Interprofessional Education: An Argument for Starting Early

by Kimberly A. Toussaint, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

When was your first professional encounter with a physician? What about a nurse? For me, it was during my fourth year of pharmacy school, on my first clinical rotation. Prior to that time, my collaborative experience with other health care professionals was merely theoretical – as abstract as the patient cases that we were given to write SOAP notes about during my therapeutics labs.  During pharmacy school, there are numerous opportunities to gain teamwork experiences.  Many schools require group journal club presentations, SOAP note write-ups, and case presentations.  However, this group experience typically involves only other student pharmacists.  Although many health professionals are educated on universities located on a academic health center that include pharmacy, medical, nursing and dental schools (within walking distance of one another), integration of the education of these various disciplines is rare.

Although health professional disciplines work together on a daily basis, at the beginning of their professional experiences they are often unsure of the extent of the other disciplines’ training and knowledge. This is likely due to the fact that health professionals have little exposure to the curriculum, knowledge base, and perspectives of other disciplines during school.  Familiarity with other disciplines typically improves after health professionals are licensed and begin practicing (and even then, misperceptions are common).  When I started my first clinical rotation, I had no frame of reference for how much instruction regarding pharmacology or pharmacokinetics the medical interns on my team had during their classes. For this reason, I was unsure of how to phrase my recommendations. Often, I was concerned that I was regurgitating information they’d heard numerous times. As it turned out, I probably wasn’t explaining things well enough because my knowledge and perspectives were different.

The “Seamless Care” model addresses the need for interprofessional practice experience during training, and has been studied in Canada and Australia.  This model prepares students in health professional schools to become collaborative practitioners by forming teams of students from different health disciplines (medicine, nursing, pharmacy, dentistry, and dental hygiene) and having them work together for eight weeks to plan one patient’s transition from acute care to home.  The primary purpose of this model is to create a unifying task and facilitate a real-life collaboration between health professionals.  The model also serves to address a disparity in the continuity of care between hospital discharge and home. The students work under the guidance of experienced preceptors that helped to facilitate the care of the patient as well as helping the student develop team work skills by serving as a role model and mentor.^1,2

This model is built on several educational theories.  It is an example of social learning theory because the students are able to observe the ways that their preceptors work collaboratively with other disciplines, and model that behavior.  Constructivist learning theory is exhibited by the students working collaboratively to share past experiences and to increase their understanding of the patients’ care and their respective roles on the team.

A study done by Coster et. al published in the International Journal of Nursing Medicine in 2008 measured the readiness of health professional students to learn together, using a survey.  This study showed that students’ readiness for interprofessional education was high at the beginning of their professional education, but declined over time. These results support the notion that interprofessional education should start from very early in health professional students’ education.³

By integrating this interdisciplinary practice model early in the advanced pharmacy school curriculum, collaborative work habits, trust, and rapport would be facilitated between various health disciplines. Additionally, each discipline would enhance the knowledgebase of the others by contributing a new perspective. This would enhance experiential learning across all disciplines, and would benefit everyone on the team, especially our patients.  Interprofessional education involving pharmacists, physicians, and nurses providing continuity of care for patients will have long term benefits - increasing the quality for years to come.

Carlisle, Cooper, and Watkins summed it up best:

Teams have a collective responsibility that necessitates even closer interprofessional working relationships.  Complementary action is not enough.  It is essential to cultivate this working relationship, beginning in school.⁴

The future of healthcare relies on increased collaboration between health care professionals.  Collaboration is frequently limited by preconceived beliefs about other disciplines, and this is exacerbated by our limited exposure during our education.  This leads to a lack of understanding and trust among health care professionals.  Incorporating interprofessional learning into the curriculum of health professional students would increase trust and enhance collaboration between disciplines, and ultimately optimize patient care.

References

Mann K, McFetridge-Durdle J, Martin-Misener R. Interprofessional education for students of the health professions: The “Seamless Care” model. Journal of Interprofessional Care. 2009 May;23(3):224-233.

Nisbet G, Hendry G, Rolls G. Interprofessional learning for pre-qualified health care students: An outcomes-based evaluation. Journal of Interprofessional Care. 2008 January;22(1):57-68.

