Duty Hours and Their Effect on Learning

by Elizabeth A. Sinclair, Pharm.D., PGY1 Resident, Johns Hopkins Hospital

The beginning of my PGY-1 Pharmacy Practice Residency at the Johns Hopkins Hospital was filled with days and days of orientation. We covered everything from fire safety to service excellence. One day, as we reviewed the Pharmacy Residency Handbook and residency-specific policies, the topic of duty hours came up. In order to be eligible for accreditation, the American Society of Health Systems Pharmacists requires that pharmacy residency programs follow the duty hour requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). These requirements, which became effective July 1, 2003, were issued in an effort to prevent excessive fatigue, which could potentially lead to medical errors. Residency duty hours are limited as follows:

• Duty hours must not exceed 80 hours per week, averaged over a 4-week period.
• Every 7 days had to contain at least one 24-hour period free of clinical responsibilities.
• In-house call could not be more than every 3^rd night, averaged over a 4-week period.
• In-house call could not last more than 24 hours (plus 6 hours for continuity of care) per shift.
• A minimum of 10 hours between daily duty periods and after in-house call must be allowed.
• No new patients may be accepted after 24 hours of continuous duty.
• Vacation days may not count as “days off”.
• Home call must count toward the 80 hours if the resident comes to the hospital.

Duty hours were defined as: all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

After my initial review of these requirements, I found them reasonable, and I did not feel that I would be affected greatly by them. I was expecting that 80 hours per week would be the maximum I would ever need or want to work (oh, new resident, so young and naïve!). However, as I have progressed through my residency, I have discovered that I was quite mistaken. It is incredibly easy to come dangerously close to that 80-hour mark. When non-duty hours are included, I guarantee that I, along with all my fellow residents, exceed 80 hours on a weekly basis. However, as much of our work is not related to patient care, e.g. educational presentations, committee responsibilities, research activities, course work for classes not required for completion of the residency, etc., we remain within the ACGME requirements. Although I appreciate the ACGME requirements, especially when they allow me to sleep until 7:30 or 8 AM on a post-call day, there are times when they seem to make life a bit more difficult. For example, on post-call days, although it is nice to have the built in rest time, one often ends up joining rounds somewhere in the middle, not having had the opportunity to pre-round. This makes it very difficult to contribute to the team and also results in the resident spending a good portion of the day playing catch-up. Overall, I feel the effects of ACGME duty hour requirements are beneficial for my educational experience, but there are times when learning might be enhanced if they were not followed.

My mixed feelings toward the ACGME requirements are consistent with what’s been documented in the literature. In a survey of chief residents and neurosurgical program directors examining the impact of ACGME duty hour requirements on neurosurgical residents, 96% of the respondents believed that the requirements had compromised resident training, and 98% thought that it had decreased resident surgical experience. Most thought that the requirements negatively affected patient safety and access to care, and that the residents’ cognitive development and education had been compromised (Jagannathan, et al. J Neurosurg. 2009;100:820-7). Similar sentiments were seen in another study which compared the operative experience of chief residents before and after duty-hour restrictions were in effect (Damadi, et al. J Surg Ed. 2007;64:256-9). This study, which included general surgery residents, found that residents experienced an approximately 25% decrease in the number of cases during their chief-year and an approximately 15% decrease in number of cases during their non-chief years. A survey of internal medicine residents found that about 25% of residents reported spending less time teaching patients. However, these residents did report being less emotionally exhausted, and, in contrast to the previously cited studies, were more satisfied with the patient care they provided (J Hosp Med. 2009;4:476-80).

Overall, the ACGME requirements seem to have both positive and negative impact on residency training. Further study is needed to discern if training under these restrictions leads to inferior or superior job performance as residents move into independent practice.

[Editor's Commentary: Whether the ACGME duty hour restrictions has had the intended effect - reduce the risk of patient harm due to medical errors cause by fatigue - has not, to my knowledge, been clearly shown. However, there is a significant body of literature that demonstrates that excessive fatigue adversely impacts learning. The relationship between stress and learning is an interesting one. Similar to the Frank-Starling Curve of the heart, low to moderate levels of stress can improve performance and accelerate learning.

