E-Learning and Health Professional Education

by Nicholas Fusco, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

“Everyone take your seats. Let’s get started. We have a lot to cover today.”

As the lecturer quickly goes through their outline and objectives for the class, you frantically try to organize your mind for the impending deluge of information. Physiology, biochemistry, pathology, pharmacology, clinical guidelines, monitoring parameters, adverse effects and the list goes on. The lecturer unflaggingly presses forward as your wrist begins to cramp from scribbling down each bit of seemingly invaluable information. Soon, you realize you may have missed something and turn to your neighbor for help. You look to the left and find your best friend in Stage 1 of non-REM sleep. You turn to your right and find another classmate starring helplessly at the board, jaw slightly dropped, eyes glazed and you wonder if you should check his vital signs. While all this has transpired, the lecturer has moved on. No time for stragglers. Every student for themselves! Before you know it, the lecture is over. You’re left floating in a sea of new information. I hope you can swim (or at least brought a raft).

Sound familiar? Traditional, instructor-centered teaching placed the teacher in control of the learning experience. Increasing demands on academic faculty to accommodate the ever-expanding field of biomedical science and to incorporate new fields of practice has challenged the way in which they deliver this information. Emerging from these challenges is a new, learner-centered model that allows the student to be in control of their learning experience. One vehicle by which information can be delivered that supports the learner-centered model is that of “E-learning” or Web-based learning. E-learning is the use of any Internet or computer-based technology as a source of instruction. It can be broken in to two broad categories of distance learning and computer-assisted instruction. Distance learning describes those technologies that allow for the delivery of information to remote sites from a central location. Computer-assisted instruction utilizes one or more sources of multimedia to aid in the delivery of information. These terms are not mutually exclusive, nor do they need to be separated from traditional, instructor-led learning. In fact, most instructors already take a blended approach, supplementing a traditional lecture with online or computer-based aids.

The advantages of E-learning can be summarized in two main categories, learning delivery and learning enhancement. For the student, well-designed E-learning scenarios increase their accessibility to the content, allows them to customize their learning experience and control the pace, time and even the media by which the instruction is delivered. For the instructor, the ease by which online multimedia can be updated, distributed and standardized sets it apart from traditional print media. Learning enhancement is less well described, but is just as important as learning delivery. As more institutions embrace competency-based curricula, a greater emphasis is being placed on learning outcomes. By allowing the student greater accessibility and customization of online multimedia, E-learning supports a more efficient learning process. Based on it’s interactive nature and the degree of control that the student exhibits over the delivery of the content, E-learning can potentially motivate the student to become more engaged with the content and through this increase retention rates.

A unique challenge of E-learning is in its evaluation. As more learning becomes student-based, the instructor’s role will evolve from a transmitter of information to a facilitator / evaluator of learning. The process of E-learning must be closely evaluated to determine whether the experience was appropriate, well designed, and met the needs of the students that it was intended for. Likewise, outcomes must be measured to determine how efficiently E-learning was able to alter a student’s knowledge or skills. It is important to make a distinction at this point between learner satisfaction and efficacy. E-learning should be interacting and engaging, which certainly will provide some degree of entertainment to the learner. Subjective evaluations of E-learning may yield high levels of learner satisfaction if the experience was fun or entertaining, and may falsely lead the instructor to believe the learning experience was efficient or effective. Poor content can be masked by an entertaining design and may lead to ineffective learning. It is therefore important to develop effective, instructor-mediated strategies for the evaluation of outcomes of E-learning. In many health care professions, the preferred technique for evaluation of skills is direct observation. This can be time consuming, costly and inefficient. A combination of web-based competency evaluations combined with direct observation may allow the instructors to perform a more thorough evaluation of the student’s knowledge, while still engaging the student in traditional, face-to-face assessments. Further development of this area is needed and may potentially be a source of scholarship to academic faculty in the future.

E-learning offers several advantages to both the student and the instructor. Wouldn’t it have been nice to be able to press “Pause” during some lectures to recollect your thoughts before moving on to the next, big idea? Customization of learning experiences may better accommodate different learning styles, which can simultaneously enhance the learning process and improve outcomes. As E-learning becomes a more integral part of health professional education, students and instructors will benefit from this vehicle to navigate the great sea of knowledge.

