Collaborative Teaching: One Way to Improve Teaching and Learning

by Giang Le, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-Golden Triangle

I came across this interesting article the other day entitled “Teacher collaboration in curriculum design teams: effects, mechanisms, and conditions.”¹ This article got me thinking about my years in school. I recall only a few class sessions that had two or more teachers providing instruction together. For many courses, students are essentially learning from one teacher’s perspective — which is to say, one person’s perspective. Students might assume that what that teacher says is accurate and that piece of information must be the best answer.  I’m not sure that’s always true.  From the teacher’s perspective, I wonder if they get bored teaching the same materials every year? Do teachers ever get so used to their way of teaching that they become reluctant to change? Or unaware of the need to update their content or instructional methods? Maybe teachers need a partner. Maybe instruction is better when taught by a team. Indeed, there is evidence that collaborative teaching can help teachers update their knowledge, improve their practice, and enhance learners’ outcomes.^1,2

What are collaborative teaching design teams? These teams involve educators working together to design all classroom activities, including developing a curriculum, selecting the most effective teaching methods, creating test questions, and developing tools to assess performance. An essential part of being an educator is to continue to learn – not only about the content but also ways of teaching. However, it can be hard to keep up with all the newly available information, especially when there are thousands and thousands of scientific articles published every day. In the process of balancing work life and personal life, teachers can find themselves in situations where they quickly skim an abstract or a summary. Teachers often rely on their existing knowledge and beliefs to develop learning materials. This is when collaborative teaching can be of benefit. Having people with different knowledge, skills, and perspectives on a team creates more opportunities to share knowledge.¹ If a conflict arises (a conflict of ideas, not philosophies or personalities), teachers will have to provide evidence to support their reasoning and convince their peers. In this process of solving “constructive” conflicts, teachers begin to self-reflect on their existing knowledge and their ways of practice. Self-reflection is a critical and we should practice it every day, but it is always easier said than done. Collaborative design teams create the opportunities for constructive conflict and stimulate self-reflection.

One may agree that collaborative teaching can improve teachers’ knowledge, but the more important question is: Can it improve learner outcomes? That’s the ultimate goal that every educator should strive to achieve — improvements in students performance. This means that at the end of the course, we want our students to not only understand or recall but also be able to apply the materials in a variety of circumstances. Theoretically, all teachers should have a tool to assess the students’ performance to guide their teaching. With collaborative teaching design teams, teachers can work together to create these tools. Everyone can contribute based on their experience and what’s available in the educational literature. 

In a recent study, the investigators examined three specific forms of collaboration in teaching: (1) instruction-related, (2) project-related, and (3) organization, performance, and problems-related. Their study is a secondary analysis of the German Program for International Assessment (PISA) data. A sample of 869 schoolteachers was matched with a corresponding sample of 869 students. Students’ achievement in this study was measured by comparing their grades in the first half-year of the academic period. The relationship between the different forms of teacher collaboration and student achievement was estimated through a structural equation model. They found that the third form of collaboration—modified teaching based on students’ performance—positively influenced students’ achievement. However, an interesting aspect of this study was that the subject matter taught were primarily sciences (like maths, biology, physics, and chemistry). This might explain why the third form of collaboration focusing on practice problems would produce a positive outcome. In other subjects involving more discussions and debates, the knowledge-sharing and planning process might play a more important role.

Collaborative teaching design teams can theoretically improve other aspects of the learning process. For example, I remember when my class was divided into groups to do group assignments. From time to time, the professor would be occupied with one group and unavailable to others. This quickly led to frustration among students who had a hard time understanding the materials. Instructions that may seem easy to follow for the professor might not be interpreted the same way by the students. To finish the assignment within the class period, the students would turn in poorly done work and minimal learning occurred. Collaborative teaching would give students greater access to more instructors. This benefit also applies to practical labs where one professor cannot supervise the whole class to ensure everybody follows the instructions.

How do we implement effective collaboration? This process can be time-consuming since it requires team members to gather, discuss, and revise the course materials. A course may need to be developed a year in advance and regularly revised based on students’ feedback and performance. Another strategy for effective collaboration is to allow time to build relationships and foster a culture of trust, respect, and humility between the teachers on the team.³ It is best if each team member is willing and able to contribute in meaningful ways to the work of the group. Here is my favorite quote about teaching collaboration: “As a successful co-teacher, you need to (a) know yourself, (b) know your partner(s), (c) know your students, and (d) know your ‘stuff’.”⁴  Teachers will vary in their ability to effectively collaborate. Some may find it hard to work with partners who have different beliefs and teaching styles.  Others may find it hard to assess how well the students understand the materials. If teachers know their strengths and weaknesses, they can complement each other and support one another. While team teaching can be great, forcing collaboration when teachers are not on the same page will create more classroom confusion and negatively affect learners’ outcomes.

Collaborative teaching is an ongoing process with evidence that it can improve teachers’ and learners’ outcomes. Teachers may find the collaboration not only a beneficial way to enhance their knowledge but also an opportunity to update what and how they teach.  Like any form of collaboration, the process will take time, effort, and commitment to achieve success.

References

1. Voogt JM, Pieters JM, Handelzalts A. Teacher collaboration in curriculum design teams: effects, mechanisms, and conditions. Educational Research and Evaluation. 2016; 22: 121-140.
2. Mora-Ruano JG, Heine JH, Gebhardt M. Does teacher collaboration improve student achievement? Analysis of the German PISA 2012 sample. Frontiers in Education. 2019; 13: Article 3389. (Accessed 2021 Oct 12).
3. Lauren D. Teacher collaboration: how to approach it in 2020. Schoology Exchange. 2020. https://www.schoology.com/blog/teacher-collaboration (Accessed 2021 Oct 12).
4. Keefe EB, Moore V, Duff F. The four “knows” of collaborative teaching. Teaching Exceptional Children. 2004; 36 (5): 36-42.

Listen, Clarify, and Appreciate! Best Practices When Receiving Feedback

by Camron Jones, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

 “It takes humility to seek feedback. It takes wisdom to understand it, analyze it and appropriately act on it”
-Stephen Covey.¹

What do you feel when you hear the word feedback? Do you feel nervous?  Perhaps scared about what the person might say? Do you clam up thinking you have done something wrong? I have a love/hate relationship with feedback. I love knowing how I am performing.  But I sometimes fixate on the things I did “wrong.” It can be intimidating and sometimes we get stressed out about the small things. For many people, it’s hard to accept feedback because it’s perceived as a negative judgment. I have grown to appreciate feedback because it helps me understand what I am doing well and what I need to work on. I think it’s intimidating to ask for feedback. This is something that I am working on. Not only is feedback hard to ask for, but it’s hard to give.

Feedback is the act of someone providing information about a person’s performance of a task and the recipient using the information as a basis for improvement.² Frequently we talk about how to formulate feedback so that we can help another person excel. But receiving feedback is a critical skill too. All of us need to learn to receive feedback graciously and not jump to conclusions. Both giving and receiving feedback are difficult! If we use the right techniques, we can learn as well as teach others. Let’s take a deep dive into receiving feedback by examining the best practices and how to teach it.

There are three crucial steps that should be adhered to if we want to maximize the benefits of receiving feedback. These include actively listening, clarifying the feedback, and expressing gratitude.^3,4  Listening with an open mind is a huge part of the feedback process. Listening promotes our personal and professional growth. Too quickly we jump the gun and interrupt the person providing the feedback. In the Christian Bible, there is a saying that resonates with that I believe applies to receiving feedback: “..let every man be swift to hear, slow to speak.” When receiving feedback, we must consider all of it before responding. Reflecting on the feedback is so important because it helps us grow.

