Empowering Patients - Social Learning and Health Outcomes

By Whitney Redding, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins University Hospital

Social learning is defined, in the simplest terms, as the process by which a person learns from observing others. The belief is that we are most likely to model our behavior based on what we have learned from watching those around us.  The best models are those to whom we relate the most – often our peers.¹ Learning in a social setting plays a critical role in how we gather information and adapt successfully to our environment, but it can also be how we pick up less effective, less healthy habits.

As a freshman, I lived in a dormitory on a special floor designed for pre-pharmacy students, called a “Pharmacy Learning Community.” Our neighbors became our colleagues and we learned from each other not only the material taught in our classes, but also how to study and adapt to college life. I would say that I learned many good behaviors from those with good study habits on my floor, and I learned what not to do from those with poor study habits. I also picked up some very poor eating habits from my college peers, which differed from the environment in which I was raised.

For my sophomore year, I enrolled in Organic Chemistry. Our professor divided us into study groups the first week based on our previous GPAs. Together we discussed problems during class, completed extra credit assignments, studied and took exams. In addition to the active learning strategies used in the classroom this course created an atmosphere that embraced social learning among peers.  Groups that collaborated outside the classroom learned more and performed better than the groups that spent less quality time together.²

When it comes to our health, social learning is also a key element to success. Patients, as the learners, adopt habits from their friends and family that impact their risk of disease.  In a study published in the New England Journal of Medicine by Christakis and Fowler, it was found that among groups of friends, if one friend developed obesity, the other friend(s) was 171% more likely to become obese.³  And this increased risk of obesity was correlated to social closeness (rather than geographic closeness). In another study, smoking cessation was increased when a spouse or family member quit smoking. Moreover, smoking cessation tended to occur in clusters of people (not single individuals, one at a time) and in those with larger social networks.⁴ This research provides evidence that the impact of social networks on health cannot be ignored.

I wonder how effective it would be to create health learning communities for our patients, or health study groups. This has already been done in the setting of Alcoholics Anonymous, diabetes education and cancer support networks, but could also be expanded to smoking cessation, obesity and any number of other health-related behaviors. Research has been expanding in the areas of online health networks, and their impact on social learning.  Even television has tried to take advantage of observational learning in such shows as The Biggest Loser. The trend towards not only patient-centered care, but also family-centered care, is another example of ways the healthcare system should embrace social learning to improve health outcomes.

It is important to look at the big picture of health. How successful will a patient be at losing weight … when his or her closest friend is gaining weight? How easy will it be to quit smoking, when one’s social network continues to smoke?  How reliably will one take his or her medication, when his or her spouse has difficulty (or doesn’t believe in) taking medications? It seems to me a patient’s social environment and the role of social learning must be considered when implementing patient interventions.  How do we learn to use the power of social learning? Our patients may help us gain a better understanding of how to encourage healthy behavior.  Perhaps pharmacy education could provide opportunities for us to utilize this theory of learning to advance patient care. Both patients and healthcare workers alike would benefit from discussing the impact of how society and our own social networks impact our health.

¹Schunk DH, Hanson AR. Peer models: Influence on children’s self-efficacy and achievement. Journal of Educational Psychology 1985;77:313-322.

²Loudon GM. What happens when we change the way we teach organic chemistry?

³Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007;357:370-9.

⁴Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. N Engl J Med 2008;358:249-58.

[Editor's Commentary:  Clearly the social context in which we learn has a powerful impact on our behaviors.  Cultural norms of behavior are generally acquired through modeling ... not through explicit instruction.  While teachers and health care practitioners do have some influence on behaviors, we need to face the (sad) truth that our influence is rather small.  Very small.  Direct instruction - lecturing and/or counselling people on what they should (or should not) do - is ineffectual.  Active engagement improves the odds that someone will adopt a behavior ... and social engagement with influential peers improves the odds further still.  The risk of disease and the management of chronic illness is far more dependent on the social context than any "traditional" intervention that health professional "prescribe" or "counsel" patients to do.  And yet, our expectations as a society (and our payment systems) are built around one-on-one interactions between a patient and a health care provider ... rather than working with families and communities.  Public health practitioners have known for a long time the power of family and community on health outcomes.  Perhaps under a reformed healthcare system in the United States we'll learn how to PAY FOR best practices that harness the power of social learning.  To see what the University of Maryland School of Pharmacy is doing to improve the health of our community and to be a role model for social learning, check out our Rx for Health Habits website. - S.H.]