References:

Ruiz JG, Mintzer MJ, Leipzig RM. The impact of E-learning in medical education. Acad Med 2006;81:207-12.

Leung WC. Competency based medical training: review. BMJ 2002;325:693-6.

Ward JP, Gordon J, Field MJ, Lehmann HP. Communication and information technology in medical education. Lancet 2001;357:792-6.

[Editor's Commentary:  E-learning includes a range of electronic tools (hardware and software) that are employed in the learning process. When most people think about e-learning, they immediately think of computers connected to the Internet but it also includes mobile devices like cell phones and MP3 players … as well as a range of software tools, increasingly web-based applications.  Mobile computing devices and the Internet have revolutionized the way we can deliver instructional materials.  But is this new delivery method better or worse than older methods of deliver (namely, oral expository in a classroom and written materials in the form of books, journals, and handouts)?  This dichotomous question, is e-learning better or worse than traditional methods of learning, forces us to think in terms of either/or rather than examining things in a more holistic manner.  Most instruction delivered through an e-learning conduit is no better or worse than the face-to-face methods it is attempting to “replace.”  Indeed, most instruction delivered online is merely a replica of what would have been delivered had the learner been seated a few feet in front of the teacher. Perhaps the biggest advantage of e-learning is that it often can increase availability and access.  Most e-learning materials are available to students in an enduring way – and accessible from any computer 24/7 anywhere in the world.  Face-to-face instruction often enjoys an advantage with regard to greater social connection and interactivity – thus the transactional distance between the teacher and learners (and among learners) is smaller.  Clearly an important benefit.  Thus institutions and instructors who have embraced “blended learning” have an opportunity to maximize student learning by using a variety of instructional tools and methods, online and in the classroom, exploiting the advantages that each has to offer.  So the decision to use e-learning should not be a yes or no proposition, but rather a who, what, why, when, and how analysis. –SH]

Early Practice Experiences & Curricular Reform

by Liana Mark, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

Standard number 11 of the 2006 ACPE Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree states that “the pharmacy school must use and integrate teaching and learning methods that produce graduates who become competent pharmacists by fostering the development and maturation of critical thinking and problem skills.”  The Standards also go on to say that “the pharmacy school must enable students to transition from dependent to active, self-directed lifelong learners.”  This lofty goal is easier said than done, and I am not entirely convinced that the majority of pharmacy school curriculums enable students to achieve these objectives upon graduation.

My school of pharmacy implemented early (i.e. pre-P4) experiential learning into its curriculum after the 2006 Standards were published.  As such, I participated in both introductory and intermediate pharmacy practice experiences during the summers after my P1 and P2 years in addition to P4 advanced pharmacy practice rotations (APPEs).  During the school year, most learning was passive via didactic lectures and, in some cases, active through laboratory experiences and discussions.  Looking back, it seems as though I grew as a professional and as a learner at an exponential rate during my P4 APPEs, compared to the rather modest growth in the first few years of professional schooling.  My capacity to learn and apply resembles a J-curve, with a significant upswing towards the end of my student years.  However, now that I have the ability to look at pharmacy education from a bird’s eye view, I must say that I would have preferred my learning curve to resemble first-order kinetics during those years; with a steady, progressive increase that would have allowed me to build upon my prior knowledge and learn how to problem solve and critically think through problems early on, rather than just retaining factual knowledge and finally having a number of “a-ha!” moments at the end of my student career when everything suddenly fell into place.

So, the question is, how can first-order learning be promoted?  First, we must identify the barriers.  Passive learning techniques employed in the didactic portion of the Pharm.D. program provide limited opportunity for the development of problem solving and critical thinking skills.  This obstacle is mainly due to the factual nature and the sheer volume of information that pharmacy students must learn in order to create a substantial knowledge base.  A student can manage to pass via “cramming” and regurgitating the information on an exam, but this method of retention (because it is clearly not learning) benefits neither the learner nor his/her future patients.  Additionally, factual information, especially in the field of pharmacy, changes from year to year.  Taking this into account, treatment guidelines learned in the P1 year may not be applicable by the time the student reaches APPE rotations.  Thus, honing the skills of critical thinking and problem solving is absolutely necessary to prepare the student pharmacist for independent practice and satisfactory patient care.