When you hear words that you interpret as negative it can bring you down. But it’s important to ask questions because without getting clarification, you can create an injustice and take feedback too personally. The feedback is about your performance, not about you as a person. I feel like this is critical to understanding how to receive feedback. The person giving the feedback is only trying to help us succeed and grow.  If we dismiss or reject the feedback, we are disadvantaging ourselves.  So, ask clarifying questions!  Make certain you fully understand what the person giving the feedback is telling you. Ask for specific examples.

Finally, it’s important to express appreciation to the person providing the feedback. Remember, the person giving the feedback is usually uncomfortable.  Giving feedback and telling someone something they might perceive as negative can be intimidating. It's easier just to not say anything.  Or to tell someone everything is perfect. But the person giving feedback took the time to carefully consider how to help you improve and they want you to succeed! If we show appreciation, they will feel encouraged and more willing to share with us. 

Tips for Receiving Feedback:3

Be a good listener When in doubt, ask for clarification Embrace the feedback session as a learning opportunity Remember to pause and think before responding Avoid jumping to conclusions, and show that you are invested in the learning process and keen to improve Think positively and be open to helpful hints Learn from your mistakes and be motivated Be a good sport and show appreciation Be proactive – ask for feedback!

Studies have repeatedly shown that effective feedback has a powerful influence on how people learn. In one study involving medical students, they looked at methods to teach how to use feedback. They developed a 2-hr workshop that focused on writing goals in a learning contract, defining effective characteristics of feedback and practicing the use of feedback in response to feedback received. Following the workshop, student group scores increased significantly. They also looked at how coaching improved students' perception of their feedback skills. They noted how students' feedback interactions improved, especially during informal interactions. In a model that defines the communication pathway, they described how the process of feedback could falter. This could be due to previous experiences from the receiver, also the fear of damaging relationships between the giver and receiver.⁴

Another study enrolled second and third-year internal medicine residents. This study focused on a One-Minute Preceptor model. This was a conversation between the resident and the teacher to help improve the resident's clinical skills. One of the greatest benefits of the One-Minute Preceptor model is feedback. At baseline, feedback was ranked as one of the weaker areas. Significant improvements were reported at the end of the study. Feedback was shown to have the greatest impact on performance.⁵ 

Another good resource is the ask-tell-ask feedback model.⁶ For example, say you are a student, and you provided education to a patient about anticoagulation therapy. With the first ask, the preceptor asks the student to talk about how they thought the experience went. The preceptor then gives feedback on what was observed, both positive and negative aspects of the performance.  This is the tell component of the model. During the last ask, the student then reflects on what the preceptor has told them and they both set goals moving forward.⁶ This allows the receiver to actively participate in the conversation and formulate an action plan. I personally experienced this method of feedback in my last year of pharmacy school. Not only did it help me improve, but it also helped me be more open to feedback.

As teachers, we must learn to give feedback in a way that positively affects our students. We should allow students time to self-reflect before giving feedback. This gives the students an opportunity to think about the strengths and weaknesses of their performance. As a learner, we must learn from the feedback and use it as a tool for us to improve. Be sure to listen, clarify, and appreciate!

References

1. Covey, SR. Stephen R. Covey interactive reader-4 books in 1: The 7 habits of highly effective people, first things first, and the best of the most renowned leadership teacher of our time (Internet). Mango Media. 2015 (Cited 2021Oct1)
2. “Feedback”. Merriam-webster.com dictionary, merriam-webster. www.merriam-webster.com/dictonary/feedback. (Cited 2021Sept29).
3. Hardavella G, Aamil-Gaagnat A, Saad N, et. al. How to give and receive feedback effectively. Breathe 2017; 13:327-333. 
4. Bing-You RG, Bertsch T, Thompson JA. Coaching medical students in receiving effective feedback. Teaching and Learning in Medicine 1998; 10(4):228-231. 
5. Furney SL, Orsini AN, Orsetti KE, et al. Teaching the one-minute preceptor. J Gen Intern Med. 2001;16:620-624.
6. Jug R, Jiang X, Bean S. Giving and receiving effective feedback: a review article and how to guide. Arch Pathol Lab Med 2019; 143 (2):244-250.

The Flipped Classroom Model in the Age of Virtual Learning

by Emily Plauche, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Virtual learning played a huge role in higher education during the COVID-19 pandemic. In March 2020 when the pandemic first began to spread in the United States, educators had little time to transition to an online learning environment. Some schools gave students a few weeks off to allow time for administrators and teachers to make plans and learn how to use the technology while others immediately transitioned to an online platform with little guidance. Virtual teaching can be done synchronously via platforms such as Zoom and asynchronously using pre-recorded lectures or other online resources. Live classes allow for more interactive learning but may be limited by technical difficulties and students’ access to technology. Pre-recorded lectures provide students with more flexibility in terms of how and when they prefer to study, but students may feel disconnected from their classmates and instructors.¹  In order to best recreate the flipped classroom model, asynchronous pre-class assignments with synchronous/ live in-class activities would be ideal. Now that the education system has had more time to adapt and is able to provide almost all features of an in-person classroom experience in a virtual platform, it raises the question of whether the flipped classroom model is still effective in a virtual learning setting.  Giving students the option to attend class in person or online may become common practice as the COVID-19 pandemic persists, technology advances, and our comfort with virtual learning grows. 

The flipped classroom model is a somewhat new teaching strategy that focuses on in-class application, rather than lecturing. Instead of homework after class, students complete pre-class assignments in order to prepare for class and class time is reserved for discussions, case studies, and other activities that require students to apply what they learned prior to class. The flipped class has become increasingly popular over the last decade. A meta-analysis studying the flipped classroom model in health professions education found that the model provided several benefits including a statistically significant improvement in learner performance compared with traditional teaching methods, more time for active learning during class time, and the opportunity for students to study at their own pace before class. The analysis also found that more students favored this method of learning over traditional lecturing. However, this model requires students to prepare ahead of time in order for the activities in class to be productive. The increased burden on the student can be a limitation to its success and should be considered when teachers assign out-of-class activities.²

Traditionally, pre-class assignments are done remotely via pre-recorded lectures and required readings, and the interactive classroom activity is done in person. However, COVID-19 required all learning activities to be done virtually. Educators wanting to implement this model while teaching virtually should provide both pre-recorded lectures and live but virtual classes in order to effectively mimic the model. The question is whether a flipped classroom model is still effective in an online learning environment. A study performed in Spain specifically compared performance and emotions towards the flipped classroom model in undergraduate STEM courses before and after the COVID-19 pandemic comparing two groups: “face to face” and “face to screen.” The course consisted of three hours of live class with pre-recorded lessons to watch in preparation for class in both groups. The instruction methodologies, syllabi, and structure were identical in both groups. The study did not disclose what type of assessments were used but the “pass rate” was similar in the two groups with 67.1% of students in the face-to-face group achieving a “passing” score compared with 70.3% in the face-to-screen group.  The difference was not statistically significant. Face-to-face instruction was associated with more positive emotions such as enthusiasm, confidence, tranquility, and fun while face-to-screen instruction was associated with more negative emotions including concern, nervousness, fear, and boredom.³

Some of these negative emotions observed in the face-to-screen group were likely influenced by the uncertainties at the beginning of the pandemic and were not solely due to virtual learning. As students become more acquainted with distant learning, it is likely the virtual classroom will be perceived less negatively. However, student engagement and attention in the virtual classroom may be persistent challenges. It is promising that there was not a statistically significant difference in performance between the groups, suggesting that the flipped classroom is an acceptable approach to teaching in a virtual setting.