But, similar to the heart muscle, there is a point of diminishing returns. As the graph illustrates, initially, stress (end diastolic pressure) has a positive influence on learning (peak systolic pressure) .... but excessive stress results in (brain and muscle) fatigue and eventually learning (peak systolic pressure) begins to decline. But where is the point of diminishing returns (you may be asking)? Similar to the heart muscle, the point of diminishing returns depends on a number of factors and varies from person to person. A young heart (or brain) is generally more resilient than an older heart (or brain) ... and can withstand greater pressure over longer periods of time. But do we really want to push people to their limits? Duty hour limits are a good idea - even if they (occasionally) result in missed opportunities for learning. -S.H.]

The Clinical Pharmacy Movement

By Dachelle Johnson, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

The profession of pharmacy has undergone many changes. The pharmacist is no longer confined to a strict dispensing role but now has multiple responsibilities including consultative services to health care professionals regarding general and patient-specific issues related to drug therapy. In preparing for these new roles, pharmacy education has changed as well. An article by John A Biles published in 1983 (JAMA. 1983; 259(9): 1157-1160) addressed the evolution of pharmacy in the context of the clinical pharmacy movement. This commentary and accompanying editorial (Lundberg GD. The Clinical Pharmacist. JAMA. 1983; 249(9): 1193) were interesting to me because it provided some insights regarding the history of my profession. As a clinician in training I found it fascinating to evaluate where the profession of pharmacy has come from, where it is going, and what education methods have been applied at different time points.

Clinical pharmacy services were developed in the 1960’s after extensive reports in the medical literature regarding drug interactions and medication errors. A group of “forward thinking educators” at the University of California, San Francisco, the University of the Pacific at Stockton, California, and the University of Southern California are credited with coming up with the concept of "the clinical pharmacist." In order to successfully prepare pharmacists for this new role, the pharmacy curriculum had to change. The degree program transitioned from a baccalaureate to a doctor of pharmacy. This transition is reminiscent of andragogy in that a subset of educators during that time did not feel as though the pedagogy methods were sufficient. The implementation of clinical rotations as a requirement for the Doctor of Pharmacy degree utilizes many adult learning principles. Learners are involved in planning there course of study by choosing which electives and rotations they would prefer, rather than a strict assignment. Also, self directed learning is important during clinical rotations. Learners must ask questions, identify their own knowledge and skill gaps, and utilize the resources available to make interventions and get the most out of their experience.

In addition to the new degree program and the additional clinical rotations, residencies and fellowships were implemented (residencies date back to the 1930’s but standards and an accreditation process was implemented in the 1960’s). These post graduate training programs act as a bridge from student to practitioner. In the setting of post graduate training, the learner (resident) also uses self directed learning skills.

Constructivism is another educational theory that has been applied in pharmacy education. The teacher (preceptor) facilitates learning, rather than transmitting knowledge. In accordance with the principles of constructivism, the preceptor explores inconsistencies between students’ current understanding and their experiences.

The profession of pharmacy has seen many changes and will continue to evolve in the future. As stated by Robert H. Ebert, MD, professor of medicine at Harvard University, “the future of the pharmacist lies in the direction of clinical medicine and the education of the pharmacist must reflect this need.” The newest change in pharmacy education is the increasing use of technology in the classroom. The number of pharmacy schools is increasing much quicker than the number of pharmacists pursuing academia as a career; this shortage makes web-based learning and distance education a potential solution.

One conclusion that Biles made in his commentary more than 20 years ago (and I agree with) - the future of the clinical pharmacist will be determined by an ability and desire to participate in patient care and relate effectively to physicians, nurses, and patients. Desire is not something that can be taught, but post graduate training gives the pharmacist the necessary tools. As the profession continues to change, the way we educate future pharmacists will need to change as well. The result is pharmacists who are better prepared to improve patient outcomes. As stated in our oath, “I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.”

[Editor's Commentary: Its taken nearly four decades to transform pharmacy from a product-centered to a patient-centered profession. This transformation has required pharmacists and pharmacy educators to acquire new knowledge, skills, and - most importantly - attitudes. However, the clinical pharmacist isn't merely a fountain of knowledge (although, he or she should, of course, be knowledgeable) about drug products but rather a trusted advisor who evaluates data and synthesizes solutions that are most likely to succeed. This requires considerable judgment and wisdom. Wisdom requires more than knowledge, skills, and attitudes but also experience and maturity. Thus, the training of clinical pharmacists, similar to the training of physicians, requires an extensive period of time to acquire the "real life" experiences needed to become a fully developed clinician. Long ago pharmacists trained for many years as apprentices under the guidance of a more experienced practitioner. Perhaps pharmacy education is coming full circle? An excellent review of the history of the clinical pharmacy movement was just published: Clinical Pharmacy in the United States: Transformation of a Profession by Robert Elenbaas and Dennis Worthen. Check it out! - S.H.]