Coster S, Normal I, Murrells T. Interprofessional attitudes amongst undergraduate students in the health professions: A longitudinal questionnaire survey. International Journal of Nursing Studies. 2008;45:1667-1681.

Carlisle C, Cooper H, Watkins C. “Do none of you talk to each other?”: the challenges facing the implementation of interprofessional education. Medical Teacher. 2004;26(6);545-552.


[Editor's Commentary:  There has been increased interest in interprofessional education at most health professional schools over the past decade - but, unfortunately, there has been limited progress despite calls by many professional organizations and the Institute of Medicine to introduce interprofessional education early (and more often) within our curricula.  Deep in our hearts, we believe patients would gain from increased interprofessional collaboration.  The data to support this belief is accumulating.  Intuitively it makes sense to harness the power of people of various knowledge and skills into a cohesive unit.   But getting people to play in the same sand box isn't always easy - particularly when everyone has had their own sandbox in the past.  The patient-centered medical home or accountable care team model is emerging under health care reform as THE health care delivery model.  Under such models of care, payment structures reward interprofessional team work and meeting quality standards.  But how to get from here (silo care) to there (interprofessional care).  Its not going to be easy and its not going to happen over night.  Certain teaching our students in an interprofessional, collaborative manner will go along way toward breakdown barriers.  Dobson and colleagues at the University of Saskatchewan describe the work of interprofessional student teams including pharmacists, nurses, dietitians, and physical therapists in a paper entitled "A Quality Improvement Activity to Promote Interprofessional Collaboration Among Health Professions Students."  During this activity, small groups of students participated in a quality improvement project following the Plan-Do-Study-Act (PDSA) model.  Through this work, the students increased their understanding of their respective roles as well as the value that each member of the team brought to the project.  It is not difficult to imagine that these kinds of "hands on" projects could be implemented at various times throughout the curricula of health professional schools.  Moreover, guided by experienced practitioners from each discipline, the groups would design and implement projects that meaningfully contribute to the care of patients in a variety of settings.  The American College of Clinical Pharmacy has a strong policy statement regarding interprofessional education and recently published a white paper on this topic that I encourage everyone to read. - S.H.]

Simulation in Health Professional Education

By Chris Shaw, Pharm.D., PGY2 Emergency Medicine Pharmacy Resident, Johns Hopkins Hospital

Passive versus active. “Chalk and talk” versus hands-on.  Educators and theorists have suggested that active learning and learner participation produce better educational outcomes than traditional, lecture-based teaching methods. Lecture, and other forms of simple information dispersion, may still be required depending on the content area and students’ prior knowledge. However, it is not until the learner is able to apply that information to a given situation, thereby linking the theory with practice that true understanding materializes. One method that can be used to achieve this linking is through the use of simulation.

Simulation training has been used for decades in military and aeronautics training with positive results. In the realm of healthcare, surgery simulation has been well described and simulation has been used extensively to train cardiopulmonary resuscitative techniques and emergency preparedness. A simple PubMed search will retrieve thousands of results for ‘simulation training.’ Formal simulation labs as well as medical and surgical simulation fellowships have been created at some of the top medical centers around the country, including The Johns Hopkins Hospital, Duke University Medical Center, Harvard, and The Mayo Clinic. The recently formed Society for Simulation in Healthcare, which publishes a peer-reviewed journal, is a forum for scholars interested in simulation technology and techniques. Simulation in the training of health professionals seems to have cemented itself in the culture of health professional education. Why is that? I believe the answer is that as health care professionals, we are always looking for ways to continually improve our knowledge and skills, with the ultimate goal of improving patient care and outcomes.

The initial and continual training of health professionals is an important factor that contributes to this goal. Human patient simulation (HPS), or “a technique to replace or amplify real patient experiences … which evoke or replicate substantial aspects of the real world in a fully interactive manner,” is one method of active learning to help build and maintain skills. HPS is able to offer a method for putting theory into practice, while maintaining a non-threatening, safe environment for students to achieve competence through repetition.  HPS can be use to reproduce a variety of clinical scenarios. This is done with a wide margin for error as real patients are not put in harm’s way, illustrating the principle of risk minimization. For a list of additional pros and cons related to the use of medical simulation training, I refer you to a previous post on this blog.