Instructors can work to increase virtual student engagement by offering a variety of ways for students to participate. Some may prefer to use the microphone, type in a chat box, or use the raise hand feature. By offering multiple options, students are able to interact in a way that they feel most comfortable. Breakout rooms can also be used to facilitate work in small groups, which might reduce students' anxiety about taking in front of a large group. Teachers can also ask their students for feedback throughout the semester to better understand students’ needs and concerns. To minimize technical difficulties, teachers should perform test runs before live class sessions to ensure Zoom links, internet connection, and sound are working properly.

The flipped classroom model allows for more interactive classroom experiences between students and teachers and has been shown to improve student performance when compared to more traditional methods to teach. While we have limited data from studies, the flipped classroom method still works in a virtual classroom setting. Teachers planning to utilize the flipped classroom model in an online class may face challenges including technical difficulties along with reduced student engagement, attention, and attitude towards virtual learning. Teachers should keep this in mind as they develop material to teach virtually. As more research is published about online teaching methods, educators will have a better understanding of how to approach teaching in virtual classrooms.

References:

1. Camargo CP, Tempski PZ, Busnardo FF, Martins M de A, Gemperli R. Online learning and COVID-19: a meta-synthesis analysis. Clinics 2020;75: e2286.
2. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ. 2018;18(1):38.
3. Jeong JS, González-Gómez D. A STEM Course Analysis During COVID-19: A Comparison Study in Performance and Affective Domain of PSTs Between F2F and F2S Flipped Classroom. Front Psychol. 2021;12:669855.

Get Down with the Feeling: Teacher Empathy

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

Empathy involves understanding another person’s experiences by imagining oneself in the other person’s situation.¹ We live in an increasingly diverse society today and empathy improves social cohesiveness.  For this reason, empathy is particularly important in classrooms and influences how teachers and students interact. Studies have shown that cognitive and emotional empathy can promote students’ learning as well as help teachers have a more positive mindset and avoid burnout.^2,3,4 Teacher empathy is not a widely talked about subject. This article will look at how teacher empathy can help promote student learning and success.

The term empathy originates from a German word that means "feeling into.” There are two forms of empathy: emotional and cognitive. Most people conceptualize empathy as emotional empathy whereby the individual feels the same emotion as another person.  When a person has personal distress, emotional empathy enables us to feel compassion or empathic concern. Empathic concern is typically developed later in life as it builds off and requires more self-control. Empathic concern also triggers prosocial and helping behaviors.  Emotional empathy is positively correlated with a willingness to help people even if it requires personal sacrifices.¹ Intense emotional empathy is often called empathic accuracy. Empathic accuracy allows a person to have more accurate and complete knowledge about what is going on in a person’s mind and how they feel.

Cognitive empathy is the extent to which we perceive or presuming another person's thoughts and feelings.  This can involve an understanding of what someone might be thinking during tasks – from simple tasks to more complex ones. Simple tasks can include visually perceiving standing in a classroom teaching and imagining what another person walking by the classroom might see (observe). Complex tasks can include thinking about what a group might perceive or think. Cognitive empathy still requires sensitivity and knowledge of what other people are thinking and feeling but does not necessarily mean that a person cares about the other person.  This means cognitive empathy can be used to harm others. Con artists, for example, have well-developed cognitive empathy in that they understand what others are likely thinking and feeling but they don’t care about the welfare of the person they are taking advantage of. Cognitive empathy is part of our mental development because we grow to understand that another person's thoughts differ from our own.¹ 

Studies that have looked at teacher empathy toward students have found that it can have a positive influence on both students and teachers. One study looked at empathetic climates in the classroom and measured student success.² Empathetic climates are created when the teacher pays attention to student opinions, values what students have to say, and when students believe the teacher “understands our frame of references”. The study enrolled nearly 500 middle and high-school students. Results from this study showed that an empathetic climate was positively correlated with students’ success even if a class was deemed particularly hard. Success was defined by students ranking their performance in the course using a 6-point Likert scale. The students succeeded, even in difficult classes, if they felt unconditional regard from the teacher.

Another study followed 178 elementary school teachers and looked at the benefits teachers received based on their level of cognitive empathy. Results showed that higher levels of cognitive empathy were associated with lower job burnout, positive mindsets about student behavior, better relationship closeness, and better competence in handling students’ problem behaviors. On the other hand, teachers who experienced high empathetic distress, such as becoming overwhelmed by the student’s emotional experiences, showed that there was higher job burnout, less competence with students’ problem behavior, negative mindsets with misbehavior, and fewer problem-solving strategies.³

There are 4 ways that teachers (you) can create a more empathic climate:⁴

1. Perspective-taking –this means putting aside your perspective and looking at the situation from a different angle. Consider asking, “Do I believe my students are doing the very best they can?”  Every student is not going to have the same skill set when it comes to learning which means they may be trying their best already. Encouraging them through a challenging subject is important.
2. Putting aside judgment – this means to step back and not jump to conclusions solely based on what is seen. Consider asking, “What more do I need to learn and understand about the situation?”  For example, if you have a student who is struggling with assignments and submitting them on time, do not assume that they are lazy. Come in at a different angle and make sure that home life is okay first.
3. Trying to understand the student’s feelings – tap into your own experiences to try to find a way to understand what the student is going through or to remember when you went through a similar experience; however, remember that everyone does not feel the same things, and we each have unique experiences. Consider asking, “What more do I need to learn and understand about how other people are reacting to or perceiving the situation?” If a student loses a family member, it is important to try and understand how you felt at this time and then give leniency as the student may or may not have difficulty coping.
4. Communicate that you understand – talk to students with reflective phrases such as “It sounds like you…” or “I hear that you…”; this can help build trust and can help students to solve problems, with you in the beginning and eventually on their own. This step requires self-reflection so consider asking, “What more do I need to learn and understand about how I react?” and “What more do I need to learn about how to communicate to others that I hear them, even while experiencing my own emotions?” For example, if a student has many tests one week and is late on assignments, reaching out and say “It sounds like this week may have been overwhelming for you.”

Empathy is understanding what others are feeling and thinking and is associated with helping behaviors even it involves some personal sacrifice. Empathy also involves an understanding that we do not all think in the same manner. Teachers who cultivate an empathetic climate can achieve positive outcomes not only for the student but also for themselves.

References:

1. Hodges SD, Myers MW. Empathy. 2007 (Accessed 2021 Sept 11).
2. Bozkurt T, Ozden MS. The relationship between empathetic classroom climate and students’ success. Procedia - Social and Behavioral Sciences. 2010;5:231–4.
3. Wink MN, LaRusso MD, Smith RL. Teacher empathy and students with problem behaviors: Examining teachers’ perceptions, responses, relationships, and burnout. Psychology in the Schools. 2021;58(8):1575–96.
4. Morin A. Teaching With Empathy: Why It’s Important. Understood.org [Internet]. (Accessed 2021 Sep 11).

Creating Valid Multiple-Choice Exams

by Scott Ross, PharmD, PGY1 Pharmacy Practice Resident, Mississippi State Department of Health

With increased class sizes and teacher load, multiple-choice exams have become the primary method for evaluating health professions students. There are many pros and cons to using multiple-choice tests. This article aims to investigate the cons and improper techniques and offer potential solutions to improve the quality of questions and enhance student learning.

