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.]

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.]