Learning portfolios: an opportunity for continuing professional development

By Sujin Lee, Pharm.D., BCPP, Clinical Pharmacist - Psychiatry, Johns Hopkins Hospital

Learning is a life-long process. With the changing role of the pharmacist, individuals must take an increasingly active role to ensure their continuing professional development. Continuing professional development (CPD), based on the principles of Kolb’s learning model, is a structured, self-directed, outcomes-focused cycle of learning involving reflection, planning, action, evaluation and documentation. The reflection stage requires the individual to consider their current practice and assess their knowledge, skills, and competence to identify areas of development and improvement. The planning and action stages allow the individual to create and implement a personal learning plan, addressing the needs that were identified. Goals should be specific, measurable, achievable, and relevant. Plans may include structured programs (i.e. CE programs) and informal learning opportunities and based on the individual's learning style(s). The evaluation stage assesses the effectiveness of the educational interventions and the utility and success of the plan. Although self-evaluations are important, evaluations from supervisors, peers, students and others may also provide valuable insight. Documentation of activities provides evidence that development has occurred. A portfolio allows individuals to organize their learning activities and serves as a comprehensive demonstration of their development and competency. Although there is no universally accepted format for a learning portfolio, the goal is to include documents that represent the individual stages discussed above. The contents can include reflective diary entries, presentations, evaluations, etc. The key is quality, not quantity! Ideally, the learning cycle continues by repeatedly returning to the reflection stage.

By definition, a portfolio is “a selection of work compiled over a period of time and used for assessing performance or progress.” Traditionally, a portfolio is used during annual performance evaluations. However, the portfolio has evolved so that today, with the inclusion of introspection and self-assessment, it can be used for professional development. For example, in the United Kingdom, Australia and Canada, licensing agencies require practitioners to maintain a learning portfolio as evidence of CPD to demonstrate and enhance competency. Although the portfolio is not a requirement at this time in the United States, there are pilot projects in progress. Using the experiences of our international colleagues as models, the Department of Pharmacy at CHRISTUS Santa Rosa Health Care (San Antonio, Texas) implemented a portfolio system. Submitted during annual evaluations, the portfolios were reviewed by supervisors, managers, and the director of pharmacy. Initially, individuals did not fully appreciate the value of the portfolio and most had difficulty identifying their personal learning needs, articulating professional goals, and developing a strategy. However, over time, acceptance, comfort and familiarity of the portfolio process increased and the quality and comprehensiveness of the portfolios improved.

Based on the recommendations of Accreditation Council for Pharmacy Education (ACPE), colleges of pharmacy now require students to maintain a portfolio during their academic career; residency programs also use portfolios for accreditation purposes. To assist them, many professional associations, including ASHP and APhA, are providing students and residents with tools to develop their portfolio. Unfortunately, some may view the portfolio as a “scrapbook of rotation memorabilia” and many find the initial stages difficult or tedious; however, the activities required in these early stages may provide the most benefit. The reflection and planning stages are critical to maximize the learning portfolio experience: an honest self-appraisal must occur to identify areas that require further development. The “action” phase then allows individuals to take a committed role in developing and implementing their personalized plan. By making learning more tangible, individuals are also able to reinforce the information by relating their academic and clinical assignments to the skills and knowledge that they will use in the future. Without a true investment in the learning cycle, students and residents may view the portfolio as just another assignment that they must complete.

The principles of the learning portfolio can be used by educators to assist students and residents to further their development. Although the creation of a portfolio is highly recommended, students and residents may not have the opportunity to prepare one, depending on their schedule (i.e. one month rotation vs. twelve month program). However, the principles of “continued professional development” can still be addressed. For example, the five stages of the learning cycle may be discussed with the student or resident before and after an assignment and during the midpoint and final evaluation. The entire process may be difficult for students and residents to accomplish on their own. However, with the assistance from preceptors and mentors, the student's or resident's experiences may be enhanced. Moreover, this process will ideally lead to a more reflective learner and result in a lifelong cycle of continuing professional development.

In summary, the learning portfolio may become a requirement for pharmacists in the future. Indeed, it is already part of the licensure process in many other countries. Based on the recommendations of national pharmacy organizations, portfolios have become requisites for successful completion of the Doctor of Pharmacy degree and residency training programs. However, in order for portfolios to be successful, individuals must invest themselves in the learning process; otherwise, the experience will likely be a burden rather than an opportunity for continued self growth and development.