Multiple-choice exams remain a popular form of assessment because they have several advantages, including ease of grading, standardization, the objectiveness of scoring, and the ability to test many discrete concepts. And teachers can administer multiple versions of the same test.^1,2 Furthermore, evidence suggests that a well-constructed multiple-choice exam is just as effective as a short-answer test in terms of promoting the retention of material.^3,4 However, a poorly constructed multiple-choice exam will not accurately measure learning and can lead to frustration. There are several best practices that many teachers fail to follow, including using "all of the above" or "none of the above" answer choices, writing "throw-away" answers as potential choices, asking students questions that focus on their ability to memorize and recall trivial details, and authoring stems that are unclear/vague.^1,5

While seen commonly on multiple-choice exams, the "none of the above" answer choice leaves students wondering what the correct answer is. Indeed, it could be argued that the best possible answer is not among the answer choices, and thus "none of the above" would always be the best option. In many cases, students view "none of the above" as a throw-away answer that can be ignored. Similar but different issues arise with the "all of the above" answer choice. Using the "all of the above" answer choice may have the benefit of determining if the student is aware that more than one choice is correct, but this quickly results in guessing and relying on partial knowledge of the material to answer correctly.⁶ When the "all of the above" choice frequently appears on an exam, students will likely pick up on trends and will lean towards selecting this answer even when they lack an understanding of the material. Thus, "none of the above" and "all of the above" answer choices should be avoided.⁶ Instead, consider using "select all that apply" questions because they thwart guessing — but admittedly, they are more difficult. To discourage guessing, some instructors award points for each correct response but take off points if a student selects an incorrect answer or does not select a correct response.¹ While this is undoubtedly more challenging, it is more efficient and less cognitively demanding than asking students to respond to series of open-ended questions.

Another common issue when constructing multiple-choice tests is including "throw-away" answers — answers that are so obviously incorrect that even those who do not know the subject matter can quickly eliminate them. Including these answer choices is harmful because it increases the odds of guessing correctly. It is a best practice to include at least 3 but no more than 5 plausible answer choices.⁷  The key word here is plausible – at least they should seem reasonable to the learner who is not sufficiently knowledgeable about the subject matter.

Some critics of multiple-choice testing state that exam scores using this format do not always correlate to the learner's understanding of the material — the method simply asks students to memorize and recall information.⁵ This is important to keep in mind when forming questions as many instructors rely too heavily on "recall" or knowledge-based type questions. While they are more challenging to write, it is possible to create questions that require critical thinking. Forming thoughtful questions that require students to analyze, apply, and evaluate is vital to ensuring they develop the skills needed in their future careers.

Another common problem is forming misleading or vague question stems or answer choices that lead to confusion or misunderstandings. It is also best to avoid negative phrasing (e.g., "which of the following is not true …") in exams since this can cause students to misread the question. If a question truly cannot be phrased positively, it is best to make the negative wording stand out by using italics, capitalization, or bolding of the word(s). Having clear answer choices is just as important as forming clear question stems. An excellent way to ensure that questions and answers are worded clearly and concisely is to send the material to someone else to review. It is crucial to keep in mind how the answer choices relate to each other. Answer choices should be homogenous in the sense that they relate to the same content and have a similar sentence structure and length. This is to prevent giving clues to students as to what the correct answer is. Another strategy to prevent clues is to always present the choices in numerical or alphabetical order.

Perhaps the biggest concern with multiple-choice tests is the format itself. Most choices will not be provided to the health professional.  Rather they must recall and weigh the potential options themselves.  Thus, multiple-choice exams are not authentic assessments — they do not reflect real life. Real-life decision-making comes from generating choices for ourselves and formulating our own answers by considering multiple pieces of information and then making a judgment. Thus, relying solely on multiple-choice assessments to determine a student's progress does not accurately reflect whether a student is competent.  Other forms of assessment, including objective structured clinical exams (OSCE), evaluations of authentic work products, and observations during field-based activities, must also be used.

Creating valid multiple-choice exams is a vital skill that all teachers should master to ensure their students have mastered the material. However, there are several common problems that should be avoided, and multiple-choice assessments have several limitations. Using a combination of assessment strategies is essential to get a comprehensive view of each student's knowledge, skill, and abilities.

 

References

1. Weimer M. Multiple-choice tests: Revisiting the pros and cons [Internet]. Faculty Focus. 2019 [cited 2021Sep19].
2. Medawela RMS, Ratanayake DRDL, Abesinghe W, et al. Effectiveness of "fill in the blanks" over multiple choice questions in assessing final year dental undergraduates. Educación Médica 2017, 19 (2): 72-76.
3. Khan JS, Mukhtar O, Tabasum S, et al. Relationship of Awards in multiple choice questions and structured answer questions in the undergraduate years and their effectiveness in evaluation. Journal of Ayub Medical College 2010; 22 (2): 191-195.
4. Haynie W. Effects of Multiple-Choice and Short-Answer Tests on Delayed Retention Learning [Internet]. Journal of Technology Education 1994; 6 (1): 32-44.
5. Fors K. Opinion: Multiple choice tests don't prepare students [Internet]. The Utah Statesman. 2020 [cited 2021Sep19].
6. Butler A. Multiple-choice testing: Are the best practices for assessment also good for learning? [Internet]. The Learning Scientists. 2017 [cited 2021Sep19].
7. Butler AC. Multiple-choice testing in education: Are the best practices for assessment also good for learning?. Journal of Applied Research in Memory and Cognition 2018; 7 (3): 323-331.

If You Feel Like an Imposter, Perhaps It Is Time to Change Your Mindset

by Abby Bradley, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

The brain is theoretically the most powerful organ in the body and is responsible for processing and storing thoughts, memories, and experiences that happen throughout one’s life. It is these three things that shape who we are as a person and create our mindset towards ourselves and others. Our mindset plays a powerful role in what we believe. In Mindset: The New Psychology of Success, Carol S. Dweck describes the difference between those with a fixed mindset, a belief that abilities can’t be changed, and a growth mindset, a belief that abilities can be developed.^1,2  Many pharmacists (and other health professionals) feel like “imposters” which arises from a belief that their success is largely due to luck and timing, rather than their own effort.  The imposter phenomenon might be related to a fixed mindset. With a growth mindset, perhaps new graduates can better manage the inevitable challenges as they enter the workforce?

What is the difference between the person who crumbles versus the person who thrives after receiving negative feedback?  Mindset. A person with a fixed mindset assumes abilities and talents are relatively fixed.  Either someone has the ability to do something well or does not. A fixed mindset can be identified by characteristics such as avoiding challenges, feeling threatened by others, giving up easily, resorting to cheating and deception to get ahead, and focusing on the outcome rather than the process. On the other hand, those with a growth mindset believe that one's abilities, intelligence, and skills can be grown and developed through effort and hard work. Failure is seen as an opportunity for growth and criticism is a tool to better one's self. With a growth mindset, hard work and determination are embraced — there is a passion for learning (the process) rather than a hunger for success (the outcome). It is important to keep in mind that individuals often have different mindsets towards different domains in their lives, and mindsets can change.

	Fixed Mindset	Growth mindset
Belief	Abilities and intelligence is fixed	Abilities and intelligence can be developed
Skills	Fine the way it is, nothing to change	How can I improve?
Effort	Give up easily	Persevere when faced with failure and setbacks
Mistakes	Avoid new experiences due to fear of failure, blames others	Embraces and sees as an opportunity to learn
Feedback	Defensive, takes it personally	Accepts as a way to learn

One intriguing question that has been recently proposed: Is there a correlation between a fixed mindset and the imposter syndrome? The imposter phenomenon (IP) is the official psychological term and it describes a pattern of thinking whereby successful individuals feel unworthy of the success they have achieved.  They don’t feel competent and worry that their lack of skill will be “discovered.” In one study that surveyed medical, dental, nursing, and pharmacy students, significant levels of distress and rates of IP were found.³  Indeed, pharmacy students were at the highest risk for the IP when compared to other health professions.³ A recent study found a significantly higher prevalence of IP among pharmacy residents in comparison to trainees in other healthcare professions.⁴  These data show a worrisome pattern but can we do anything about it?  Although a correlation between IP and a fixed mindset has not been conclusively proven, some researchers believe that adopting a growth mindset could reduce the risk of IP. By implementing techniques that foster a growth mindset early in pharmacy education, students would learn to be better equipped to handle the stress and competitive environment of pharmacy school as well as the workforce.

