286.
3. Browning A. Mindfulness in Education: An Approach to Cultivating Self-Awareness That Can Bolster Kids' Learning. WestEd(2020). Accessed: February 6, 2021.
4. Ager k, Albrecht NJ, and Cohen M. Mindfulness in Schools Research Project: Exploring Students’ Perspectives of Mindfulness—What are students’ perspectives of learning mindfulness practices at school? Psychology 2015; 6 (7): 896-914.
5. Murry LT, Witry MJ. ‘Wasting Time Inside My Mind’: Exploring Student Pharmacists’ Perspectives on Engaging in Mindfulness Oriented Meditation Using Concepts From Education Research. Pharmacy Education [Internet]. 2020;204–214. Accessed: February 6, 2021.
6. Malcom DR. Being Present With Learners and the Deeper Lessons From Acting. Am J Pharm Educ [Internet]. 2020; 84: Article 8062.
7. O’Driscoll M, Sahm LJ, Byrne H, et al. Impact of a Mindfulness-Based Intervention on Undergraduate Pharmacy Students’ Stress and Distress: Quantitative Results of a Mixed-Methods Study. Curr Pharm Teach Learn [Internet]. 2019;11:876–887.
8. Schlesselman LS, Cain J, DiVall M. Improving and Restoring the Well-Being and Resilience of Pharmacy Students During a Pandemic. Am J Pharm Educ [Internet]. 2020; 84: Article 8144.

Preparing Health Professions Students for Telehealth

by Madeline Wolters, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Telehealth is a rapidly growing modality for delivering health care services.  It can improve access to care, enhance quality and frequency of visits, and reduce costs.¹ Telehealth can be administered in many ways but the most common are video conferencing, telephonic communication, and remote patient monitoring.² The World Health Organization defines telehealth as:

The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.¹

As a pharmacist who trained in Mississippi, I did receive some instruction regarding the delivery of teleservices since access to transportation and the geographic availability of providers are common barriers in rural areas. However, with the arrival of the COVID-19 pandemic, we have seen traditional healthcare delivery restructured, moving away from face-to-face visits to telehealth services.

Technology and virtual services are here to stay, so we must provide instruction to students of all health professions about telehealth.  Here are the key elements that should be addressed in the core curriculum:³

1. Professionalism in a virtual age
2. Appropriate use of mobile health information and technology
3. Communication skills in online environments

In my own experience as a pharmacy student, I was taught these skills through a series of lectures, training courses, professional assemblies, and practice-based experiences. There are countless ways to present and teach about telehealth to fit the needs of learners. Because health professionals must earn and maintain the trust of the people we serve, as practitioners and educators, it is our responsibility to uphold professionalism and teach those principles to the next generation. It is also important to remember that what may seem obvious to an “old pro” might not be intuitive for a novice learner.

Most health profession programs begin with instruction that is primarily classroom-based.  Early in the curriculum is the ideal time to introduce the concepts of professionalism, appropriate use of technology and patient information, and the foundations of successful communication. As learners progress and enter into the experiential or clinical portion of their education, these concepts can be expanded and reinforced through hands-on experiences and practice. In an interview on how telehealth is transforming healthcare during the COVID-19 pandemic, Dr. Richard Van Eck of the University of North Dakota School of Medicine and Health Sciences stressed the importance of putting learners in simulated and realistic environments to truly understand telehealth.⁴ He stated,” you can do all the didactics you want, but until you're in the midst of doing it [telehealth], you don't really understand what's involved”.⁴

The American Medical Association released a “Telehealth Visit Etiquette Checklist” which provides valuable tips that can be applied to all patient care interactions.⁵ A telehealth visit should mimic an in-person appointment as close as possible. If the patient will be using video-capable technology during an encounter, the student should be aware to dress in the same level of professional attire, including a white coat, if applicable.⁵ Just as a practitioner would prepare an exam room, the student should prepare their virtual environment.⁵ The necessary technology should be accessible, the electronic health record (EHR) should be open, and the background scenery and lighting should be appropriate for the encounter. For telephone calls, make sure the student is either using a telephone owned by the healthcare facility or an application that scrambles or protects the student’s personal phone number. The teaching institution should be able to provide any space and equipment that the learner should need.

Learners should also be taught how to appropriately use and share health information and technology. The patient’s confidentiality should be ensured by managing the appointment in a private space and following HIPAA (Health Insurance Portability and Accountability Act) requirements. It is also important to teach what health information may or may not be sent through non-secure platforms like email or text messages. If written patient information is to be shared with other providers, students need to be taught how to encrypt emails or navigate messaging through the EHR. The student should know who to contact if he or she feels the patient’s privacy may have been breached. Additionally, students need to know how and when they are permitted to use personal and institutional issued technology. Specific policies may vary from site to site, but ultimately a student should be taught a general guide to appropriate technology use.