Active learning is a more effective learning method for long term retention.  This method of learning includes discussion, practicing by doing, and teaching others.  Experiential learning is employed in many healthcare professions to prepare the student for independent practice, pharmacy included.  However, pharmacy experiential learning comes much later in the student pharmacist education as compared to other healthcare professions, and the experiential learning we do get early on is sparse and, in my experience, not fully maximized.  Students of dentistry, optometry, medicine, and physical therapy all have active, hands-on learning placed very early on in their curricula.  As such, by the time these students graduate, they have a strong fundamental, and, more importantly, applicable, knowledge base.  Individuals in these professions are well-equipped upon graduation to walk into a real-life setting, given that they have been in the setting as an apprentice for years.

A potential solution for student pharmacists is to incorporate weekly practice experience starting in the first few days of the Pharm.D. curriculum.  This integration would allow the student to apply facts learned in the classroom to a real situation, thus enabling him or her to critically think, problem solve, and retain the information in a different way than strictly classroom-based learning allows.  Weekly practice experiences may not be feasible due to course load.  Thus, another solution, which is employed at a number of pharmacy schools, is co-operative experiential learning, wherein the student pharmacist alternates classroom learning and experiential training from one semester to the next.  The experiential training, of course, must be coordinated with the classroom learning of the student.  My school’s current format that consists of IPPEs and APPEs could be maximized by ensuring that preceptors have a better understanding about their responsibility to the pharmacy student and to their profession.

It is clear that pharmacy education lags behind other professions in its active learning experiences.  Pharmacists need to be exposed to real-life situations earlier in their careers in order to meet the ACPE Standard that encourages the development of critical thinking and problem solving capabilities in the Pharm.D. curriculum.  Through active learning techniques, student pharmacists will be able to retain knowledge and create for themselves usable, applicable databases that will serve to improve their clinical abilities as practitioners and, additionally, encourage the pursuit of lifelong learning.

DiPiro JT. Making the most of pharmacy school. Am J Pharm Educ 2008; 72(1) Article 15. 

DiPiro JT. Why do we still lecture?  Am J Pharm Educ 2009; 73(8) Article 137. 

Duncan-Hewitt W and Austin Z. Pharmacy schools as expert communities of practice? A proposal to radically restructure pharmacy education to optimize learning. Am J Pharm Educ 2005; 69 (3) Article 54.

[Editor's Commentary:  Is the typical pharmacy curriculum backward ... based on outdated, unproven notions about how people learn?  Should we provide students with experiences first and then talk about the theory and science that supports the practice of pharmacy afterward?  There are perhaps practical reasons why pharmacy schools (and most other professional schools) have elected to front load their curricula with didactic course work and save the practical experiences for the end. But most of the reasons have more to do with scheduling and resource allocation, not pedagogy or instructional design. Let's examine how one would go about teaching people to play a guitar (and to be good enough to make money playing it).  Now, learning how to play a guitar is complicated stuff.  To get really good at it you have to learn new terminology (e.g. adagio, allegro, forte), read (and perhaps even write) an entirely new form of communication (e.g. music notations), play different styles of music, and coordinate your actions with other people who are simultaneously playing their musical instruments or singing. If we approached learning how to play a guitar the same way we approach pharmacy education, we'd have the students sit through a series of didactic lectures about the guitar and its history, about guitar playing techniques, how to select a guitar, how to read music, and how to be a member of a band.  We'd probably have students watch an instructor (or better yet, a resident!) play a guitar in front of the class.  And then we'd have everyone watch videos of Eric Clapton and John Scofield playing guitars - and then debrief about it for 30 minutes.  In addition, we'd have the students participate in 3 or 4 "guitar labs" each semester where three or four students would use the school-provided XBox or PS3 and play "Guitar Hero" (or something like that) - and watch each other play - for a couple of hours.  And then, we'd have a one week observation (P1) and a one-month (P2 and P3) "guitar playing" rotation with a preceptor.  The student probably wouldn't be assigned his or her own guitar to play - but would rather "assist" the preceptor with some guitar playing activities (like, for example, handing the preceptor the right pick to use).  In the fourth year of our "guitar school,"  each of the students would be sent off into the field and would be asked to start playing guitars - 40 hours a week!  This would probably overwhelm our students, who haven't yet built the skills to play guitar very well on their own nor the stamina.  But, during the last year of the curriculum, most of our students would, indeed, get pretty good at it.  Most would become competent guitar players (good enough to be street musicians) and a few would become stars (acclaimed by their audience and peers as truly great musicians).  Many of our students would arrive at our fictitious guitar school with some guitar playing experience - and nearly all of them would be innately interested in guitar playing.  But we wouldn't let them touch a guitar until they've completed a least 16 credit hours of instruction about the latest statistics regarding guitar playing in the US, music theory, and (of course) the physics of sound.