How can we foster a growth mindset among pharmacists and student pharmacists? The first step begins with educating the educator. To be able to foster a growth mindset, the educator must have good foundational knowledge and demonstrate a growth mindset themselves.  They need to be role models! Simply bringing awareness to the idea of different mindsets has been shown to foster a shift in thinking. This can be done in didactic lectures, small group discussions, and personal experiences.

Ways That Educators Promote Mindsets

Fostering a Fixed Mindset	Fostering a Growth Mindset
·  Multiple-choice exams ·  Praising intelligence, skill, talent ·  Focusing on results ·  Limited, nonspecific formative feedback	·  Socratic questioning ·  Learning experiences ·  Allowing multiple drafts ·  Pre- and post-tests ·  Frequent formative feedback

Feedback is critically important during any learning experience, but to promote a growth mindset, intentional, constructive feedback must be provided so that students are praised for their processes and improvements rather than the grades they achieve.  The teacher should focus on effort and growth. Although feedback is usually given at the end of a course or experience, the foundation should be laid at the beginning of an experience when expectations and goals are established. After having the opportunity to perform and be assessed, trainees should be provided with constructive feedback and opportunities to improve. To be considered constructive, feedback should be specific, based on direct observations (or other evidence), and objective (criterion-referenced) while also providing advice on how to improve. Self-reflection should also be used as a way for trainees to reflect upon the processes they employed when complete tasks and assignments. Thinking and talking about processes provide insight about what went well as well as areas of improvement.

Grades in general do not provide insight into the learning process or growth of a student. A single summative assessment or ranking does not promote the beliefs that foster a growth mindset; however, the use of formal assessments can be beneficial when used appropriately. Introductory and advanced pharmacy practice experiences, as well as residency training, represent ideal environments to implement pre-and post-tests to highlight the amount of growth from the experience. Rather than receiving only a final grade, trainees can tangibly see their growth by comparing their pre-rotation and post-rotation scores.

Self-assessments tools like The Mindset Assessment on The Mindset Works website provide insight into one's mindset and could be beneficial for both educators and trainees. This short assessment is a diagnostic tool that can be used to objectively assess and learn more about one's mindset; it also provides specific recommendations on how to move toward a growth mindset as well as personalized feedback.⁵

Healthcare and pharmacy practice is an everchanging field that can be taxing for students, residents, as well as practitioners. By cultivating a growth mindset, pharmacists can overcome the challenges faced during their training and after entering the workforce. Faculty and preceptors play a key role in educating and promoting a growth mindset during the early stages of their pharmacy careers. Trainees must learn to develop the skills needed to persevere in the face of failure, accept criticism as a learning opportunity, seek out challenges, and, just important, reduce the stress and anxiety from feeling like an imposter. 

References

1. Dweck CS. Self-Theories, Their Role in Motivation, Personality, and Development. Philadelphia, PA: Psychology Press; 2000.
2. Dweck CS. Mindset, The New Psychology of Success. New York: Random House Digital; 2008.
3. Henning K, Ey S, Shaw D. Perfectionism, the imposter phenomenon and psychological adjustment in medical, dental, nursing and pharmacy students. Med Educ. 1998;32(5):456-46.
4. Sullivan JB, Ryba NL. Prevalence of imposter phenomenon and assessment of well-being in pharmacy residents. Am J Health-Syst Pharm. 2020;77:690-696.
5. Burgoyne AP, Macnamara BN. The reliability and validity of the mindset assessment profile tool. PsyArXiv; 2020. doi: 10.31234/osf.io/hx53u

Prioritizing Health Literacy Education

by Bria T. Lewis, Pharm.D, MPH, PGY-1 Community Pharmacy Resident, University of Mississippi School of Pharmacy

Effective communication is an essential skill for healthcare workers. Communication between healthcare professionals and patients is multifaceted and can become complicated by reduced or poor health literacy skills. According to the U.S. Department of Health and Human Services, health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.”¹ Unlike general literacy, health literacy focuses on specific skills needed to traverse the health care system and enables clear communication between healthcare providers and patients.

Improving health literacy education for health professionals is an essential concept of the U.S. National Action Plan to Improve Health Literacy. This concept must be prioritized by all health professionals who communicate with patients, and, just as importantly, those who educate emerging health professionals. It is important that health professions educators teach ways to both assess health literacy and to strategies to communicate to patients with low health literacy. Educators must take responsibility by recognizing the importance of effectively communicating health information to patients and work to address any deficits that may impede a patient from making the best decisions.² To mitigate such deficits, educators of health professionals must teach students about the common barriers that patients experience including a lack of understanding about disease states, local health guidelines, and the interpretation of test results³. 

While there are currently no widely accepted guidelines on health literacy education for healthcare professionals, healthcare educators should focus the scope of instruction on the following key skills:

1. Identifying Patients with Low Health Literacy: Healthcare professionals may not be able to identify patients with low health literacy. Factors associated with sufficient health literacy levels include higher individual income, advanced education, and greater professional success. In contrast, older adults, minority, or low-income populations are at risk for insufficient health literacy. Low health literacy has been shown to correlate with an increased risk of death and emergency room visits followed by hospitalization.

2. Use of Plain Language: Using non-medical language can enhance understanding between the patient and the provider. Students and health professionals may need to develop alternative language to explain concepts instead of using their acquired medical terminology.  Indeed, many patients, especially those of underserved populations, may not have literacy competency above a 5th-grade level. Thus, curriculums must include teaching students how to simplify complex words and concepts into 5th-grade English terms. This can be achieved by referencing medical terms that may appear during lectures in both the form understood by the medical community and the form understood by the average citizen. 

3. Focus the Message: Limiting the information to focus on one to three key messages is crucial. Focusing the key messages on behavior modifications will help empower and motivate patients. Educators should emphasize lessons that teach students and healthcare professionals to develop short explanations for common treatments and disease states which motivate action.

4. Importance of the Teach-Back method: Reviewing and repeating key information at the end of each visit will help with reinforcement. The ‘Teach Back” method serves as an effective tool to assess understanding and increase retention of information. Educators should introduce and use this tool throughout the curriculum in a fashion that requires students to “Teach Back” health information in laymen’s terms. This can be done by establishing simulation counseling sessions where students are required to translate medical information without using jargon.

Fortunately, there are several readily accessible health literacy education resources that educators can use. The Agency for Healthcare Research and Quality (AHRQ) has developed the Health Literacy Universal Precautions Approach to health literacy. This approach supports simplifying communication and reducing the complexity of healthcare. The toolkit offers twenty-one tools for improving health literacy by addressing spoken communication, written communication, and supportive systems. This guide is available for download at: AHRQ Health Literacy Universal Precautions Toolkit.  The CDC Clear Communication Index is a tool used to develop and assess public communication materials to determine if a message or material will likely match the health literacy skills of your intended audience.

Health literacy affects the health status of patients. Health literacy is a national concern. To provide the best care to our patients, all health professionals need to learn the key concepts and how to communicate complex ideas to patients using simple, clear language. 

References:

1. Health Literacy. Official Web Site of the U.S. Health Resources & Services Administration.” HRSA.gov, 31 Mar. 2017. Accessed 17 June 2021.
2. Bowen D. 5 How To’s for Teaching Health Literacy. Paeaonline.org. Accessed 17 June 2021.
3. Health Literacy. National Library of Medicine. NLM.gov, 2010. Accessed 17 June 2021.

