November 9, 2010

Pay Attention to the External Realities

by Kathleen Fuller, Pharm.D., PGY2 Pharmacotherapy Resident, University of Maryland
With the recent midterm elections, public education reform has again been the center of much media buzz. The documentary Waiting for Superman1, directed by Academy Award-winning director Davis Guggenheim, identifies some of the major problems with the current American public education system, while also offering a glimpse of possible solutions. The film highlights the success of public charter school programs including the Harlem Children Zone (HCZ)2 and the Knowledge is Power Program (KIPP)3. These programs are built on the concept that education must extend beyond the school day to correct for the external factors that influence how learning occurs in the classroom. While these programs have been developed for primary education, they offer lessons that are applicable to both adult and patient education.
The Knowledge is Power Program

"Every day KIPP students across the nation
 are proving 
that demographics do not define destiny."3
Started as single school in 1994 by Mike Feinberg and Dave Levin, the KIPP network now consists of 99 schools in underprivileged areas of 20 cities nationwide enrolling 26,000 students. The program is based on five pillars: high expectations, choice and commitment, more time, power to lead and focus on results. The programs are rigorous and both the school days and the academic years are extended. Curriculum is built around character, leadership and community involvement, as well as traditional subjects. But what may be most important, high expectations are placed on children who may otherwise not be expected to graduate high school or attend college.3
Over 85% of KIPP students enroll in college, compared to less than 40% of low-income students nationally. And 100% of KIPP 8th grade classes do better on state tests for math and language arts than their district averages.3

The Harlem Children’s Zone
"A child is more than just the test scores they get inside a classroom.
They live in families and communities. And where those families
and communities are struggling we have a responsibility
to help those children."2 – Geoffrey Canada

Recognizing that the unique struggles the children of Harlem, NY faced were contributing factors to the poor performance of the schools in that district, Geoffrey Canada founded the HCZ in 1997. The HCZ targets a 100 block area and serves over 10,000 children. Using a community based approach the program aims to "give poor children the things middle-class children take for granted".4 This includes programs that educate expectant and new mothers, pre-K programs, after school programs, fitness and nutrition education, internship placement, college preparatory programs with one-on-one counseling sessions, and public health initiatives.2

One of the public health initiatives provided free asthma screening in the HCZ and then deployed case managers to visit the homes of children identified as having asthma to educate on medical assistance programs and environmental trigger control. Counselors went as far as to assist tenants in contacting the building managers of apartment buildings to demand necessary repairs and rodent extermination.5 Far-reaching, all-encompassing interventions, such as this, characterize the work of the HCZ and impact every aspect of life for the children enrolled in this program.

An independent study compared winners of the HCZ enrollment lottery to those that entered the lottery but did not win. They concluded that "the effects in middle school are enough to reverse the black-white achievement gap in mathematics."6

Application to Adult and Health Education

While adult learners may not be as impressionable as the students targeted by the HCZ and KIPP programs, external factors certainly impact their educational performance.  The theories applied in these programs can be extended to adult education.
How many of the students in your program are the primary caregiver for children or parents? How many have jobs outside of your program? How many do not have the technological literacy or access to the technology necessary for your program? Ask adult learners to reflect on their experiences to identify perceived barriers to achievement.
Develop a technology primer course. Distribute literature regarding child or elder care services in your area. Create flexible deadlines that can accommodate rigorous work schedules. And finally the strategies need to be implemented and assessed.
The principles are even more important when educating patients. Patients present from tremendously varied backgrounds and living situations. It may be easy to tell your patient with heart failure to avoid prepackaged foods with high salt content. But it is harder to walk down the aisles at the discount grocery store and find such foods in the same price range. As the HCZ asthma program illustrates, educating patients to recognize environmental triggers is different than walking through their homes and coaching them on strategies to realistically modify these triggers.
While you or I may not be in a position to implement the types of sweeping change we have seen from Geoffrey Canada, Mike Feinberg and Dave Levin, each of us can start small by analyzing the students and patients we teach to identify how their external lives affect our educational efforts.

1. Guggenheim D (director). Waiting for Superman [Movie]. Paramount Pictures; 2010.
2. Harlem Children’s Zone [Internet]. New York (NY): Harlem Children’s Zone. Updated 2009.
3. Knowledge is Power Program [Internet]. San Francisco (CA): KIPP Foundation.
4. Sayles M. Geoffrey Canada [Internet]. New York (NY): The New York Times; 2010 Oct 12.
5. Perez-Pena R. An Everyday Struggle for Breath; Childhood Asthma Project Reaches out in Harlem. New York (NY): The New York Times; 2003 May 1.
6. Whitehurst GJ, Croft M. The Harlem Children’s Zone, Promise Neighborhoods and the Broader, Bolder Approach to Education. Washington (DC): The Brookings Institution; 2010 Jul 20.