HPS has been adopted by a number of pharmacy educators at schools and colleges of pharmacy in United States. There have been publications regarding the use of patient-simulation technology such as mannequins or computer programs to teach pharmacotherapeutics, pharmacokinetics, interdisciplinary team skills, advanced cardiac life support, and other topics in the pharmacy curriculum. The benefits of these simulations vary based upon the topic and simulation.

Does effective simulation require the use of expensive technologies? Why not use real people to simulate clinical situations? HPS can and often does utilize real humans. This may be one way for pharmacy programs to incorporate simulation into their curriculum if access to the simulation technologies is not an option.

In 1997, the World Health Organization published a report entitled “Preparing the Pharmacist of the Future: curricular development.” In this report, it was stated that as a communicator, the pharmacist “must be knowledgeable and confident while interacting with other health professionals and the public… communication skills involve verbal, non-verbal, listening, and writing skills.” How does this relate to simulation? The enhancement of communication skills through simulation is commonplace in pharmacy education.

HPS using humans in lieu of available technologies is a technique that has been adopted by many schools of pharmacy, including where I graduated, Northeastern University (NU), where we frequently use simulation for patient counseling. Actors would be brought in to serve as standardized patients, and different scenarios were put forth during class sessions. Students would be required to develop and deliver educational material, counsel the patients about their diagnoses and medication regimens, and answer questions. The questions posed were a combination of what had been prepared by the facilitators of the course and provided to the actors, as well as questions the actors improvised.  This added another level of complexity to the interaction. Simulation exposed us to different scenarios, enhanced our critical thinking, and provided an opportunity to practice the management of a patient encounter.  An advanced understanding of and ability to apply all the material involved in real-time was required. But most importantly, it was a way for us to link our didactic education with practice, prior to actually stepping foot in a real practice environment during clinical rotations.

Further exploration of a variety of simulation techniques should be promoted in pharmacy education. The study of both technology and human-based simulations should evolve, with the ultimate goal of producing and identifying methods to most effectively prepare tomorrow’s pharmacy professionals. Although I’ve had only  limited personal experience with simulation training, I felt much more comfortable and confident going into the “real” clinical setting. It was still a scary prospect going in out on rotations, but it was made exponentially easier as I had my prior experiences built through simulation to fall back on.

McGahie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research. Med Educ. 2010; 44: 50-63.

Schiavenato M. Reevaluating simulation in nursing education: beyond the human patient simulator. J Nurs Educ. 2009; 48(7): 388-394.

Mesquita AR, Lyra Jr DP, Brito GC, Balisa-Rocha BJ, Aguiar PM, Neto ACA. Developing communication skills in pharmacy: a systematic review of the use of simulated patient methods. Patient Educ Couns. 2010; 78: 143-148.

Haidar E. Clinical simulation: a better way of learning? Nurs Manag. 2009; 16(5): 22-23.

Learning Through Teaching

By Rachel M. Kruer, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

As pharmacy students and residents we often wonder why we are required to give frequent presentations and lead numerous topic discussions.  I have found myself wondering why it is that I am presenting a topic to my preceptor on subject matter for which she is viewed as the house-wide expert.  She obviously already knows the material.  For example, why lead a topic discussion on rapid sequence intubation to an audience of emergency department pharmacists?  Then it hit me!  After reading the material, I had a basic understanding of the mechanisms of pre-induction and induction agents.  I understood the kinetics of neuromuscular blockers.  However, it was not until I was asked to explain the sequence of drug administration and answer questions regarding the most appropriate agents for a patient with a specific injury, that I truly understood rapid sequence intubation. 

Heidi G. Elmendorf explained this phenomena quite nicely in her essay entitled “Learning through Teaching:  A New Perspective on Entering a Discipline.”   In her essay, Elmendorf describes an introductory level biology course she taught at Georgetown University targeted to non-science majors.   During a volunteer project, one of Elmendorf’s students found herself in charge of an elementary class.  The student did a quick mental scan for topics she could present to these children that would peak their interest.  In Elmendorf’s course, the student had been learning about childhood vaccinations, so she decided to lead a discussion with the elementary class on the basic scientific principles of vaccines and their use.  While teaching the subject matter she had recently learned, the student became more engaged in the material of her biology course.  When returning to Elmendorf’s course, she asked thoughtful questions so that she would be better prepared to answer the questions of others, including her elementary class students.  Elmendorf writes of her student, “Her experience spoke to the educational power of the intersection between the metacognitive engagement stimulated by the creative construction of knowledge and the affective impact of communicating that knowledge to a group eager to learn.”¹    