Lastly, communication is at the center of all patient interactions. From the very beginning, students should be taught how to engage in motivational interviewing, deliver patient education, and manage patient exams. However, adjustments may be needed when using a virtual platform. Dr. Van Eck noted that many students inexperienced with telehealth report that they have difficulty understanding what the patient is saying and they are not able to read body language.  Also, patients are more likely to say things like “Who are you?”⁴ It may be helpful to run through example scenarios to boost a student’s confidence with operating the technology and practicing how to interact with a patient. Since you are not in control of the patient’s environment, students should be taught strategies to redirect the patient’s attention. For example, if the TV is loud in the background, the student should have the practice and self-assurance to say, “I would like us to have the best visit possible. Would you be able to turn the TV off for now?²” The importance of speaking clearly and deliberately is heightened during a telehealth encounter. Students may need to make frequent pauses to allow for transmission delays.⁵ During video-capable visits, students must be taught how to maintain eye contact and use non-verbal cues as much as possible.⁵ For telephone calls, students need to learn how to introduce the encounter and explain why they are calling the patient. Since hearing will be the only sensory mechanism, students will need to learn how to use inflection with their voice and implement continuous confirmation with empathetic language.⁵ As with all patient encounters, students must know to verbalize and clarify the next steps and patient care plan. The "teach-back method" is still helpful to confirm a patient's understanding.

A recently published systematic review examined the integration of telehealth topics in health professions curricula.¹ The review noted that telehealth concepts are multifaceted and can be overwhelming for students without foundational knowledge and guided experiences.¹ However, instruction provided to students using different modalities (online delivery, clinical experiences, simulations, and face-to-face instruction) all improved student satisfaction and self-confidence with telehealth encounters.¹ Ultimately, multiple exposures to these concepts throughout the curriculum are essential for the next generation of health care works to become competent and confident using telehealth technologies.¹ As telehealth becomes commonplace, telehealth experiences must become a required component of every curriculum.

References

1. Chike-Harris KE, Durham C, Logan A, et al. Integration of Telehealth Education Into the Health Care Provider Curriculum: A Review. Telemedicine and E-Health [Internet], Published online April 3, 2020. https://doi.org/10.1089/tmj.2019.0261
2. Telehealth. American Pharmacists Association. Accessed February 05, 2021.
3. Aungst TD. Integrating mHealth and Mobile Technology Education Into the Pharmacy Curriculum. Am J Pharm Educ 2014;78: Article 78119.
4. Educators discuss integrating telehealth in student curriculum. American Medical Association, January 2021. Accessed February 12, 2021.
5. Telehealth Visit Etiquette Checklist. American Medical Association. April 2020.  Accessed Feb 15, 2020.

Benefits and Concerns with Educational Handovers

by Elizabeth Sykes, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-North Mississippi

Most health professional are familiar with hand-off or handover reports which occur at the beginning and end of a shift, when a patient is transferred from one unit to another, or when there is a change in a patient’s condition.  Handovers occur between nurse to nurse, nurse to physician, nurse to a pharmacist, and even from pharmacist to pharmacist.  These handovers occur within and across all disciplines so that patients receive the most appropriate care.  Handovers are very important for patient safety and continuity of care.  It has been shown that poor or inaccurate handovers may lead to delayed and inappropriate treatment, medical errors, and inaccurate assessments and diagnoses.  Perhaps an educational handover between teachers and educational programs can have similar benefits?

An educational handover, the sharing of appropriate learner performance information between teachers and preceptors to support the learner’s ongoing training and development, is a potentially valuable way to support learning over time.¹ In this way, feedback about performance problems can be made based on multiple, longitudinal observations.¹  Benefits of educational handovers may include improved learning through more tailored feedback and support, improvements in a supervisor’s ability to assess learners related to specific competencies, increased assessor accountability, and improved patient safety through the early identification of weak or problematic behaviors.² 

However, not everyone agrees that educational handovers are useful, valuable, or appropriate.  Despite the potential benefits of an educational handover, there are some concerns associated with it.  Informing future teachers or preceptors about potential performance problems may introduce bias into the assessment process and it may lead instructors to treat some learners differently or label them. This could then lead to both the learner and the assessor acting in ways and viewing the learner’s performance through a lens that lines up with prior assessments. In addition, an educational handover may violate a learner’s right to confidentiality and privacy.²

A study performed at McGill University examined the potential bias from an educational handover on workplace-based assessment scores in medical education.  When given handover reports mentioning weaknesses, the hypothesis was that supervisors would provide lower assessment scores and more negative comments than those who did not receive learner reports.  This was a mixed-methods randomized, controlled, experimental study.  All participants viewed two videos of a simulated resident-patient encounter and then assessed the residents’ performance using the mini-Clinical Evaluation Exercise (mini-CEX).  The two videos viewed them in the same order.    The participants were randomized into three groups that differed based on the educational handover condition: no education handover report (control group), educational handover report indicating weaknesses in medical expertise, and educational handover report showing weaknesses in communication.  Participants had to complete a questionnaire that included questions about basic demographic variables (age, gender), clinical and educational variables (specialty, years of experience supervising, years of experience assessing), and mindset.  An analysis of variance was used to compare mean scores, percentages of negative comments, comments focusing on medical expertise, and comments focusing on communication across experimental groups.³