Scary Word of the Day: Advocacy

by Mary Reagan Richardson, PharmD, PGY1 Community Pharmacy Resident, Mississippi State Department of Health

Advocacy is a term that is thrown around with different meanings in different settings.¹ All professional students have, at one point or another, heard the word advocacy mentioned as something they should do. But how do we advocate?  And is it something that can be taught? It seems that everyone agrees that advocacy is necessary and important but defining the competencies needed to “advocate” and measuring it are harder to come by.¹ In fact, when searching for primary literature on the topic, I found only four studies that mention advocacy.

So what is advocacy? One definition states that ”Advocacy is telling or demonstrating something you know to someone in order to improve the quality of life for others.”² The American Medical Association defines physician advocacy as, ”Action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.”¹ There are several other definitions but they all include two central themes: knowledge propagation and a call to action.

There is a distinction between advocacy and self-advocacy. Advocacy is primarily about asking others to take action to benefit another person or a community. Self-advocacy is all about informing someone about what you or your profession can do. It is still a form of advocacy, just not done for the benefit of others. Self-advocacy is often a part of advocacy. If you cannot clearly articulate what it is you do and why only you can do it, how can you ask for an action-oriented change to occur? Self-advocacy fulfills the knowledge propagation step of advocacy.

Pharmacists, nurses, physicians, and other health professionals are all taught what it is their profession does as well as what they can or perhaps should be permitted to do. So, it only makes sense that advocacy is taught during professional degree programs. There is some evidence about the benefits for teaching self-advocacy to elementary school children, however, consensus on ways to teach how to advocate for others is not well developed.³ In my readings, it seems that advocacy can be broken down into three major types; person-to-person communication, using your knowledge to fill a need in the community, and direct, participatory communication with legislators or primary stakeholders.^1,2,3,4

For example, I am a pharmacist in a community, independent pharmacy. A patient comes in talking about how long the wait is and complains “why can’t you just put the pills in the bottle already?” There are several approaches that can be taken here: A) ignore the comment, B) apologize for taking so long C) explain what pharmacists do when filling a prescription. The pharmacy advocate would go with option C. What if that patient knew that you called the prescriber to get the dose adjusted due to an interaction with another medication? It is through these sorts of interactions, which happen every day, that we, as practitioners, educate the public about what goes on behind the scenes to improve their health. This is person-to-person advocacy.²  Calling the physician to get the dose change is also advocacy, because the pharmacist is using his/her knowledge, on the patient’s behalf, and making a call-to-action (e.g. change the dose of the medication). Advocacy in both of these circumstances enhances the public’s understanding of the pharmacist’s professional role.

Another example of advocacy is when you see a need for something in your community and take action. Like implementing COVID-19 vaccination clinics in a community pharmacy. The rules and regulations can be onerous and the additional demands of such a service can be very disruptive to a pharmacy’s workflow. However, pharmacies all over the country are implementing them to address the largest public health crisis in a century. You are advocating for your patients and community by taking on the added cost, stress, and time to administer these vaccines to improve the health of the community.

On a much larger scale, advocacy encompasses talking to local, state, and federal legislators and other policymakers about issues pertaining to your profession. However, many health professionals find it quite daunting to advocate for their profession directly to legislators. Many people are unsure of how to go about talking with legislators about what they do and the problems they encounter. The best way to prepare for these conversations is to stay up-to-date with the latest news about your profession, locally and nationally. The more informed you are as a practitioner, the better your case to a legislator will be. For example, when I spoke with a legislator in 2018 about expanding the scope of pharmacist practice in Mississippi, his first question to me was, “Have other states done this?” If I had not done my homework and known that, in fact, other states had authorized pharmacists to do similar things and the positive impact it had, that conversation would have ended right then and there. Speaking with legislators about a topic doesn’t have to be an in-person discussion. You can always send an email to your local or state senators explaining why and how you see a problem being fixed. Regularly communicating with your legislators and other policymakers is the most active and participatory form of advocacy.⁵

These examples provide a road map on ways in which we can advocate for our professions. In terms of teaching how best to teach students to advocate, there are very few published examples.  There are some residency programs that have advocacy curriculums that have been successful.⁴ Most professional degree programs include something about advocacy in their curriculums but do not have published learning objectives or competencies.⁶

I believe that there should be an advocacy course in the required curriculum or, at the very least, offered as an elective. This course would focus on how to research an issue, how to identify the major stakeholders, and how to make an “ask” (i.e. the call to action) This course should get students thinking critically about the problems their profession and the patient they serve face. A lobbyist could be brought in to discuss speaking strategies and the “how to’s” of talking to policymakers. The learning objectives and competencies should assess whether a student could effectively deliver an “elevator pitch” on an issue. Advocacy is something that becomes more natural as you practice it. For this reason, any advocacy course should have simulation activities and field-based exercises that students need to complete. Teaching students that advocacy can be as easy as talking with your family or calling your United States Senator can help make advocacy more approachable and an inherent expectation of being a professional.⁴

^References

1. RoyeaAJ, Appl DJ. Every voice matters: The importance of advocacy. Early Childhood Educ J 2009; 37: 89-91.
2. Earnest MA, Wong S, Federico SG. Perspective: Physician advocacy: What is it and how do we do it? Acad Med 2010; 85: 63-67.
3. Lee, A. (2021, April 12). The importance of self-advocacy for kids who learn and think differently. Retrieved April 21, 2021, from https://www.understood.org/en/friends-feelings/empowering-your-child/self-advocacy/the-importance-of-self-advocacy
4. Servaes J, Malikhao P. Advocacy strategies for health communication. Public Relations Review 2010; 36: 42-49.
5. Chamberlain LJ, Sanders, LM, Takayama JI. Child advocacy training. Curriculum Outcomes and Resident Satisfaction. Arch Pediatrics & Adoles Med 2005;159: 842-847.
6. Douglas A, Mak D, Bulsara C, Macey D., Samarawickrema I. The teaching and learning of health advocacy in an Australian medical school. Inter J Med Educ 2018; 9, 26-34.

Adapting to Adaptive Learning Technology

by Endya L. Young, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

While humans tend to be alike in more ways than not, we are also very different. We differ in the ways we think, feel, and act. And we differ in the ways we learn. Students each have their own learning style, strengths, and weaknesses that do not always align with a “one size fits all” approach. What if there was a technology to meet the different needs of students? What if this technology had the potential to foster self-directed learning skills? Such a technology would be a great addition to health professions curricula in combination with other teaching methods. This technology exists today!  Although it is fairly new, the technology has the potential to provide some significant benefits to students in the long run.

What is adaptive learning technology (ALT)? It is computer-based software that provides a personalized learning experience based on how the student performs.¹ It allows the student’s learning experience to be navigated in a way that fits the student’s needs and increases the likelihood that the student will be successful.² How does this work? ALT modifies the student’s learning materials in real-time based on their interaction with the program.³ Based on the student’s responses, ALT identifies the student’s strengths and address weaknesses and then adjusts the instructional materials, changes the pace, modifies the assessments, or provides feedback specific to the learner’s needs. ALT provides an efficient and flexible way to remediate learners who have not yet mastered a lesson while presenting new information to those who have.⁴

The number of studies on the effectiveness of adaptive learning technologies in pharmacy curricula is limited, but I believe it could be of significant benefit to students.  Using adaptive learning technology would prompt students to further develop their self-directed learning and their independence when learning — skills they need after they graduate. It has the potential to reduce gaps in learning and help to identify students who may be struggling.⁴ Use of this technology in pharmacy schools seems promising because of the need to retain the foundational knowledge while acquiring new information from the ever-evolving, ever-changing world of healthcare.