November 4, 2010

Inspiring Students - My Path Towards Nuclear Pharmacy

by Amber Mae Todd, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy
If someone had told me in my first year of school that I was going to choose nuclear pharmacy for my career, I would not have believed them. I would have never guessed that I would spend the next two summers learning how to elute technetium from a generator at 2 am, or discussing the properties of medronate while watching the sunrise. What could have happened that changed my perspective so much. I went from having no clue about where I wanted to go, to falling in love with any drug that sets off a Geiger counter. There had to be one very inspiring teacher in my life for this to transpire.

I have often wondered what qualities an inspiring teacher possesses. What does it take to inspire a student? One study by van der Zee and de Jung entitled “Teachers as a Source of Inspiration in Catholic Schools”, defines inspiration in the following way:
inspiration may be regarded as mental causation of perlocutionary effects that, through the outstanding qualities of the source of inspiration, may motivate people, on the basis of suitable aptitudes, to have certain thoughts and desires and to perform certain actions.1
In other words, inspiring teachers, using the special qualities that they possess, can change the actions and perceptions of their student(s). In my opinion, this is the definition of what it means to teach. A teacher should always leave a lasting impression on their students' perceptions. I believe the student should walk away from the experience changed in some positive and profound way. It was certainly the case for me; I was never the same after crossing paths with my teacher.
What qualities make a teacher inspiring? Certainly enthusiasm, patience, empathy, and the ability to explain a subject proficiently are important qualities.1  van der Zee and Jung describe the teacher as a leader. They contend that a teacher must inspire their students in the same way a leader of an organization would inspire their followers.  Some of the leadership qualities that they point out include: vision, charisma, promoting intellectual stimulation (challenging a student), and being a role model. I do not believe a teacher must have all these attributes to inspire. However, having a few of these characteristics are probably necessary. In my case, my teacher was enthusiastic, patient, and proficient at explaining details. He challenged me and he was an excellent role model. His enthusiasm helped me to see the significance and life-changing nature of every radiopharmaceutical we made.
There are other factors that can affect the inspiration process. In Barbara Davis’ chapter entitled “Motivating Students” in the book Tools for Teaching, she points out several classroom strategies that can help motivate learning and inspire students.2 These include: making students active participants in learning, hold high but realistic expectations of your students, help students set goals for themselves, and explaining to students what they need to do to succeed.  These methods can help boost student confidence and help students to begin working and thinking independently.
My teacher inspired me. His proficiency at explaining concepts was amazing; this included his patience in repeating points where I was confused. A teacher who can explain things clearly is easier to follow. This will provide a greater understanding that leads to confidence and the ability to complete tasks successfully. Challenging a student can help increase that student’s confidence, as well as teach them to “work outside the box.” Challenges can show them that they can apply their understanding to new and stressful situations.  Lastly, my teacher was a role model.  The purpose of a role model is “to trigger a thought, an assurance, a vision, a character and a way of life, which can serve as the impetus for a students' personal and professional growth.”3 My teacher did that.  He showed me night after night what a great nuclear pharmacist could look like. It’s an image I took to heart.
It is no small thing to change a student’s perceptions.  Often, an inspired student will remember the lessons the teacher bestowed on them for the rest of his/her life. It takes a unique set of attributes to inspire someone.  I was lucky to find a teacher who had so many of them. He inspired me to take the path to nuclear pharmacy. When we become teachers, we must try to inspire our students … and change the path they take in their lives.
Sources:
1. van der Zee T, de Jong A. Teachers as a source of inspiration in catholic schools. Journal of Empirical Theology 2009 06;22(1):7-29. 
2. Gross Davis Barbara. Tools for Teaching. Hoboken: Joey-Bass, An Imprint of Wiley. c1999. Motivating Students.
3. Meetu. Teachers as Role Models. [Internet] BrightHub. 2010 Apr 5. [cited 2010 Oct 29] Available from: http://www.brighthub.com/education/special/articles/17266.aspx

November 3, 2010

Application of the Socratic Method in Health Professionals Education

by Stacy Elder, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

The Socratic Method is a widely used term for teaching via question and answer dialogue between a teacher and a student. However, the Socratic Method has undergone many changes since its first documentation by Plato, a student of Socrates.  Health professional instructors frequently employ various forms of this style of teaching in order to explore the critical thinking of their students and trainees. Analysis of the Socratic Method in the healthcare setting is a prime example of the evolution and contemporary utility of this mode of teaching.