Seventy-two supervisors completed the study with 21 participants in the control group, 21 in the educational handover group indicating weakness in medical expertise, and 30 participants in the group receiving the educational handover indicating communication weaknesses.  No differences were detected in demographic characteristics, rater experience, or mindset across the three groups.  There was no effect of the handover report on assessment scores (F(2, 69) = 0.31, P = 0.74) or percentage of negative comments (F(2, 60) = 0.33, P = 0.72).  However, the participants who received a report indicating communication weakness generated a higher percentage of comments about communication skills than the control group (63% vs. 50%), P = 0.03).³ 

	Control Group (no handover report) n = 21	Medical Expertise Weakness Group n = 21	Communication Weakness Group n = 30
Mean score for Video 1	5.6 (4.9-6.2)	5 (4.2-5.8)	4.9 (4.5-5.4)
Mean score for Video 2	4.8 (4.2-5.4)	5 (4.4-5.6)	4.9 (4.4-5.5)
Mean score for both videos	5.2 (4.6-5.7)	5 (4.4-5.6)	4.9 (4.5-5.3)

This study suggests that an educational handover can lead to more targeted feedback without influencing scores.  Further studies are needed to examine the influence of reports of various performance levels, areas of weakness, and learner behaviors.³ 

Competency-based medical education (CBME) is becoming the cornerstone of medical education programs.  But the transition from undergraduate medical education to graduate medical education is not a smooth process.  It has been suggested that an educational handover at the end of medical school might help with this transition and would help students become more prepared to care of patients.  The Medical Student Performance Evaluation (MSPE) is submitted in early October each year, and there is very little information provided about the final year of medical school.  In April 2018, the American Medical Association’s Accelerating Change in Medical Education consortium developed five recommendations for developing an educational handover that would be provided to residency programs at the end of medical school.  The 5 recommendations are: (1) The purpose of the educational handover is to provide performance data to guide continued improvement in the learner’s ability and performance, (2) the process used to create an education handover should be philosophically and practically aligned with the learner’s continuous improvement, (3) the educational handover should be learner-driven with a focus on individualized learning plans that are co-produced by the learner and his/her coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest inadequate infrastructure to support learner improvement.

Despite these recommendations, there are still challenges with educational handovers between educational programs.  Medical schools would have to develop a curriculum for educational handovers that focuses on assessing individuals' performance.  These should include authentic workplace-based assessments coupled with a formative feedback process.  The Family Educational Rights and Privacy Act (FERPA) regulations apply to educational handovers.  Even though medical school graduates transfer from one educational setting to another, FERPA protects the privacy of learners in both contexts.  Thus, any educational handover will need to comply with FERPA.  Medical schools would need to develop a standardized process to support meaningful communication.  Lastly, creating an educational handover should support a successful transition.  Gathering assessments and adjusting each trainee’s experience during the first few months of a residency would be challenging.  But to be truly effective, the content of the educational handover should be used to implement learner-specific curricular modifications.⁵

Health profession educational programs should have some form of handover, but many of them don’t, or they may lack the appropriate framework.⁴  I believe educational handovers would help prepare learners (students and residents) for the next step in their career.  It can provide future preceptors and employers with information about the learners’ past performance and how they should tailor experiences to help address potential weaknesses.  Educational handovers may lead to some bias, but I believe with appropriate training, preceptors and residency program directors can learn to appropriately use this information to address learner needs. 

References 

1. Guidelines for Educational Handover in Competence by Design. Royal College Committee on Specialty Education: 2018 May 
2. (Gumuchian ST, Pal NE, Young M, Danoff D, Plotnick LH, Cummings BA, et al. Learner handover: Perspectives and recommendations from the front-line. Perspect Med Educ. 2020;9:294-301. 
3. Dory V, Danoff D, Plotnick LH, Cummings BA, Gomez-Garibello C, Pal NE, et al. Does Education Handover Influence Subsequent Assessment? Acad Med. 2021;96:118-125.
4. Gordon M, Hill E, Stojan JN, Daniel M. Educational Interventions to Improve Handover in Health Care:  An Updated Systematic Review. Acad Med. 2018;93(8):1234-1244. 
5. Morgan HK, Mejicano GC, Skochelak S, Lomis K, Hawkins R, Tunkel AR, et al. A Responsible Educational Handover: Improving Communication to Improve Learning. Acad Med. 2020;95:194-199.