A recent study analyzed changes in self-directed learning when adaptive learning technology was used. This study enrolled first-year pharmacy students who were completing a two-semester Pharmacists’ Patient Care Process (PPCP) course series.³ In the first semester of this course, professors used active learning during traditional lectures, for example requiring students to complete pre-readings and reflections on course content followed by in-class quizzes.³ Adaptive learning technology was then used during the second semester of the course. Students were required to complete midterm and final examinations in both semesters. Surveys were completed by the students to assess the following: assignment management, stress management, procrastination management, seminar (lecture) learning proficiency, comprehension competence, examination management, and time management.³ To measure the students’ experiences and perceptions of ALT, focus groups were also used to gather additional feedback. The investigators report that students appreciated the additional practice and assessments that ALT provided. The study also concluded that using ALT freed up time during class for the instructors and students to engage in more active learning activities.

The themes identified from the student focus groups in this study convinced me that adaptive learning technology is something that should be incorporated into the pharmacy curriculum. The first theme was student learning preferences. Students overall found the assessments in ALT to be helpful, but also stated that the use of this technology made it more difficult to study for examinations.³ The students in this group stated that they would have liked to have some sort of guide such as PowerPoint slides to aid them in identifying the most pertinent information. The second theme mentioned was teaching methods. Students liked the mix of the teaching methods used, such as pre-class activities, mini-lectures to highlight key points in the learning material, and in-class activities to reinforce their learning.³ It is important to note that some students did not engage with ALT as they should have, often only answering the assessment questions and bypassing course material.  This is important because another study that used ALT in a physics course at a South African University found that students who spent more time engaging with the program performed better on examinations.⁵ The third theme was valued. Students seemed to benefit more from hearing their professor’s insight on the material being taught and helped them to apply concepts as they progressed. The fourth theme was technology and the challenges the students encountered with its use.

Although the findings in this particular study showed that the use of ALT was not favored by most students, I think that some of the student’s concerns are due to a lack of familiarity. Their desire to be given notes and the fact that many students struggled with procrastination and time management makes me think they oppose ALT simply because it is not something they have used before and have not yet developed the skills to be self-directed learners. Students may have had difficulties because they the lack skills needed to discern important information on their own.³ They preferred to have all of the information provided to them and to have the teacher point out what is important during class. Some students also did not engage with the ALT as they should have, often prioritized other classes. Using a combination of in-class active learning activities with ALT in between class sessions, in my opinion, gives the students the opportunity to learn from and engage with the professor but also develop life-long learning skills.  This will require some major adjustments for student students (and instructors!). Such a major change should be introduced gradually. Overall, I believe ALT has great potential – helping students who have not yet mastered the material a personalized experience while simultaneously promoting the development of self-directed learning skills. 

References

1. Forsyth B, Kimble C, Birch J, Deel G, Brauer T. Maximizing the Adaptive Learning Technology Experience. Journal of Higher Education Theory and Practice [Internet]. 2016;16(4):80-88.
2. Liu M, Kang J, Zou W, Lee H, Pan Z, Corliss S. Using Data to Understand How to Better Design Adaptive Learning. Technology, Knowledge and Learning. 2017;22(3):271–98. 
3. Toth J, Rosenthal M, Pate K. Use of Adaptive Learning Technology to Promote Self-Directed Learning in a Pharmacists’ Patient Care Process Course. American Journal of Pharmaceutical Education [Internet]. 2020;85(1): Article 7971.
4. Moskal P, Carter D, Johnson D. 7 Things You Should Know About Adaptive Learning [Internet]. EDUCASE 2017.
5. Basitere M, Ivala E. Evaluation of an adaptive learning technology in a first-year extended curriculum programme physics course. South African Computer Journal; 2017; 29 (3):1-15.

The Role of Peer Instruction in Health Professions Education

by Whitley Tassin, MBS, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Instructors are always looking for methods to improve student participation and engage learners in the classroom. Multiple methods have been proposed including pop quizzes, audience response systems, small group discussion, group work, case vignettes, and more. But what is the evidence to support these methods and what are the best methods to engage learners? In recent years, peer instruction has gained increasing support and has become widely used in undergraduate education in an effort to not only engage students but, most importantly, improve learning.¹ Multiple methods of peer instruction have been developed and there are subtle differences between each of these methods.  Table 1 below describes the different peer instruction methods.

Table 1: Types of Peer Instruction¹

Term	Definition
Peer Teaching	Learners with similar levels of expertise and from comparable social groups (but who are not professional teachers) assist each other to learn and learn by teaching
Peer Modeling	The teacher provides (or points out) a competent exemplar(s) by a learner(s) in the group with the purpose that others will emulate these examples
Peer Education	Learners share information and talk about attitudes or behaviors with the goal of educating people, clarifying general life problems, and identifying solutions
Peer Monitoring	Learners observing and checking to determine if their partners/peers are engaged in appropriate and effective processes for learning and studying
Peer Assessment	Learners provide feedback or score/grade (or both) their peers’ performance based on a set criteria

 

While these tactics have been employed across various disciplines, few have been studied in pharmacy education. However, the literature consistently points to the positive impact that peer instruction has had on improving learning outcomes.

One study at Cedarville University looked at the effect of peer instruction in a self-care course within a Doctor of Pharmacy program.² Peer instruction was employed for seven topics: constipation and anorectal disorders; nausea, vomiting, and diarrhea; allergies; cough and cold; fungal and wounds; ophthalmic, otic, and oral; and dermatitis and sun care. Students were asked to prepare for each topic before class in anticipation of a “quiz” given on each topic. They were paired with a peer to discuss each topic after the quiz. If the average was above 70%, this indicated that most students had a good understanding of the concept, and discussion was not needed. When a score fell below 30%, this indicated that most students did understand of the topic, and the instructor provided additional instruction about the concept. If the score was between 30% and 70%, students would then engage in a discussion about their answers.  Students were instructed to justify their answers to their peers. Following this brief period of peer instruction, the questions were again presented to the class and scored. Results showed that scores improved significantly for each topic when peer instruction was implemented. In addition, students were asked to voluntarily complete a survey about their opinions and experiences with peer instruction. More than 80% of students responded to the survey and the results suggested that students felt very positive about peer instruction. Students reported that defending their thoughts was beneficial and that peer instruction reduced the awkwardness and “embarrassment” of approaching a professor with a question. They also reported that they enjoyed discussing concepts with their classmates and that they would like to see this technique used more frequently and in other courses.

Another study at the University of California San Francisco looked at the effectiveness of peer instruction in a pharmacology course taught by pharmacy students to physical therapy students.³ Physical therapy students were instructed to review pre-recorded lectures prior to attending class and take quizzes on the material. Under the mentorship of a faculty member, all lectures, quizzes, cases, and final assessments were developed by pharmacy students. In-class sessions consisted of working in small groups and then presenting what was discussed to the larger group. Pharmacy students served as teaching assistants and were present to answer questions and facilitate discussion. When surveyed at the end of the course, physical therapy students reported that they felt that learning about other healthcare professions from someone outside of their discipline was beneficial and it increased their comfort interacting with other members of the healthcare team. This demonstrates that peer instruction improves student’s learning and can also be a potential tool to increase interprofessional interaction.

What are some best practices that faculty should follow if they wish to use peer instruction in their classes? A recently published scoping review sought to determine the best methods for peer instruction, identify barriers to implementation, and student perceptions of peer instruction in pharmacy education.¹ The results suggested there was a positive impact on learning and feedback from students was positive regardless of what type of peer instruction was used. Using both quantitative and qualitative survey methods, students in the included studies reported that participating in peer instruction would likely result in a higher grade and they are open to using this learning method more often. Students also reported that peer instruction challenged them to think critically, defend answer choices, and discuss aspects of the topic they might not have otherwise considered.^1,2

While peer instruction has several potential benefits, faculty should be aware of the potential barriers when implementing this teaching strategy. It is important to train peers instructors and reviewers. If the peer instructor doesn’t have a good understanding of the topic, this can lead to misinformation and would obviously negatively impact student learning. In addition, when peer assessment is used, the students giving feedback must have very clear guidelines or rubrics that should be used when delivering feedback. Peer reviewers should receive training not only on the appropriate use of the rubric but also on how to effectively deliver constructive feedback. Thus, students who are actively teaching or leading any portion of peer instruction must receive proper training in order for the program to succeed.¹  This requires the teacher to spend an adequate amount of time and energy developing train-the-trainer materials.