The classic Socratic Method involves dismantling prior ideas in order to free the mind to think about a topic without the constraints of preconceived notions. By definition, this method deconstructs all prior thoughts on a topic and leaves the learner without a satisfactory answer to the primary question. Socrates taught that the only person who cannot learn, is the person who thinks he already knows the answer, so it is logical to remove prior beliefs in order to make way for the creation of new ideas. An example of the classic Socratic Method is observed in Meno, where Socrates asks Meno to define virtue. They discovered that they could not define virtue and, furthermore, virtue could not be taught. Meno learned that even this common term, when broken down to its fundamental parts, was actually not definable. As you might imagine, it was an Earth-shattering revelation for Meno to realize that it was impossible to trust even the most basic beliefs. The abolishment of prior beliefs on a subject is the deconstructive phase of the Socratic Method.

Once the student’s mind is freed from the constraints of prior beliefs, the teacher is free to bring forth new ideas during the constructive phase.  Notably, the teacher’s role in this scenario is to help the student clear away previous ideas in the deconstructive phase so that he may build new ideas in the constructive phase. Socrates stressed the importance of humility on the part of the teacher, due to the need to create a safe environment for the student to have these revelations. He believed that the teacher served to help the student do his own learning and asking questions was his method to facilitate that goal.
The classic definition of the Socratic Method is not always practical for teaching health professionals.  After the abolishment of the definition of virtue during Meno’s lesson with Socrates, Meno suggested a paradox that no one could ever question anything if definitions are impossible. Science, in general, does not accept the impossibility of defined answers, making the classic Socratic Method incompatible with the field of science. Also, healthcare does not generally involve discussion of abstract ideas. Established definitions of terms used to describe conditions and disease states are a critical part of healthcare learning. Standard, well-accepted “truths” in medicine make it possible to advance patient care by using the outcomes from research in a specific subset of patients in order to apply the highest level of decision making to patient care. However, the Socratic Method is still utilized in healthcare teaching, in a modified form.

The modern Socratic Method differs from the classic method by establishing that knowledge is recollection. Another of Socrates’ theories was that a student can only learn that which he already knows. Therefore, the teacher’s role is to facilitate the production of a constant progression of defined knowledge from the students pre-existing stores. In general, the teacher asks direct questions that have a predefined range of answers, allowing the student to answer correctly before moving on to the next step in the construction of an idea. If the student is unable to answer the question at hand, the teacher is responsible for guiding the student to a point where he/she can conquer the question.  This is accomplished by helping in the student/trainee recollection prior knowledge required to answer the question.  The modern Socratic Method is compatible with the training of health professionals, and it remains within the scope of Socrates’ belief that a student can only learn things that he already knows.

Using the Socratic Method is more than asking a lot of questions. In contrast to “pimping,” the Socratic Method requires the teacher to create a nurturing environment and ask helpful questions to achieve the desired lessons for the student.  Teachers must recognize that these probing questions can expose ignorance … and this can invoke fear in the student.  But Socrates described the role of the teacher as similar to a midwife, in that they facilitate by clearing the way for the student to bring forth new knowledge without intimidation. In any setting, finding the balance between using progressive questions to provoke deep thought while maintaining a comfortable environment for learning is the key to using the Socratic Method of teaching.

References
2    Fritts, HW. Are We Socratic Teachers? Trans Am Clin Climatol Assoc 1979;90:109–115.
3    Gordon, LA. Is the Socratic Method Illegal? Am Surg 2003;69:181-182.

October 21, 2010

I Finally Earned My Doctorate!!! Wait…Can I Find a Job?