To learn more read: Purcell K. Use of performance portfolios for pharmacy personnel. Am J Health-Syst Pharm 2009;66:801-4.

[Editor's Commentary: Reflection and planning are important ingredients to self-development. Learning portfolios can assist us in the learning process and help us meet personal and professional goals. Portfolios can take many forms. Many people continue to maintain paper-based portfolios ... but in this digital age, web-based portfolios enable us to store a wide variety of interconnected media - not just documents. I can image a day when our personal and professional development, from birth to death, is warehoused on a personal website. These sites make our reflections, plans, actions, evaluations, and outcomes of our learning readily available to our teachers and mentors anywhere in the world. If you'd like to get started building your own digital portfolio, check out Dr. Helen Barrett's eletronic portfolio site at: http://electronicportfolios.com/ and series of her presentations at: http://eportfolios.blip.tv/ Her keynote address to the National Institute for Adult Continuing Education (NIACE) is a great introduction to this topic. - S.H.]

I Have No Idea What It Means to be a Teacher

by Michael Wunder, Doctor of Pharmacy Candidate, Palm Beach Atlantic University Gregory School of Pharmacy

I have seen every stage of a teacher. I have seen the passion of one who has found the profession. I have seen the fulfillment of one who has retired for the profession. I have seen the joy, worry, suffering, sorrow, anger, elation, and laughter that have come with this profession. I am the son of a teacher, the brother of a teacher, and the husband of a teacher, and I have no idea what it means to be a teacher.

I spent every summer growing up reorganizing classrooms, putting up bulletin boards, and copying papers. I have helped grade papers in the fall, winter, and spring. I have cut out numerous shapes and laminated a million papers. I have broken down boxes and moved classrooms and closed classrooms. I have no idea what it means to be a teacher.

I have seen a child learn to read. I have seen a child learn to count. I have seen a teenager stand in class and declare that they understood Holden Caulfield. I have seen a teenager learn accounting. I have seen a teacher rejoice at each of these moments. I have seen a teacher hold a moment like these for the rest of their life. I have no idea what it means to be a teacher.

I have seen a child refuse to listen, scream, and throw crayons. I have seen a teenager throw a desk, stab another student, and then threaten the life of a teacher. I have no idea what it means to be a teacher.

I have seen the letters from parents praising a teacher for reaching their child’s life and encouraging their soul. I have seen the letters from parents threatening to sue a teacher because their child did not get enough attention. I have seen administrators and school districts turn their backs on their teachers. I have seen hours of lesson plans and curriculum meetings be tossed to the side because of the disruption of one student. I have no idea what it means to be a teacher.

I have seen a teacher cry in a classroom. I have seen a teacher cry at home. I have heard a teacher curse many a student and administrator too. I have heard a teacher whisper “I just don’t know what to do.” I have heard a teacher scream, “That’s it, I’m through.” I have no idea what it means to be a teacher.

I have seen a teacher cry when their student past a reading test they worked so hard for. I have seen a teacher smile when a student says “I’ll miss you.” I have seen a teacher laugh and feel true achievement as two teenage boys acted out … in Don Quixote. I have seen a teacher cry recalling when police took a student right out of his chair for murder. I have no idea what it means to be a teacher.

I have seen a teacher anticipate what their students might be like. I have seen a teacher clean up a party and say their goodbyes. I seen a teacher work a summer job to earn enough to pay for that rug they need for their reading center. I have seen a teacher stand in a field after graduation because a student wants that picture with their favorite teacher. I have heard a kindergartener say “I love you and I don’t want to have another teacher.” I have seen the letter from a death row inmate who was pulled from his chair in class that says, “Miss, I am sorry for interrupting your class. You were the only one that ever cared.”

I have no idea what it means to be a teacher.

[Editor's commentary: I think this essay by Michael Wunder says it all. -S.H.]

Implementing Self-Directed Learning

By Sandeep Devabhakthuni, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

Self-directed learning is basically the process in which an individual matures from a dependent learner in a highly structured environment (often a classroom) to an independent learner with the motivation to continuously self-monitor and self-manage his/her learning process. In the healthcare setting, the recent paradigm shift to evidence-based medicine requires the engagement of healthcare professional students in self-directed learning. Typically, healthcare professional schools design academic curriculums that will at minimum prepare students to become competent practitioners. While I learned a tremendous amount of information that will serve me well in my clinical practice, I realized that the program of study I completed was designed to help me achieve the minimum competencies needed to be a general practitioner. Despite having just graduated with a Doctor of Pharmacy degree, I recognize there are several ways I can improve myself. Thus, I am a big proponent for self-directed learning because I want to become a highly competent healthcare provider.