Deep Learning Strategies

by Grace Orman, PharmD, PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

We have all been there. The night before a big test. Maybe the week was busy. Maybe time got lost. Maybe this was the plan all along — to wait until the last minute. The next handful of hours are dedicated to quickly reviewing weeks’ worth of lectures and somehow manage to retain all those details to successfully pass the test. You may be great at cramming. You might even pass that test. But will you remember the information in a year? A month? Even this afternoon?

This is an example of surface learning. A form of learning where there is no understanding or application, only rote memorization.¹ The information gathered during “cramming” or last-minute studying for a test is not elaborated nor is the knowledge applied in any way. Often, the information is retained for only a brief period of time, if at all.² Surface, or shallow learning, is maybe the first step when learning new vocabulary or concepts, but it should not be the last step. Surface learning might get a student through an exam, a class, and maybe even a series of courses. But as teachers, we should encourage students to get beyond shallow learning and provide them with strategies for deep learning.³

Healthcare workers should possess a broad knowledge base, flexibility, problem-solving ability, and be pro-active.¹ Rote recall of an expansive fund of knowledge is not enough to excel in the professional and personal world post-graduation.² The ability to retain core knowledge is the minimum requirement in the world today. The ability to communicate knowledge and integrate that knowledge to solve problems is critical.  Moreover, all health professionals must be in charge of their own continuing education as knowledge is constantly evolving.^3,4 Thus deep learning is needed.  The fundamentals must be applied and repeated to re-enforce concepts. To achieve deeper learning, we have to change the way we educate. There are a handful of strategies to help facilitate deeper learning. These strategies align with three domains: cognitive, interpersonal, and intrapersonal.

The cognitive domain is where the basis of deeper learning stems: the mastery of core academic content and incorporating critical thinking skills. The Hewlett Foundation defines the mastery of this domain as the skillset to “develop and draw from a baseline understanding of knowledge in an academic discipline and to transfer knowledge to other situations.” Thus fundamental knowledge is used and applied in new situations.^2,3,4 This would incorporate “problem-based learning,” where the student would need to know the basics of the subject but then apply it to a series of cases (simulated “real-world” situations). This not only merges together the student’s core knowledge but also draws upon their experiences and imagination. Incorporating internship opportunities outside of school is another great way to practice and solidify one’s fundamental knowledge in a real-world environment. Other strategies to enhance the cognitive domain are self-check quizzing and discussion boards.

The second domain to promote deep learning is the interpersonal domain. This domain requires communication and collaboration. The ability to effectively communicate complex ideas to others and to collaborate together is essential in the world post-graduation. Effective communication can be achieved through peer teaching and presenting information to others. This can also foster peer-to-peer review and feedback. Group projects with alternating leaders allow for both communication and collaborative effects, allowing students to see the benefits and outcomes of working together. Internships can also help foster this domain. Incorporating these into the curriculum, whereby students are placed in real-work environments several days a week could solidify collaborative work between team-mates and co-workers.

Lastly, the intrapersonal domain consists of learning how to learn over a lifetime. Continuing education is a critical component of a life-long learner. It is essential to stay “in the know” of new concepts, information, and guidelines in healthcare. Being able to develop a process for self-directed learning is a key to staying current throughout one’s career. Students must be responsible for determining own their goals and assessing their progress. This could be achieved by self-management and self-evaluations. Teachers can help the student find their strengths and weaknesses and help guide them to self-reflection after group work or other activities. Instead of enforcing strict deadlines, letting students progress at their own pace while encouraging deeper learning, can foster the skills needed to continue to grow outside of the classroom.⁴

To become deeper learners, students must be active and engaged in their learning. Bringing together these three domains — the cognitive, the interpersonal, and the intrapersonal — can have a profound impact not only on their academic performance but preparing students for the life they must outside of the classroom. As teachers and mentors, we want our students to thrive in life as well as in class. Providing students with strategies that foster deeper learning can prepare them for life.

References: 

1. Lombardi P. Instructional Methods, Strategies, and Technologies to Meet the Needs of All Learners [Internet]. Montreal: Pressbooks; 2019. [cited 2021 Jan 24].
2. Peng M, Chen C. The Effect of Instructor’s Learning Modes on Deep Approach to Student Learning and Learning Outcomes. Educational Sciences: Theory & Practice. 2019;19(3):65-85.
3. Hailikari T, Katajavuori N, Ylanne S. The Relevance of Prior Knowledge in Learning and Institutional Design. Am J Pharm Educ 2008;72(5): Article 113.
4. Huberman M, Bitter C, Anthony J, O’Day J. The Shape of Deeper Learning: Strategies, Structures and Cultures in Deeper Learning Network High Schools [Internet]. Washington, DC. American Institutes for Research. 2014, 1-38. [cited 2020 Jan 17]

Reducing Black and White Thinking: Constructing Partial Credit Multiple Choice Exams

by Lauryn Easley, PharmD, PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

During my many years in school, exams were given primarily in the classic, multiple-choice question format. The form of assessment has been the gold standard for many years.¹ While multiple-choice question examinations aren’t perfect, many would argue that “if it’s not broken, don’t fix it”. However, I would argue there is one significant shortcoming for the single best answer, multiple-choice tests —students begin to assume there is only one correct answer. This has led generations of students to view concepts with a “black or white” mentality. You are either right or you are wrong.  This kind of thinking is not helpful. Life is more nuanced. We need to help students understand that the world and our knowledge is actually rather grey.