The essay reminds us of a supposition previously proposed by David Perkins, that learning facts is not equivalent to learning for understanding.²  Elmendorf describes a three-fold theory of understanding.  The first step is basal understanding of fundamentals. Next is structured understanding of the organization of ideas into a larger conceptual framework and how ideas from other disciplines are connected.  The final step is translational understanding in which the learner is able to move fluidly between organizational levels of information.  It is not until the third step is reached that one becomes fluent in a content area.  These steps in understanding correlate with the educational theories discussed in our course.  Behaviorists help us to understand the formation of a solid foundation of knowledge, while constructivists describe the mechanisms by which knowledge is internalized and organized.

Elmendorf believes that by teaching, students re-learn basic concepts in a way that deepens previous superficial understanding.  Learning through teaching has certainly been helpful in my practice thus far.  I often feel that my knowledge of a topic is superficial at best, until I really dig in and prepare a presentation or topic discussion in such a manner that I feel comfortable (well, as comfortable as possible) answering questions from the content experts.  It seems as though this concept of teaching through learning is used widely in the development of pharmacy residents.  It is also employed when we counsel patients.  We often ask patients to repeat back how they are going to take a given medication.  This model may be further utilized by asking patients to teach us how to take a medication, or use an inhaler, for example. 

Additionally, this model could be explored to a greater extent in formal pharmacy education.  Students are often asked to prepare presentations and topic discussions during their experiential rotations, however, this model could prove to be beneficial as a part of didactic teaching and learning.  Perhaps students would have a deeper knowledge of disease states after being required to teach the topic to others, whether that be students or content experts, prior to going on advanced experiential rotations.   The take home message from the Elmendorf essay reveals “that casting students in the role of teacher is a remarkably powerful way of making visible, to both the students and their instructors, some invisible shortcomings of traditional educational approaches.”

1. Elmendorf, Heidi G. “Learning Through Teaching: A New Perspective on Entering a Discipline”, Change: The Magazine of Higher Learning 2006; 38: 6, 36 — 41.

2. Perkins, David, “What is Understanding,” in Teaching for Understanding: Linking Research with Practice, M. Wiske, ed., San Francisco: Jossey-Bass, 1997.

[Editor's Commentary:  Research has shown that deep learning is facilitated when the learner articulates and expresses his / her understanding of the material.  This can be accomplished through writing about the subject, answering questions about the subject, or giving an oral presentation about the subject.  Teaching others typically requires the learner to do all three.  It is through these forms of expression - by explaining one's thoughts -  that a learner begins to solidify mental schema, organizational structures, and inter-relationships with prior knowledge.  Teaching requires thoughtful preparation.  The learner has to decide what information is most critical to convey, how to organize and sequence the material, as well as create visuals (or stories or analogies) that convey important concepts.  Moreover, teaching is a public activity - one that has potential consequences for those being taught.  So the incentives are strong and the stakes are high.  A learner who is teaching others is highly motivated to do a "good job" explaining the material.  The old adage "see one, do one, teach one" rings true.  So rather than giving your students a dull lecture on some topic ... ask them to teach you instead! - S.H.]

Engaging the Whole Mind

by Samantha Lee, Pharm.D., Clinical Toxicology Fellow, Maryland Poison Center/University of Maryland School of Pharmacy

Let’s begin with a simple exercise.  It doesn’t require a calculator to solve a kinetics problem or a reference book to look up a drug fact.  This only requires one thing: your brain.  Actually, the right side of your brain.  See that cartoon on the left side of the page?  Your task is to come up with a humorous caption to go with it.  Easy, right?

by Leo Cullum
Published in The New Yorker 8/21/2006
Available from the Cartoon Bank

This may seem like a fun activity that a middle school student might do, but it’s really a sample test question created for the Rainbow Project at Yale University.  As part of the project, they are developing an alternative scholastic aptitude test (SAT) designed to measure whole-minded abilities.  Concepts such as the Rainbow Project stemmed from the question: is our education system designed to help students to think creatively and express their true aptitudes, or are we just preparing them to survive rounds of multiple-choice exams that may not truly capture what they know and have learned?  Do we only place emphasis on standardization, routine performance and compliance?