by Mina Kim, Pharm.D., PGY2 Pain and Palliative Care Resident, University of Maryland School of Pharmacy
By Jeff Parker
Available from floridatoday.com
This cartoon depicts an unfortunate reality over the past 2 years.  Due to the economic recession, many graduates have found themselves without jobs or having to take positions outside of their career choices.  Many people who were employed found themselves jobless with no promising options for re-employment.  The once abundant pharmacist employment market diminished as well due to a number of factors:  1) the recession, 2) increasing number of pharmacy graduates, and 3) delayed retirements.  Just a few years ago, every pharmacy student walked across their graduation stage with a diploma in one hand and a few employment offers in the other.  Now, finding employment after graduation has become a daunting challenge due to the tight market in all fields, including pharmacy practice.
A solution that many adults have turned to during times of economic recession has been more education. With the increased competitiveness for jobs, the need for additional education to boost one’s resume and career has become a necessary measure.  An article about continuing education (post-secondary education) in the New York Times, stated that most college graduates will experience five to seven job changes during their career and thus need more education to remain competitive.   Continuing education institutions also follow the job market to create programs in fields that are growing and will have job opportunities.  Some career counselors no longer encourage adults to simply follow their passion but to take into consideration practical values such as the availability and salary of jobs when making career decisions.
When looking at the profession of pharmacy, the economy has prompted many changes.  Numerous graduating students now choose to take one or two years to complete a residency and boost their Curriculum Vitae (C.V.).  The hope is that with additional training and experience will make them more qualified/marketable and be able to obtain the position they desire.  Of note, in 2006, ACCP stated that by year 2020, a residency should be mandatory for pharmacists involved in direct patient care.  Direct patient care was defined as pharmacist’s observation of the patient and contributions to the selection, modification and monitoring of patient-specific drug therapy.  Whether or not this is feasible or necessary is a separate issue; but there is no doubt of the increasing demand for residency training – both among employers and graduating students.  As the job market remains competitive, having a residency for many clinical positions is becoming a minimum requirement.  Paradoxically, while the poor economic conditions incentivize more students and pharmacists to pursue residency training, institutions have a limited ability to increase the number of residency positions due to financial constraints.
Pharmacists who already have a position in clinical practice feel additional pressure to obtain board certification through the Board of Pharmacy Specialties.  In a recently published article by Connor et. al in the American Journal of Health System Pharmacists, the benefits of board certification include “increased therapeutics knowledge, enhanced professional and clinical opportunities…greater marketability and monetary compensation.”  Although it has not been common for pharmacists to lose their jobs in this recession, as they look towards promotions, new career opportunities, and even tenure, experience is no longer sufficient.  To supplement their C.V.s, board certification is one avenue for pharmacists to demonstrate that they have attained (and are maintaining their) advanced knowledge.
Compensation (monetary and other rewards) has always played a role in influencing career choices and goals.  The economic recession has had a key role in the encouraging continuing education.  A struggling economy serves as a stimulus for people to pursue further education to remain competitive in their profession and pharmacy is no exception.  A Pharm.D.alone is no longer enough for pharmacists to secure a satisfying position or get promoted.
I fear (and this fear is possibly shared by other residents) that all the effort, energy and time exerted into my education and training (8+ years of post-secondary education and training!) will still not be enough for me to secure my “dream job.”  But I can only keep my fingers crossed – and demonstrate that I’m qualified, ready, willing, and able to make substantial contributions.
References:
Greenhouse S.  Learning Curves on the Career Path.  The New York Times [Internet]. 2010 Aug 25  Education.  [cited 2010 Oct 17]
Connor KA, Hamilton LA.  Pursuing Board of Pharmacy Specialties Certification.  Am J Health Syst Pharm 2010;67:1146-1151.
Bright DR, Adams AJ, Black CD, Powers MF.  The Mandatory Residency Dilemma: Parallels to Historical Transitions in Pharmacy Education.  Ann Pharmacother 2010;44.  Epub  2010 Oct 5.
[Editor's Commentary:  Dr. Kim's essay expresses the fears of many graduates today - not only in pharmacy but nursing, medicine, and other health professional fields too.  While a significant shortage of health professionals remains and will continue to grow as our population ages, the short term impact of the worse economic downturn in over 75 years has had ripple effects that has impacted even the most stable areas of employment.  According to some experts the current pharmacy job market has grown tight due to two competing factors:  1) increased number of graduates (which we need to meet future demand!) and 2) a very significant delay in retirements.  In other words, people who normally would have left the workforce aren't (and this is a moral dilemma the profession must address if the over-abundance of highly qualified practitioners continues for very long).  Of course the employment prospects for Dr. Kim and her well-trained brothers and sisters is far brighter than most ... but still, its all a bit unsettling when compared to the prospects just two or three short years ago.  There is little question that medication use is more problematic (and costly) than ever and the need for caring and well-qualified professionals, like Dr. Kim, is greater than ever. However, Dr. Kim's essay points to an important adult learning principle.  Adults are motivated to learn by relevancy and applicability.  The economic downturn has made training and credentials (like residencies and board certification) more relevant and applicable!  The motivations to learn often vary at different stages of life.  In the early stages of one's career, acquiring the "right" credentials for the "dream job" is often most important.  In mid-career, the desire to expand one's skill set beyond the core professional domains is often motivated by changes in responsibility.  In the later stages of one's career, cultivating deeply personal qualities (e.g. mentoring skills, religious faith) or engaging in new pursuits (e.g. playing the fiddle, photography) begin to emerge as motivations to learn and change.  So while a recession and the poor job market may seem like it has little to do with educational theory and practice, the motivation to learn is driven by many factors.  Needless to say, the prospects of unemployment and a mountain of debt is a strong motivator!  -S.H.]