In a world full of possibilities, leading our students to develop black and white thinking causes them to misunderstand situations. They only see the two extremes and not the in-betweens.¹ Traditional multiple-choice examinations potentially stifle students’ creativity, as well as enable them to put forth minimal effort, thus producing lazy learners.^1,2 If students were made to explain their reasoning or defend their choices, we could move away from simplistic answers and move towards students better able to stand by their viewpoints and use evidence to support them.^1,2 Furthermore, multiple-choice exams inhibit the instructor’s ability to truly know whether the students fully grasp the concepts being taught. With traditional multiple-choice exams, students can guess the answers to most questions and still pass. A savvy test-taker might not actually comprehend the material.

Traditional multiple-choice tests can lead to “over-thinking” because the student assumes there is only one correct answer, even though other answer choices seem appropriate.² As a type-A, over-thinker, I would find myself reading a question and looking for additional details to help make a complex decision.  But sometimes I was making the question far more complicated than the teacher intended. Because of this, I would sometimes pick an “incorrect” answer simply because I misunderstood what the teacher was asking me. In traditional multiple-choice exams, I had no way of explaining my reasoning.  I was forced to choose one answer over another. For this reason, I rarely reviewed questions I answered incorrectly on a test because I did not like to rehash my errors. Looking back, this was not a healthy mindset. None-the-less, I think it’s an important question. Should we move away from traditional multiple-choice exams, and if so, what are some suitable alternatives?

There are, in fact, a few different options, including awarding partial credit for answers that are okay but less than ideal, utilizing select all that apply questions, and short-answer questions.^1,2,3

Partial credit focuses on awarding the most points to students picking the “most correct” or “best” answer but not fully penalizing students for picking an answer that may not have been the best option among the choices offered but is a reasonable option in some circumstances. Scoring questions in this manner can also help instructors move away from factual, straightforward, there is only one “right” answer to questions and move toward conceptual questions that require deeper thinking.^1,2  For example, a question might ask about various treatment options for a disease or problem. While the “best” or “preferred” option might be among the choices, the student might be awarded partial credit for an option that is effective and unlikely to cause patient harm. In this case, the answer choice the student picked could be awarded partial credit, rather than full credit. The instills the idea that some answers are better than others but there is a range of “acceptable” choices. Other advantages of awarding partial credit – it may be easier for instructors to create distractors for the question and there may be fewer post-exam arguments from students seeking credit for their selected answers.

 Duckor and Holmberg give the example below to illustrate the benefits of organizing answer choices into bins, where certain bins are worth partial credit and other bins are considered incorrect.³

When the time is taken to organize and categorize each answer choice, instructors will have a better grasp of how well their students understand the topic, where common misconceptions lie, and where clarification with additional instruction may be beneficial. 

Select all that apply questions always discouraged me as a student because they were treated as all-or-nothing questions at my school.  You had to select ONLY the correct options and not select the incorrect options in order to get credit.  If you selected (or didn’t select) 5 out of the 6 options correctly, you go NO points. In other words, a student who got 5 out of 6 options correctly received the same number of points as a student who got 0 out of the 6 options correct.  It seemly likely the two students' understanding of the material is VERY different, but in terms of performance on the exam, they both received the same score. While some national certification examinations score select all that apply questions as all-or-nothing, this is not conducive to learning and doesn’t acknowledge what students DO know about the subject matter. To encourage students, they should be granted partial credit for each correct response option chosen and, conversely, points should be deducted for each incorrect option chosen. So, for example, if a student was correct on 5 out of 6 options, the student would receive +5 – 1 = 4 points.  If a student had 3 out of 6 options correct, the student would receive +3 – 3 = 0.  Awarding partial credit while also subtracting points for incorrect answers prevents students from gaming the system and simply selecting all options just to get some points.

As a student, I’ll admit that I didn’t like short-answer questions. However, in employing this testing format, we allow students to show us how much they understand and we can get a glimpse of each student’s thinking.¹ Short-answer essay questions really require students to thoroughly prepare. The student is forced to formulate a response – they can’t rely on recall to select from a list of possible responses.  Short-answer essays can be combined with the multiple-choice format whereby the student must provide a rationale for the response they selected.  In this way, students must know the correct or “best” answers but also must defend their choice.¹  Points could be independently awarded for selecting the correct answer and for the rationale.  Or points might be awarded only when the correct rationale is provided.  This would prevent “guessing” the correct answer.