Seems a bit absurd, doesn't it?  If you wanted to learn how to play guitar, the first thing you'd do is pick a guitar and try to make some sounds with it (not take a series of didactic lectures about it).  And a good teacher would encourage you to do so.  In fact, you probably wouldn't be allowed into "guitar school" unless you had access to a guitar and could get practice using it several hours a week.

I encourage you to read a provocative article by Wendy Duncan-Hewitt and Zubin Austin published in AJPE.  I think the traditional pharmacy curriculum is a relic of the past.  Its time to rethink and radically restructure things. -SH]

Experiential Learning: On-Call!

by John Hammer Pharm.D, MBA, PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

Aristotle once said, "For the things we have to learn before we can do them, we learn by doing them."  I believe this quote encompasses what is meant by experiential learning.  I think of experiential learning simply as learning by doing.

Experiential learning is what residency training is all about.  Residency training is about learning new concepts and building on knowledge previously obtained in pharmacy school through hands on learning.  It is true that students learn through their experiences as well, but it is to a lesser degree – perhaps due to less responsibility.

I feel that the amount of knowledge gained during residency training, whether we are talking about a pharmacy residency or a medical residency, is second to no other learning experience.  A residency teaches one how to act as an individual practitioner and through this we gain practical application of the theoretical knowledge learned in pharmacy school.  As residents we are frequently faced with issues that we have never seen or even read about before.

I believe that an on call program is a great hands-on experience to add to residency training.  When on call, the resident achieves another level of responsibility; acting as the clinical pharmacist that handles code coverage, pharmacokinetics, drug information questions, and whatever issues may arise during after hours.  For new residents, this responsibility may cause some anxiety – particularly given that you don’t know what may come your way - like a code.  But this is a good thing.  Residency training has a lot to do with going outside of you comfort zone in order to learn new things.  After experiencing something once you will be less uneasy and able to handle the situation better the next time.

I know this was true for me and many other residents at Johns Hopkins Hospital.  During the first code everything seemed to happen so quickly. There were a number of people packed tightly into a room, while someone was giving orders and others were running around quickly to perform important tasks.  I remember standing by the dispensing cabinet, trying to stay out of the way, when the physician asked me to prepare three drugs STAT [immediately] – drugs that I had only vague familiarity.  My hands were shaking as I pulled out my resources to verify the appropriateness of the doses and confirm how to prepare them.  I fumbled around with vials and syringes; which never seemed to be an issue for me in the past.  I triple checked my math and had someone else check the doses.  Even though I was nervous and fearful that I might do something wrong, the situation went well and the patient was fine.

I feel that it is experiences like this, where you are by yourself and forced to learn something new, under pressure, that make for the best learning experiences.  Experiences that take you outside your comfort zone occur all the time during residency training, but I feel that these experiences are more abundant while acting as the resident on call.

Experiential learning is the primary method for learning during a residency.  The variety of those experiences help to make one well rounded, and a residency on call program is useful in that it exposes one to a variety of unique experiences and responsibilities that one otherwise might not obtain.

