Creating a Critical Learning Environment

By Calvin J. Meaney, Pharm.D., PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

In his widely celebrated book “What the Best College Teachers Do”, Ken Bain proposes that a vital asset of an effective teacher is the ability to create a “natural critical learning environment.”¹ In this environment, a student is able to apply prior knowledge and encounter a new idea or concept.  In so doing, the student is require to critically evaluate the idea and draw conclusions based on guidance from the teacher and shaped by their own knowledge in collaboration with other students.

An atmosphere such as this would be ideal!  But many educators struggle with implementation.  Bain argues that such an environment can be created in nearly any class or discipline.  Below is a step-wise guide:

1. Ask a question

By posing an intriguing question or problem to students they will be internally motivated and feel engaged in their learning.  It demonstrates to the students that the teacher respects their autonomous thought process and has genuine interest in their assessment of the question.  Selecting a provocative or controversial topic is an effective technique to stir the pot and stimulate student participation.
 
2.  Explain the significance of the question

The context and importance of the question/problem needs to be emphasized by the teacher.  This will further motivate students.
 
3. Encourage high-order intellectual activity

Bloom’s taxonomy recognizes that evaluation, analysis, and synthesis are at the top of the cognitive pyramid.²  Engaging in these higher order activities are the goal of a critical learning environment.  Bain defines effective learning in that it makes “a sustained, substantial, and positive influence on the way a student acts, thinks, and feels”.  This is achieved through high-order intellectual activity.  This step is the “meat” of the critical learning environment and often the most difficult to achieve.  Engaging in active learning techniques is fundamental.  Michael Prince reviewed the available literature on effectiveness of active learning techniques in an engineering curriculum.³  He concluded that all modalities of active learning have proven benefits, with problem solving and cooperative activities having the largest effect size.
 
4. Facilitate the student’s ability to answer the question 

An effective critical learning environment should foster the ability of the students to draw conclusions based on evidence and prior knowledge.  The teacher needs to recognize when re-direction needs to be given students or groups by evaluating their progress through the given problem.  Key verbs are:  encourage, engage, and challenge.  Students should be motivated to make a stance and defend it. In order for a student to think critically they must feel comfortable.  The atmosphere should be non-judgmental, feedback should be constructive and consistent, and collaboration between students should be encouraged. 

5. Leave the students with a question

If the learning environment has been successful, students should leave with a thorough understanding of the topic, but should also be inquisitive about what comes next.  The “so now what?” question should be raised at the end of class to emphasize this.

 

How do we apply this to pharmacy education? 


In pharmacy education, the case-based approach appears to be the ideal mechanism by which to create a natural critical learning environment.  This student and problem-centered approach to instruction has been shown to improve critical thinking and clinical decision making.^4,5  An active learning approach to the cases facilitates the learner’s involvement and can improve participation and motivation.


From my own experience in my doctor of pharmacy program, I can recall class sessions when active, case-based learning activities created an effective critical learning environment.  My large class was divided into groups of ten students and each group was given a different case related to the same topic.  There were four questions posed for each case that were intriguing because they were open, complex, and controversial.  Each group was given time to research the case, consider the questions, and discuss their responses.  The instructor would walk around the room during the small-group research/discussion period to foster critical thinking by asking additional questions, providing guidance in a non-judgmental fashion, and giving feedback on preliminary answers.  Later, each group presented the case, questions, and answers to the whole class.  As each group presented their case, the questions were displayed on the screen so that the other groups could consider what their own responses might be.  The group would then present their responses, justifications, and defend them if questioned by other groups or the teacher.  At the end of each session, students were asked to write on an index card two things that they learned and two unanswered questions.


This method incorporates all 5 steps outlined in best practices for creating a critical learning environment and was, in my opinion, a very effective teaching strategy.  Indeed, the performance of the students on the exam we took after this session was one of the highest during our entire four-year program.

References

1.  Bain K. What the Best College Teachers Do. Cambridge, Massachusetts: Harvard University Press; 2004.

2.  Bloom B, Engelhart M, Furst E, Hill W, Krathwohl D. Taxonomy of educational objectives: the classification of educational goals. In: Green, editor. Handbook I: Cognitive Domain. New York: Longmans; 1956.