October 20, 2010

Psychological Safety - A Key Component to Students’ Motivation

by Kimberly Still, Pharm.D., PGY1 Pharmacy Practice Resident, Baltimore VA Medical Center
Have you ever had a truly stellar professor? The kind who made you feel like no question was a dumb question?  Who made you energized about the subject and confident that you would succeed? Ever had the complete opposite? A professor so intimidating and negative you’d rather bite your tongue (literally) than ask a question for fear of looking stupid? What’s the main difference between these two extreme cases? The answer: the presence/absence of psychological safety.
So what does this term mean exactly? Psychological safety basically endorses the concept that students learn better when they feel safe. Embracing this idea means creating an environment where students feel comfortable enough to acknowledge their own weaknesses, voice their gaps in knowledge, and ask for help when they need it.  The importance of this concept lies in its link to student motivation. However, in order to understand how the two are related, we must first take a look at what creates motivation.
Though there are many theories surrounding student motivation, it is pretty well summarized by the following equation from Barron and Hulleman:
1
motivation = expectancy x value
“Expectancy” in this case means the extent to which a student believes that he/she can perform a particular task. “Value” means the level of interest and degree of importance the student places on a task. Psychological safety ties into this equation in a number of ways. Creating a positive and safe learning environment can be empowering for students, giving them the confidence to take on the challenge presented to them, which translates to a high level of expectancy. Furthermore, allowing students to feel safe asking questions prevents the suppression of any innate interest they might already have for a particular topic, which helps preserve perceived value.

While most instructors are unlikely to fall into the extreme category of the negative and demeaning persona presented at the beginning of this discussion, evidence suggests that many teachers have lost sight of the importance of psychological safety, specifically as it relates to student-teacher rapport. One survey of teachers and undergraduates revealed only 7% of professors ranked rapport in the list of top 10 master teaching qualities, compared to 42% of students.
2 Another student survey by Benson, et al, examined the association of rapport with student attitudes and motivation. They found a positive relationship between rapport and many proacademic behaviors such as “attending class, paying attention during class, and studying.” When asked to identify the characteristics needed to establish rapport, among the most common responses included open-mindedness, accessibility, approachability, and concern for students.3

So how does one go about establishing a rapport and promoting psychological safety in the classroom? The possibilities are numerous. Here are just a few suggestions:
4
  • Address students by name. With a large class size this can be an arduous task, but it can go a long way with letting your students know that you care about them.
  • Set your students up for early success. Start off easy and gradually increase the level of difficulty in content. Such a strategy will help build their confidence and their comfort level with the subject.
  • Provide positive feedback early and often.
  • Avoid demeaning comments.
  • Don’t be afraid to admit “I don’t know.”  This will help increase your students’ comfort level in voicing their own gaps in knowledge.
  • Never underestimate the utility of the compliment sandwich!
  • When providing individualized negative feedback, identify with your student if possible.  At a minimum encourage him/her by expressing a sincere belief that he/she can improve (Ex. “I noticed you had some difficulty putting things into layman’s terms for the patient. I had trouble with that as well when I was first starting out. Here are some tips that I find handy… Don’t stress, I know you’ll get the hang of it, it just takes practice.”)
These suggestions may sound fairly simple, but attempting to utilize such strategies while still maintaining focus on the successful implementation of the course/rotation can be quite challenging. Nonetheless, adhering to these principles is vital in order to maintain a positive learning experience and cultivate each student’s motivation to succeed.
References:
1. Barron KE and Hulleman CS. Is there a formula to help understand and improve student motivation? Essays from e-xcellence in teaching. 2006 ;8:33-8.  [cited 2010 Oct 18]
2. Buskist W, Sikorski J, Buckley T, & Saville BK. The teaching of psychology: Essays in honor of Wilbert J. McKeachie and Charles L. Brewer. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2002. Elements of master teaching; p. 27-39.
3. Benson TA and Cohen AL. Rapport: its relation to student abilities and behaviors toward teachers and classes. Teach Psychol 2005;32:237-9. [cited 2010 Oct 18]
4. Davis BG. Tools for teaching. 2nd ed. San Francisco: Jossey-Bass; 2009. Chapter 31, Motivating Students; p. 278-87.