[Editor’s Commentary:  Pharmacy residency on-call programs have existed for many years.  Perhaps the best known and oldest pharmacy residency on-call program was described in the American Journal of Health-System Pharmacy by Dr. Karen Smith and her colleagues at the University of Kentucky (AJHP 2003; 60: 2236-41).  Most residency on-call programs require the resident to troubleshoot drug-related problems that emerge during off hours (e.g. between 5pm and 7am).  This includes participation in hospital emergency care (aka "medical codes").  On-call programs require residents to act autonomously - to make decisions on their own - and in so doing, its intended to build self-directed learning skills.  For the new practitioner who is not yet accustomed to making decisions on his/her own or directing his/her own learning, this can (and should) produce some degree of anxiety.  By placing residents in situations of responsibility, residents develop a greater (and sometimes urgent) awareness of their gaps in knowledge and skills ... and this is an important step in the experiential learning process.  John describes this gap in his essay (vague familiarity with the three drugs used during the code) ... and, similar to the experiential learning model described by Kolb, he identified resources to help him fill that gap.  In this case, it was a drug information source available at the bedside.  Like the experiential learning model, he implemented strategies (obtained information, calculated doses, and had someone else double check him) and reflected on the success of those strategies (in this case, "the patient was fine.").  It is the last step, the thoughtful reflection about the experience, which is perhaps the most critical.  Without reflection, one is unlikely to learn from the experience or to actively identify gaps, seek resources, and implement new strategies in the future.  Life is FULL of experiences - but many (perhaps most) are not learning experiences.  As teachers, we must be mindful of the experiential learning process - and help our trainees learn from their experiences.  Perhaps the most important thing we can do is to set aside time for reflection (by the student or resident) and discussion (with us) at regular intervals.  It is often through a dialog with a skilled preceptor and experienced practitioner that the trainee will have those "ah ha" moments of understanding.  Reflection and discussion should occur as soon as possible after the experience - preferably within hours for major new experiences and less frequently (a few days) for experiences that have slightly new features (relative to the trainee's past experiences).  In addition to setting aside time for reflection, we should strive to prepare our trainees for major new experiences by helping them to identify gaps and assemble resources ahead of time.  The EXPERIENCE is solely the student's or resident's to have.  As much as we might like to take away their anxiety or to be at their side to take the weight of the responsibility, attempting to do so (all the time) is a disservice.  Indeed, it is the EXPERIENCE that sets the learning process in motion. - S.H.]

Rethinking the Art of Pimping

By Courtney Patterson, Pharm.D., PGY2 Oncology Pharmacy Resident, Johns Hopkins Hospital

The art of  medicine, the art of patient counseling, the art of using medications sound wonderful when discussed in the context of patient care, but there is another art that’s often used in the training of these fields - - it’s called pimping.

Palms sweating, beads forming on my forehead, and my mouth becoming dry as my preceptor hovers over me asking absurd questions that I am sure he / she knows I have no clue what the answers are. I knew there had to be a reason as a student, as a first year and now a second year resident, that there was a method behind making me so uncomfortable - - it’s called pimping.

Where there is established hierarchy, whether it be in the medical profession, pharmacy or nursing, there is a certain style of questioning that oftentimes prevails- - it’s called pimping.

Earlier this year an article by Detsky entitled, “The Art of Pimping” (JAMA 2009; 302: 1379-981) appeared in my social networking email.   Unfamiliar with the concept , I opened my email to find this art hit close to home - striking several personal nerves. Amazingly, a previous article written by Brancati also entitled “The Art of Pimping” appeared in JAMA some twenty years ago (JAMA 1989; 262: 89-90). This blog essay is my attempt to delve into this “art” and offer some advice on how to revamp this feared form of questioning.

Pimping occurs when an attending or preceptor (the Pimper) poses a series of difficult questions to a student or resident (the Pimpee).  The setting for this style of teaching typically occurs during rounds, topic discussions or in a circumstance where the Pimper has the expectation to retrieve direct answers from the Pimpee.  In this situation, the Pimper exudes power and fear as they are evaluating the Pimpee’s performance and are their superior.

Pimping is quite an old concept, as the earliest reference dates back to 1628 where Harvey, a physician, laments his students lack of enthusiasm, “O that I might see them pimped!” In 1889, Koch recorded a series of “Pimp Questions” that he later used on medical rounds. This concept has even fluttered through Johns Hopkins - in 1916 Abraham Flexer made the observation, “Rounded with Osler today. Riddles house officers with questions, like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”

In the 21^st century, pimping has survived because it’s based in the age-old style of question and answer. In this light, pimping can resemble the Socratic method but there are some distinct differences. The Socratic method is a kind of questioning that requires the student or resident to do more in depth thinking, it oftentimes presumes that the student knows the answer and the instructor is attempting to allow the student to answer their own question by bringing about questions that will better formulate the student’s answer. Pimping however, is asking questions with minimal expectation that the pimpee will know the answer. This form of questioning is used to either bring about a teaching point or show superiority of the pimper. Thus the difference between these methods is the intent behind the questioning.