The Power of Praise ... Use it Wisely

by Brian L’Heureux, Pharm.D., PGY1 Pharmacy Practice Resident, Suburban Hospital

I’m sure you’ve been in the same situation.  The big presentation is finally over, and now it’s time for the evaluation.  Hoping for some valuable feedback to further improve your presentation content or hone your presentation skills, all you get is a “good job, great presentation” or maybe a “keep up the good work.”

In today’s culture, feedback always seems to come heavy on the praise and light on the criticism, for fear of hurting the student’s self-esteem.  While no student or teacher would enjoy outright criticism, praise can be equally damaging by not affording students opportunity to better themselves intellectually. In trying not to trample on a person’s self-esteem, feedback is falling flat and teachers are often not giving enough content to enable students to better their skills.  Is the problem the lack of constructive criticism?  Or is it the type or the amount of praise given?

In “How Not to Talk to Your Kids,” an article that appeared in the New York Magazine, Po Bronson writes about the inverse power of praise, and how too much praise may actually hinder intellectual growth.  Although the research presented was primarily done in elementary school-aged children, there is a definite connection with learners of any age.  The article outlines what characteristics of praise produce negative outcomes and the kind of praise that promotes the best results.  Praise should emphasize the student’s effort, be specific by highlighting the behaviors that are desirable, and be genuine.  Research by Dr. Carol Dweck indicates that when students were continuously praised on their intelligence, which is a quality that is outside of students’ control, they are more likely to underestimate their skills and only attempt easy tasks for fear of showing their intellectual vulnerabilities.  Dweck also demonstrated that when students are praised on their effort, which is something they can control, the children were more likely to try harder tasks and therefore have the opportunity to learn and improve their skills.  Secondly, praising specific behaviors, not issuing general platitudes, has been shown in many studies to be most effective.  One study described the effects of selective and specific praise on a losing hockey team.  The team started winning when they were given self-esteem boosting praise that was specifically directed at the number of checks each player gave during games.  Lastly, the article points out that by the age of 7, children become suspicious of praise.  If the child determines that the praise is disingenuous, the student may feel patronized and that the praise signifies that they’ve reached the limit of their capabilities.  Constructive criticism on the other hand, can signify to a student that they still have the ability to improve their skills.

To bring into the context of the issues we are discussing in this course, the “praise” described in the article is feedback, and the students are adults.  As pharmacists, we can appreciate the fact that learning continues throughout our lives.  Thinking back on the feedback that I’ve received in the past, I’m starting to see how I was impacted – positively and negatively.  The author also alludes to the fact that great feedback requires a good deal of effort.  The next time that you have the opportunity and responsibility of providing feedback to someone, consider the potential impact you can have on their development.  The effort can certainly be worth it.

Bronson, P.  “How Not to Talk to Your Kids.”  New York Magaine. 2007: Feb 19.


[Editor's Commentary:  Feedback is a critical component of the learning process.  Feedback from teachers can be especially powerful.  Feedback not only helps students focus on the things they did well and points out the things they can (should) improve ... but it also impacts students' motivation to learn.  Most of us think of feedback as a dichotomy - its either praise (uplifting, positive speak) or criticism (disheartening, negative speak).  Praise is believed to affirm a person's self-esteem.  While criticism is generally believed to be (potentially) destructive or harmful.  While there is little doubt that criticism can be a used (intentionally or unintentionally) like a weapon to breakdown and diminish people, praise can have a corrosive effect too.  In the book "Punished by Rewards," Alfie Kohn describes how the use of carrots (and sticks) has inadvertent and negative consequences in our schools, the workplace, and at home.  The judicious use of "praise" in the form of describing specific behaviors that the teacher feels is desirable can help students (children or adults) know what they are doing well.  But growth can only come when the teacher is willing to point out what could be done better.  Striving for better does not imply that the performance was "bad" or "poor."  It simply means there is room for growth.  And frankly, isn't there ALWAYS room for growth?  Constructive criticism, delivered in a manner that suits the individual's learning style and judiciously applied at the right time, is perhaps a teacher's most powerful tool.  Dr. Dweck's research demonstrates that our job is to help student develop a positive (growth) mindset toward learning ... and this can't be accomplished through the indiscriminate use of praise.  -S.H.]

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.]