Self-directed learning is an effective (even essential) method for training healthcare professionals. But how do we motivate students to become self-directed life-long learners? Specifically, is there a need for more guidance during the didactic portion of the curriculum before expecting students to perform self-directed learning activities during their experiential learning rotations? At the University of Maryland School of Pharmacy (UMSOP), Huynh et al considered this issue by investigating the impact of advanced pharmacy practice experiences (APPEs) on student’s readiness for self-directed learning (Am J Pharm Educ. 2009; 73(4): 65-72).

In this investigation, the authors followed pharmacy students over the course of their last year in the Doctor of Pharmacy curriculum in order to assess their readiness to engage in self-directed learning activities. During their third year before starting APPEs, pharmacy students from were invited to complete a questionnaire consisting of 2 sections: the Self-Directed Learning Readiness Scale (SDLRS) and a baseline characteristics survey. A score of 150 or greater on the SDLRS instrument was correlated with a high level of readiness for self-directed learning. After completing the required APPEs, the pharmacy students were asked to complete the SDLRS instrument again. The data from the post-APPE questionnaire was compared to the results of the pre-APPE questionnaire.

The authors reported that 77 (64%) and 80 (67%) students completed the questionnaire in the third and fourth year, respectively. Of these respondents, only 46 (38%) matched pairs completed the questionnaire in both years. From the baseline characteristics analysis, none of the characteristics such as age, gender, pre-pharmacy coursework, postgraduation plans, or leadership experiences had an impact on the SDLRS score. The overall mean SDLRS score for the pharmacy students who completed the questionnaire in the third year and fourth year were 157 ± 21 and 162 ± 21, respectively. No difference was found in the mean scores on the SDLRS for students in their third and fourth years (p > 0.05), regardless of using all student data or only matched pairs (i.e., same student before and after completion of APPEs) data.

To be honest, I was not entirely surprised that the impact of APPEs on the student’s readiness for self-directed learning was minimal. Pharmacy students need to be ready to engage in self-directed learning before they begin their experiential learning rotations. If the student does not have the expectation of performing self-directed learning during the APPEs, the student will struggle during his/her last professional year. Teaching students to engage in self-directed learning during the APPEs is probably too late. The students need to be aware of the need for self-directed learning before they apply the process during APPEs. The fact that the APPEs have a minimal impact on the student’s readiness supports this observation. Instead, the purpose of the APPEs is to provide the pharmacy student opportunities to engage actively in self-directed learning. Thus, it is crucial to provide guidance to the pharmacy students before APPEs on how to successfully engage in self-directed learning activities during APPEs.

At the time of the investigation, the authors reported that the pharmacy students at the UMSOP were not provided explicit instruction regarding how to conduct self-assessments or engage in reflective learning. The good news - most students demonstrated a high readiness for self-directed learning at baseline before beginning their APPEs. The focus should shift to helping students applying self-directed learning skills during their APPEs. In other words, preceptors should evaluate whether students successfully engage in self-directed learning activities. By giving feedback regarding the quality of these self-directed activities, students will learn how to self-evaluate and take steps to improve their knowledge and skills when they begin their practice as pharmacists.

[Editor's Commentary: Why are some people more successful in their professional lives then others? What keeps some people "on top" of their field for many years? Is it strictly a matter of internal motivation? An intrinsic personality trait? An inherent need to understand the world? Intellectual curiosity? Or is self-directed learning a learned behavior? A set of skills, habits, and attitudes learned by observing other successful people in our lives (e.g. parents, role models). Can these skills, habits, and attitudes be taught in school? Few of us have received explicit instruction about how to "be" a self-directed learner. Not surprisingly, students who are admitted to schools of pharmacy are very bright and successful. It seems likely that one of the ingredients for their success is their ability to independently recognize gaps in knowledge and skills ... and engage in self-development activities to close these perceived gaps. Indeed, the "best and brightest" often become involved in research projects (or "special projects" or "independent study") during their years in pharmacy school and pursue residency or fellowship training after graduation. And yet, these are the individuals who are most competent and best prepared to entry practice without doing a residency or fellowship. Is the ability to successfully engage in self-directed learning an intrinsic quality or a learned behavior? Is it nature or nurture? An age old debate. -S.H.]