I have alluded to the technique utilized in pimping, but there are only two components at its center: fear and power. A rapid fire session of questions combined with fear and power --you’ve got a pimping session.  Power is needed because it reinforces the relationship between the preceptor and the student or resident. Fear is present because the student or resident wants to know the answers to the questions and grimaces at not being able to respond in a manner that will quench the preceptor’s satisfaction.  And for those fellow residents, upcoming residents, and students I offer three tokens of advice in avoiding the dreaded feeling of being pimped.

First, attitude is everything.  During rounds, topic discussions, and presentations, the goal should be to learn. Even with sweaty palms as questions are being fired away at you, take it in stride, right the questions down and look them up later. There is no need to feel downtrodden; if you are being pimped then you should understand that the expectations are low for you to answer spot on. Second, be okay with not knowing the answer.  I know this is hard, maybe because of embarrassment or ego or a type A personality, but you aren’t going to know everything. Third, just because it was done to you doesn’t mean that you have to perpetuate it. Pimping is different from the Socratic method. Pimping utilizes fear and relies on the system of hierarchy. I know as a future preceptor, I hope to ask my residents what they should know and not emphasize what I know. I plan to give them the tools, assist in the search of articles and journals to assist them in order to make them better equipped when questions are posed.

Pimping is an old concept that needs to be re-examined. Going forward, I hope to use the term (it’s still a great word!), but rewire the concept by tossing out the thought that my residents should fear me or that I should be asking questions I know they don’t know. After reading these articles, I walked away with the view that I will rewire pimping by crafting questions to increase retention and hone in on key points … and diminish the embarrassment and diffuse sweating.

[Editor's Commentary:  There is a subtle difference between asking questions with the intent to teach ... and asking questions with the intent to ridicule, embarrass, or establish hierarchy.  However, on the surface it can be difficult, based solely on the phrasing of the question being asked, to determine the intent.  Questions that have very specific answers and require only factual recall of information are more likely to be "pimping" questions intended to demonstrate the superior knowledge of the questioner.  But even open-ended, analytical questions which have several potential solutions can be "pimping" questions if the intent is to exert power and fear.  Thus, context and non-verbal communication are important.  Context is the circumstances under which the question is being asked and its sets the stage (for success or failure).  Does the student have prior knowledge or experience ...  or an opportunity to prepare for the question(s) being asked?  Is the question being asked in a group setting ... and if so, is everyone encouraged to answer the question or contribute to the discussion?  Non-verbal communication also informs the student or resident about the questioner's intent.  An encouraging smile and a nod of the head can set the student at ease.  Moreover, patiently waiting and allowing the student sufficient time to think through the question and its potential solutions is important.  A preceptor or instructor who quickly answers his or her own questions really isn't interested in hearing what the student has to say - rather they just want to tell students about what HE / SHE knows.  Finally, creating an atmosphere of open dialog requires the questioner to be open to being asked questions, to expanding on important points, and redirecting statements that might not be articulated very well.  Effective questioning requires practice, practice, practice ... but its important to understand your own motivations and intent.  Pimping is about power and fear ... effective questions is about facilitating learning.  -S.H.]

Beyond Evidence-Based Medicine: Information Management

By Zachariah Deyo, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Maryland

The amount of medical information is increasing exponentially in a variety of forms.  Information is available faster than we are capable of mentally digesting.   For these reasons, it is important to develop a personal system to triage new information.   Additionally, the number of new drug therapies is continually increasing, the scope of pharmacy practice is broadening and the expectations of our profession are growing.