In his book entitled A Whole New Mind: Why Right-Brainers Will Rule the Future, author Daniel Pink makes a case for the end of the “left-brain” era with a transition to the “Conceptual Age,” where the right brainers will flourish with their highly valued traits such as creativity, imagination and innovation.  While left brain thinkers have thrived over the past several decades in the Information Age, the once dominating traits of logics, functions, and linearity are no longer sufficient to meet the demands of a new world that values a more holistic and empathic big-picture view. 

Pink recognizes three factors that are causing this shift in change and which will impact the nature of our future employment: Asia (can jobs be done cheaper overseas?  We are seeing this in medical practice, such as radiology), Automation (can a computer do it faster?  We are definitely seeing automation in pharmacy with the use of robotics.  We don't have robot teachers . . . yet.) and Abundance (The world is awash in plentiful and cheap material goods.  Are we overloading the workforce with an abundance of pharmacy graduates as more schools are opening?)

Now the author isn’t saying we should only care about right brain thinking and let’s ditch the left, but rather it should be using both hemispheres of the brain to successfully navigate through this new era.  How can we capitalize on “r-directed thinking” in our classrooms?  Daniel Pink introduces his “six senses” to help develop the whole mind needed to meet the demands of the future.

1.     Not just function but also DESIGN – Function and significance should balance.  Basically, we want things that work, but it’s even better to have functional things that are pretty and engaging to the eyes.  For educators, this can be seen in the way we present our content - are we focusing solely on the content or can we balance it with an attractive presentation that would capture the students’ attention? 

2.     Not just argument but also STORY – Communication is as important as the story that it is told through.  Our minds gravitate better toward stories since many of our experiences and knowledge can be told through a narrative.  When I was in my third year of pharmacy school, I had to create a digital story to tell my leadership story by using video, pictures, music and audio. 

3.     Not just focus but also SYMPHONY – This is the ability to put the pieces together, connect the relationships and see the big picture.  In healthcare, it’s all about the symphonic interaction of the different professionals-the pharmacists working with the physicians, nurses and other staff ... and let's not forget THE PATIENT.   Many programs are now integrating interprofessional coursework into their curricula to ensure graduates are capable of working together ... and seeing the big picture.

4.     Not just logic but also EMPATHY – We all know this one. It’s the ability to put yourself in someone else’s shoes.  It’s essential for healthcare professionals to not just look at patient’s vitals, drug regimen, and physical exam, but get to understand the whole person.  How can we do this in pharmacy school?  As educators, are we exposing the students to activities and interactions that will bring out the humanistic side?

5.     Not just seriousness but also PLAY – “When you are playing, you are activating the right side of your brain.  The logical brain is a limited brain.  The right side is unlimited.  You can be anything you want.”  Using games as learning activities is one way for an educator to add the fun to learning.  Learning is about the content, but playing while learning is soul food for the brain. 

6.     Not just accumulation but also MEANING – “Man’s main concern is not to gain pleasure or to avoid pain but rather to see a meaning in his life.”  Educating students is an opportunity to make a difference in the world.  We can impact those students ... and our students impact patients.  We need to help students connect with the meaning of our work as pharmacists - not just the content.

As Dr. Seuss once said, “Think left and think right and think low and think high.  Oh, the thinks you can think up if only you try!”  As we embark on our path to academia, let’s rethink what we’re doing in the classroom to develop this whole new mind. 

P.S.  What was your cartoon caption?

[Editor's Commentary:  Left-brain thinking is logical, sequential, analytical. And there is little question that you need to be pretty good at that stuff to be a pharmacist.  But I think most of us would agree that being logical, sequential, and analytical isn't sufficient.  Our right-brain thinking abilities - creativity, sensitivity to design and aesthetics, empathy, and contextual awareness - are equally important.  Perhaps MORE important today because computers and other forms of automation are able to do the logical, sequential, analytical stuff far better than we humans could ever hope to do.  But computers have not yet mastered right brain thinking.  So, its time to flex some right brain muscle.  We need to spend more time teaching our students how to be creative, think holistically, and relate to people in an authentic manner. - S.H.]

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.]