I think these testing formats would encourage more students to review their responses to questions on an exam and encourage them to fully grasp the concepts being tested. It could lead more students to dig deeper into the materials to assess why they missed certain questions and why the best answer was, in fact, better than the other choices.

While a majority of these testing options may require more time and effort for either preparing or grading examinations, they give us a much clearer picture of how our students are doing and how well they grasp the material.^1,2 More importantly, rather than reinforcing black and white thinking, these alternative exam formats promote critical thinking, encouraging students to weigh the merits of different options.

References: 

1. Harrnstadt D. Pivot away from multiple-choice testing [Internet]. Bethesda (MD): Walt Whitman High School, The Black & White; 2019 Mar 23 [cited 2021 Jan 28].
2. Berwick C. What Does the Research Say About Testing? [Internet]. San Rafael (CA): George Lucas Educational Foundation, Edutopia; 2019 Oct 25 [cited 2021 Jan 28].
3. Duckor B, Holmberg C. Two Strategies for Assessing for Learning: The Partial Credit Scoring Key and the Scoring Guide [Internet]. Alexandria (VA): Association for Supervision and Curriculum Development, Inservice; 2018 Jul 23 [cited 2021 Jan 28].

Mastery- vs Performance-Oriented Goals and Their influence on Motivation and Success

by Michelle Ha, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-North Mississippi

Many of us are familiar with setting goals: short-term, long-term, professional, and personal. But do ever think about your goal orientation? The concept of goal orientation was developed by psychologists in the 1980s and explains the mindset that an individual has when developing and achieving goals. There are two primary ways one can approach goals: mastery or performance.

Learners who have a mastery-orientation focus on learning to perform better in the real world – for example, learning in order to become more skillful at taking care of patients. Learners who have a performance orientation focus on demonstrating competence relative to others – for example, performing well on exams, getting high marks on performance evaluations, and (in general) looking smart in front of others. In other words, those who set mastery-oriented goals tend to compete with themselves, and satisfaction is based on internal factors. Those who have performance-oriented goals are primarily motivated by external feedback and validation.^1,2

Summary of Mastery vs Performance-Oriented Goals.³

Mastery-Oriented	Performance-Oriented
More likely to be intrinsically motivated	More likely to be extrinsically motivated
Seek feedback that accurately describes their abilities and helps them improve	Seek feedback that flatters them
Choose tasks that maximize opportunities for learning and seek out challenges	Choose tasks that maximize opportunities for demonstrating competence and avoid tasks that make them look incompetent
Views errors as a normal part of learning and uses errors to improve	Views errors as a sign of failure and incompetence
Satisfied with performance as long as they make progress	Satisfied only if they succeed
Views teacher as a resource	Views teacher as a judge, rewarder, or punisher

Goal orientation is important because it influences one's motivation and selection of learning strategies. Goal setting starts at a young age - regardless if you were aware of it or not. Thus, many people are unaware of the impact that their goal orientation has on their performance in school and life.

Imagine you have two students in your class: Marcus and Marilyn.

Marcus wants to perform well in school. He studies hard and would like to earn an “A” in pharmacology. He pushes himself hard to make his parents proud. However, he sometimes worries about whether he'll get an "A", failing to live up to his parents' expectations, and looking incompetent in front of the teacher/preceptor. He knows what learning methods work best for him and does not want to try other studying strategies. When he performs poorly on an exam, he submits challenges to the instructor in order to “get” points, even if he really didn’t understand the concepts that well. Although Marcus nearly always meets his goals, he beats himself up when he falls a bit short.

On the other hand, Marilyn enjoys the process of learning. She goes beyond the expectations set by the instructor in her pharmacology course and seeks out outside opportunities to learn more about the topic. While getting an “A” in the course would be great, she’s not too worried about the grade, so long as she’s learning new things she feels are important to her future career. She is most happy when she meets her personal goals and continues to strive to do better each day. When she struggles to learn about a concept, she seeks help and tries new strategies, and uses new resources.  When she performs poorly on an exam, she seeks help from the instructor and signs up for tutoring help. Although Marilyn nearly always meets her goals, she knows that stretching herself and falling short is part of the process.

A person can have both mastery and performance-orientations.  Indeed, most people don’t fall exclusively in one camp or the other and their orientation can be different in different circumstances and courses. However, researchers have found that mastery-oriented goals are more effective in terms of student motivation. Satisfaction is not related to external factors. Performance goals are often helpful in the short-term; however, they may stifle a student growing to their full potential.