Overall, the results of numerous studies demonstrate that peer instruction can have many beneficial effects. Implementing peer instruction throughout the curriculum can increase student engagement, improve learning outcomes, and build important critical thinking skills.

References

1. Aburahma M, Mohamed H. Peer Teaching as an Educational Tool in Pharmacy Schools; Fruitful or Futile. Currents in Pharmacy Teaching and Learning [Internet]. 2017; 9(6): 1170-1179.
2. Straw A, Wicker E, Harper N. Effect of Peer Instruction Pedagogy on Concept Mastery in a First Professional Year Pharmacy Self-Care Course. Currents in Pharmacy Teaching and Learning [Internet]. 2021; 13(3): 273-278.
3. Hsia S, Tran D, Beechinor R, et al. Interprofessional Peer Teaching: The Value of a Pharmacy Student-led Pharmacology Course for Physical Therapy Students. Currents in Pharmacy Teaching and Learning [Internet]. 2020; 12(10): 1252-1257.

Accelerated Curriculums: Potential Benefits … and Harms

by Brett Lambert, PharmD, PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

For those looking to pursue a career in pharmacy or other health professions, the decision as to which school to attend is often based on a few key factors. Important factors applicants typically assess include the duration of the program, the passage rates on licensure exams, the quality of the education, the benefit to their career, and the memories that can be made with peers or the quality of the social life. Some colleges/schools offering an accelerated program and prospective students are left to consider the benefits of completing their desired curriculum faster than normal. It is therefore important to consider the potential benefits (and harms) of completing an accelerated curriculum.

Accelerated programs provide an opportunity for students to complete their preferred professional program in a shorter period of time than a normal curriculum length. For pharmacy schools, this means students complete their doctoral degree in three years rather than the usual four years. To accomplish the same curriculum in 3 years, accelerate program conduct classes year-round without end of semester breaks like summer or winter break. According to the American Association of Colleges of Pharmacy, as of July 2020, there are a total of 142 colleges or schools of pharmacy.¹ Of these schools, there are at least fifteen programs that offer an accelerated Pharm.D. curriculum.

One way to determine if accelerated programs are as good or, perhaps, superior to traditional programs is to compare pass rates on the licensure exam.  In pharmacy, the NAPLEX (North American Pharmacist Licensure Examination) is required to become a pharmacist.  The NAPLEX first attempt passage rates from the past three years (2017,2018, and 2019) for the fifteen accelerate programs were substantially lower than the national average passage rate. Using data reported by the National Association of Board of Pharmacy,² accelerated programs averaged a passage rate that was 3-5% lower than the average national passage rate.

While this data is not a full analysis of the data available, it does provide some insight as to how these programs compare to the traditional four-year programs. However, the length of the curriculum is but one factor and there are other factors that could affect NAPLEX pass rates. One of which is the age (or maturity) of the program. In a recent survey that examined pharmacy school characteristics and their first-time NAPLEX pass rates, pharmacy schools established before 2000 had significantly higher first attempt pass rates on the NAPLEX than those established after.³ Thus historic (or more mature) programs seem to produce students better prepared to pass the NAPLEX on the first attempt. The authors also reported that between 2015 and 2016 when the NAPLEX testing structure was changed, a smaller percentage of four-year programs experienced a 10% or greater decrease in first-time pass rates than three-year accelerated programs (c²=5.54, p=.02).³ The pass rate dropped from 92.5 to 86.6 among traditional four-year programs and from 90.2 to 80.4 in three-year accelerated programs.  This difference was significant.³

Another study compared the length of advanced pharmacy practice experiences (APPE) to determine the correlation with first-time pass rates. The lengths of the APPEs included four, five, or six-week blocks.⁴ However, the results provide no evidence that APPE rotation length correlated with a higher first attempt pass rate for the NAPLEX. This would argue that the length of clinical rotations does not affect a student’s ability to pass the NAPLEX.

One metric that some programs use to boast about the quality of graduates they produce is the number of students that match with PGY-1 and PGY-2 residency programs. According to the National Matching Service, the official matching program for PGY-1 and PGY-2’s, in 2020 there was a total of 7535 students who registered for the match and 3904 who matched; which is a 51.8% match rate for all programs. The 15 three-year programs had a match rate of 39.7% compared to a 53.1% match rate for four-year pharmacy programs.⁶

Another difference between programs of different lengths that is more difficult to quantify is the impact an accelerated curriculum might have on a student’s social life. A curriculum that completely consumes a student’s life and does not allow enough time to get involved in professional or social organizations, maintain hobbies, or spend time with family reduces opportunities for a healthy social life. These barriers to social and professional development could affect the student’s interactions with patients, peers, or co-workers.

Given the potentially negative consequences of accelerated curriculum, why would any student consider applying to or attending such a program? The most obvious benefit is that by graduating a year early the student enters practice a year sooner – which translates in an extra year of work, an extra year of practical experience as a pharmacist, and can lead to an improved financial situation in both the short and long-term. However, there is no promise of a better job, career, or future opportunities.

The debate about accelerated professional programs is not unique to pharmacy — the medical professional is now deliberating the merits of accelerated medical school programs. Recently, there have been medical school programs that are reviving a three-year program structure. These three-year accelerated programs originated during WWII when there was a shortage of physicians.⁵ Once the war was over, the students who graduated from the accelerated programs felt the need for more courses.⁵ Which suggests that graduates from these accelerated programs didn’t feel fully prepared despite the fact that they received on-the-job experience. Surprisingly, these three-year programs were not discontinued due to lower pass rates of the USMLE (the United States Medical Licensing Examination) compared to those of four-year programs. Indeed, there are no differences between the pass rates based on program length.⁵

It seems to me that when designing a program and teaching students, there needs to be time for the information to sink in. The literature suggests that out-of-class learning, including extra-curricular activities, can be very beneficial to one's career. This includes building leadership skills through service in professional organizations and developing social skills.  Students also need time to think deeply about the material covered in class. There are many factors that influence licensure pass rates, but I don’t think we know yet the key ingredients to creating a shorter curriculum that is equally effective.

References

1. Academic Pharmacy's Vital Statistics. American Association of Colleges of Pharmacy. Published July 2020. Accessed February 20, 2021.
2. North American Pharmacist Licensure Examination Passing Rates for 2017—2019 Graduates Per Pharmacy School. National Association of Board of Pharmacy. Published February 25, 2020. Accessed February 20, 2021.
3. Williams JS, Spivey CA, Hagemann TM, Phelps SJ, Chisholm-Burns M. Impact of Pharmacy School Characteristics on NAPLEX First-time Pass Rates. Am J Pharm Educ. 2019;83(6):Article 6875.
4. Ried LD. Length of advanced pharmacy practice experience and first-time NAPLEX pass rate of US pharmacy programs. Curr Pharm Teach Learn. 2020;12(1):14-19.
5. Schwartz CC, Ajjarapu AS, Stamy CD, Schwinn DA. Comprehensive history of 3-year and accelerated US medical school programs: a century in review. Med Educ Online. 2018;23(1):1530557
6. NUMBER OF APPLICANTS APPLYING FOR PGY1 PROGRAMS BY SCHOOL 2020 MATCH – COMBINED PHASE I AND PHASE II. National Matching Services. Published 2020. Accessed April 1, 2021.