In an ideal world of medical information management, clinicians can obtain valid and relevant information that is available with the least amount of work.   Slawson and Shaughnessy explore information mastery in an article entitled Teaching Evidence-Based Medicine: Should We Be Teaching Information Management Instead? (Academic Medicine. 2005;80:685-9).  Technology is a useful tool to organize information and alleviate the amount of work involved in its management.  It can be used as part of a system to decrease the time, money and effort required to obtain information, answer questions and build knowledge.  Current resources include free or paid subscription services that summarize medical research and drug information.  Examples of these resources that may be useful to pharmacist’s include: Pharmacist’s Letter, JournalWatch, Pharmacist’s FirstWatch, MedScape, MedWatch and Wallstreet Journal-Health.  Electronic tables of contents (eTOC) are available from a variety of peer reviewed journals across multiple specialties.  Professional organizations offer list-serves to network with colleagues and experts to ask and answer clinical questions.   This list is by no means complete and myriad resources exist.  Their utility may vary based on ones practice, skill level or interest.  Additionally, to manage them in a central location most can be linked to an email account.  As an alternative, really simple syndications or RSS feeds can be used with a variety of “readers” to manage resources.  Some readers offer the ability to track reading and subscription trends and offer recommendations based on browsing in an effort to pick and choose what is most relevant to ones practice.  Readers can also be used to link to blogs and professional websites.  Also, social networking sites such as facebook and Twitter can be linked to some of the resources previously mentioned.

I was introduced to feed readers as a pharmacy practice resident.  My reader is a useful tool to manage the constant influx of medical information.  As I became more familiar with information management resources, I also began to think of the importance of exposing pharmacy students as well as practicing clinicians to these new tools.  After taking several courses in biostatistics and literature evaluation (as a student), during my residency I was required to take analysis of information to another level.  Should we be incorporating knowledge management strategies into the Doctor of Pharmacy curriculum?

I found several interesting publications on this subject.  The first was an article by Phillips and Glasziou (Postgraduate Medical Journal. 2008;84:450-3) which highlights the importance of keeping up with clinical evidence while in training.  These authors give several reasons :  the need to learn evidence-based medicine(EBM) skills, developing a system that helps manage the volume of new information and helping patients ”get better sooner.”  The importance of quality patient-oriented evidence is also discussed.  The article includes an explanation of the difference between “just in case” and “just in time” learning.  Although the authors write that both are beneficial the former is much more inefficient and information overload can be attenuated by using filtered resources.  Key resources are discussed to help clinicians stay up to date.  A four step approach to EBM including asking questions, acquiring information, appraising evidence, and applying results is explained.  The authors conclude with the goal of developing lifelong learning habits.

Slawson and Shaughnessy (Academic Medicine. 2005;80:685-9) discuss helping students, residents, and clinicians develop skills beyond EBM.  The authors point out that although critically evaluating medical literature is an essential skill, clinicians (in training and practice) must be able to find, evaluate and use information at the point of care.  The authors describe a curriculum that contains three levels of education based on experience and practice.  The three core skills they describe are: selecting tools for “keeping up”, selecting the appropriate hunting tool, and developing patient-centered, not evidence centered, decision making.  In helping students incorporate these skills and tools into their daily lives we foster lifelong learning.

In a subsequent article, Shaughnessy (American Family Physician. 2009;79:25-6) describes how to set up a system for keeping up.  The system  filters information and leads to answers that are valid, efficient, evidence-based, and patient oriented.  This is “system” is often referred to by the acronym POEM (patient-oriented evidence that matters).   Phillips and Glasziou write that focusing learning on information that is directly relevant to patients produces “better” clinicians.  Even the best tools offer little benefit unless you access them on a regular basis.  It can be challenging to find enough time in the day to check email, let alone a feed reader.  By exposing students to these resources early in their professional development we instill habits that will carry into their professional lives.

My recent trip to the American Society of Health-System Pharmacist Midyear Clinical Meeting re-enforced my thoughts on this subject.  I attended an excellent continuing education (CE) session titled: In Case You Missed It: Top Papers in Medicine 2009 (http://www.softconference.com/ASHP/sessionDetail.asp?SID=155655).  This was a great session.  After the conference I thought how true it is that we cannot rely solely on annual meetings and CE to meet the cognitive demands placed on our profession.  Our goal should be aware of and read important papers soon after their publication.  Technology in the form of feed readers and other resources is just one of many tools that can be incorporated into our practices.  Moreover, we must introduce these tool during the education of current and future pharmacists.

I challenge educators in all fields to explore new technology in keeping up with information.  These concepts can be applied to any professional practice.  If you are already familiar with or use these resources, that’s great.  Share them with your students and residents.   But don’t be afraid to let students teach YOU something about these new technologies.   These new technologies are not a replacement for biostatistics or literature evaluation but rather a supplemental tool.