Back to our example, Marcus' goal was to make an A in pharmacology. Once he believes he’s achieved this goal in the class, he may be less motivated and prefer to “coast” through the rest of the course. "I've made As on the last three exams and as long as I get at least 67 points on the final, I’ll still get an A." In his mind, his success is determined by his grades. If Marcus ends up with a B in the course, he’ll probably avoid taking the pharmacology elective for fear he won’t do well and his GPA will be negatively impacted.  In contrast, for Marilyn, if she gets an A on the first 3 exams in pharmacology, she will continue to study hard and may even continue to seek out opportunities to learn more after the course has ended. If she falls short of a good grade in her pharmacology course, Marilyn might sign up for the pharmacology elective in order “to get better” at something she feels is critical to her success. The factors that move her forward are internal and within her control. Thus, it is easier for Marilyn to stay resilient and adapt during times of struggle. Marilyn experiences less anxiety and stress when she falls short.

To examine the influence of goal orientation on motivation, one study evaluated how students responded to negative feedback. The investigators used a simulation game. Prior to participating in the simulation, each student’s orientation was measured using a multi-item scale adapted from Ames and Archer (1998). Students then completed a Marketing Management Experience, where they manage a simulated company and competed against other groups. Learning implies a change in behavior which was measured by comparing the survey results over time. While both mastery and performance-oriented students performed well during this simulation, those in the mastery-oriented goal group tended to take negative feedback better. In the performance-oriented goal group, some of the students develop a learned behavior known as "learned helplessness". This is a term that describes the reaction to failure that reduces the desire to place oneself in that circumstance again. 

In another study, researchers surveyed medical, pharmacy, and veterinary students. The students completed a series of surveys at the beginning of 5 consecutive semesters that measured their mastery orientation, performance orientation, and self-efficacy. While most students were stable in terms of their goal orientation, there were some differences between students based on their gender, grades, and self-efficacy. Self-efficacy was the biggest predictor of those who adopted mastery-oriented goals. Self-efficacy is the strength of a student's belief in their ability to complete a task.⁵

Self-efficacy in itself is another important concept!  In brief, it is a good predictor of motivation and learning, especially in health professional students and practitioners. Someone with a high level of self-efficacy can visualize a positive outcome and is more likely to perform well in their daily duties such as delivering patient care. The ability to adapt and remain resilient in times of unexpected setbacks is also more easily managed among those with a high level of self-efficacy.⁶

Marilyn, our student who is focused on learning and improvement, is the ideal student. However, it is not an innate trait. Mastery-orientation to learning can be taught and cultivated! As educators, we must encourage students to approach their learning with mastery-oriented goals in mind. Because self-efficacy and mastery-oriented goals go hand in hand, it is important to give students a choice when assigning learning activities.  Asking students to think about how their learning activities link to their careers will increase the likelihood of students developing mastery-oriented goals.^1,7 Allowing students to make choices and linking those choices to career aspirations will help students feel autonomous and motivated to learn.⁷ Below is a list of other things that you may wish to try in the classroom to foster a mastery-oriented mindset.⁷ 

1. Be a role model for students. Show them that you have made mistakes but have learned from them instead of hiding them or avoiding them.
2. Give positive, constructive feedback that focuses on personal improvement. Focus less on grades and more on mastering the skill or concept.
3. Don’t compare the student’s performance to peers. Emphasize growth.  Compare the student's performance to previous performance.
4. Foster a community of trust within the classroom so that students are more likely to seek help from peers and you.

While students with performance-oriented goals are no less likely to get good grades, they may be less likely to develop life-long learning habits. Mastery-oriented goal-setters strive for improvement daily and want to become better even if that means venturing through unknown challenges. Students who approach their goals as an opportunity to master something will be the ones who love what they do and are motivated to learn more. Instilling a mastery-oriented mindset in your students will groom them for a future of success.

References:

1. Donald B. Stanford psychologist: Achievement goals can be shaped by environment [Internet]. Stanford University. 2012 [cited 2021 Jan 11].
2. Bråten I, Strømsø HI. Epistemological beliefs and implicit theories of intelligence as predictors of achievement goals. Contemporary Educational Psychology. 2004 Oct;29(4):371–88.

3. Mastery Vs Performance Goals. [Internet] Western Oregon University. [cited 11 January 2021].

4. Gentry JW, Dickinson JR, Burns AC, Mcginnis L, Park JY. The role of learning versus performance orientations when reacting to negative outcomes in simulation games. Association for Business Simulation and Experiential Learning. 2006;33.

5. Kool A, Mainhard T, Brekelmans M, van Beukelen P, Jaarsma D. Goal orientations of health profession students throughout the undergraduate program: a multilevel study. BMC Med Educ. 2016 Dec;16(1):100.

6. Zamani-Alavijeh F, Araban M, Harandy TF, Bastami F, Almasian M. Sources of health care providers’ Self-efficacy to deliver Health Education: a qualitative study. BMC Med Educ. Jan 2019;19(1):16.
7. Svinicki M. Fostering a Mastery Goal Orientation in the Classroom [Internet]. Austin; 2010 [cited 2021 Jan 23]. p. 25-28.

Team-Based Learning Promotes Self-Reflection and Creates Lifelong Learners

by Austin Simmons, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

During the first two years of any healthcare provider’s schooling, students often find themselves navigating their curriculum and trying to remember all of the little details that are thrown their way. Most students don’t engage in much self-reflection during this period due to workload demands. Then comes the third and fourth years of school. This is when students try to piece it all together and decipher what they know and what they will need to work on as they transition from student to independent practitioner. I believe team-based learning prepares students to transition from dependent learners to lifelong learners and promotes self-reflection.

Team-based learning is built on the constructivist theory which states that learners process new material and integrate it with existing understandings in order to form a new cognitive structure that is unique to them.¹ Hrynchak and Batty wrote about team-based learning and provide an analysis of how constructivist theory plays a role in student development. Essentially, the professor is a facilitator for learning.  The students encounter inconsistencies between their preconceptions and new experiences.  In team-based learning, the focus is on relevant problems and accompanied by group interactions, and this often leads to reflection.² They go on to explain that team-based learning can be used in large classes that are divided into smaller groups.  The goal should be to maximize the diversity within the teams.² Let’s take a look at the framework team-based learning uses to promote self-reflection and build lifelong learners.

Classically, the design of team-based learning is a three-step process that involves student preparation, readiness testing, and application-focused exercises.³ Now, how does this framework promote learning and increase student self-awareness? Let me draw from my own experience.  At my pharmacy school, we had a class called case studies. The intent of this class was for the students to prepare before the class session and use prior knowledge.  We would then engage in collaborative work discussing a patient case in our assigned small group. Then after our small group discussion, the classroom as a whole would come together and the professor would facilitate a conversation by asking each small group questions related to the patient case. The instructor would also encourage the entire class to openly respond to these questions. It was during these interactions, in our teams and the entire class, that we’d encounter inconsistencies between our preconceptions and the perspectives of our instructor as well as other students.² Doing so, in theory, prompts each student to reflect on his/her own understanding of the material. But what are the individual processes or parts that make team-based learning work and what are the important takeaways for a student and instructor?

From my own experience, I found that the immediate feedback from my classmates and the instructor allowed me a way to rapidly assess how well I understood the material. Our class was a 3-hour session which included the time for our small group discussion. If we discussing a case about a patient with diabetes, I might ask myself: what do the blood glucose data mean?  What are the blood glucose goals for the patient? I would rapidly assess and begin self-reflection by asking myself if I needed to review more about the treatment of diabetes. The immediate feedback is a big part of what makes team-based learning work and vital to increasing self-reflection.⁴

I believe it is important to keep in mind that all aspects of the team-based learning framework must be implemented and the intentional guidance provided by an instructor is essential.⁵ Martirosov and Moser found that a student’s understanding and performance were significantly reduced in the absence of appropriate guidance.⁵  To maximize learning, the instructor must ask probing questions. For example, a patient case about diabetes helped promote self-reflection by getting students to think through the data and recommend starting a medication, perhaps an angiotensin receptor blocker (ARB). Then the instructor would ask questions about why they think the patient should receive an ARB instead of an ACE inhibitor. By prodding the students to explain their choices, it forces them to reflect on that choice and critically examine the thought process. An instructor is the glue that prompts high-level cognitive processing and pulls forth the student’s previous knowledge.  In this way, team-based learning helps students put the pieces together.

Team-based learning is an excellent instructional strategy that many curriculums have used. Team-based learning requires students to engage in reflection because it frequently challenges their preconceived understanding of the material and, in turn, promotes life-long learning.  With guidance from the instructor, students must defend their choices, and this helps them “put it all together.” I firmly believe team-based learning helps students develop lifelong learning skills and helps them become excellent healthcare practitioners.

References:

1. Moon J. A Handbook of Reflective and Experiential Learning. 1st ed. Hoboken: Taylor and Francis; 2004.
2. Hrynchak P, Batty H. The educational theory basis of team-based learning. Medical Teacher [Internet]. 2012 [cited 2020 Nov 3];34(10):796-801.
3. Overview - Team-Based Learning Collaborative [Internet]. Team-Based Learning Collaborative. 2020 [cited 2020 Nov 3].
4. Whittaker A. Effects of Team-Based Learning on Self-Regulated Online Learning. International Journal of Nursing Education Scholarship [Internet]. 2015 [cited 2020 Nov 4];12(1):45-54.
5. Martirosov A, Moser L. How Team-Based Learning Can Promote the Development of Metacognitive Awareness and Monitoring. American Journal of Pharmaceutical Education [Internet]. 2020;84(11): Article 848112.