3.  Prince M. Does Active Learning Work? A Review of the Research. Journal of Engineering Education 2004;93:223-31.

4.  Fisher RC. The Potential for Problem-Based Learning in Pharmacy Education: A Clinical Therapeutics Course in Diabetes. Am J Pharm Educ 1994;58:183-9.

5.  Cisneros RM, Salisbury-Glennon JD, Anderson-Harper HM. Status of Problem-Based Learning Research in Pharmacy Education: A Call for Future Research. Am J Pharm Educ 2002;66.

Professionalism: An Important Lesson

by Brandon Shank, Pharm.D., PGY-1 Pharmacy Practice Resident, The Johns Hopkins Hospital

When I entered pharmacy school, the concept of professionalism was presented early in my program.  I distinctly remember reciting the Oath of a Pharmacist at my white coat ceremony.  However, at that time, I did not fully understand the importance of professionalism or the skills needed to behave as a professional. The American Pharmaceutical Association Academy of Students of Pharmacy (APhA-ASP) and the American Association of Colleges of Pharmacy Council of Deans (AACP-COD) Task Force on Professionalism defined professionalism as the demonstration of the traits of a professional.¹ The American Board of Internal Medicine describe professionalism as the commitment to the highest standards of excellence in the practice of medicine and in the generation and dissemination of knowledge, sustain the interests and welfare of patients, and the responsiveness to the health needs of society.²

The Ten Traits of a Professional according to APhA-ASP and AACP-COD are:¹

1.     Knowledge and skills of the profession

2.     Commitment to self-improvement of skills and knowledge

3.     Service orientation

4.     Pride in the profession

5.     Covenantal relationship with client

6.     Creativity and innovation

7.     Conscience and trustworthiness

8.     Accountability for his or her work

9.     Ethically sound decision making

10.  Leadership

When teaching professionalism, it is essential that educators lead by example. Faculty should act in a manner that exemplifies professionalism and creates an environment in which students can effectively learn. A systematic approach to teaching professionalism should be implemented.  Having students set goals and objectives as well as tracking and assessing progress are important steps to fostering a student’s development as a professional. Expectations should be established early on in the pharmacy program. Opportunities for students to learn and practice professionalism should be made available. Such opportunities may include professional organizations, Introductory Pharmacy Practice Experiences (IPPEs), Advanced Pharmacy Practice Experiences (APPEs), community service, and work experience.

Assessing a student’s professionalism can be challenging.  Dr. Chisholm and colleagues developed a pharmacy professionalism self-assessment instrument.³  Their 18-item instrument assesses six tenets: excellence, respect for others, altruism, duty, accountability, and honor/integrity. The authors compared the professionalism of first year pharmacy students with recent graduates. There were no differences between the two groups.  Another study found that professionalism measured by this instrument was greatest during the first and fourth professional years of pharmacy school.⁴  Therefore, widely implementing this tool may have limited utility for the purpose of monitoring an individual student’s growth. Preceptor or faculty evaluation offers another avenue for evaluating professionalism in didactic and experimental components of a pharmacy curriculum. However, the opinion of faculty and preceptors can be subjective.  Thus further research is needed to develop objective evaluation methods. At the present time, preceptor and faculty facilitated discussions and formative feedback is the most appropriate way to teach and assess professionalism until validated tools are created.

Professionalism remains a core element of a pharmacy student’s education. More research is needed regarding the effectiveness of various methods to develop student’s professionalism skills. Patient interaction throughout the curriculum, in the form of IPPEs and APPEs, will aid in fostering professionalism traits beyond what can be learned in the classroom. Schools of pharmacy should strategically integrate, assess, and track students’ professionalism.

References

1.     American Pharmaceutical Association Academy of Students of Pharmacy and American Association of Colleges of Pharmacy, Council of Deans Task Force on Professionalism. White Paper on Pharmacy Student Professionalism [Internet]. 1999 July 1 [cited 2011 Oct 2]

2.     American Board of Internal Medicine, Committees on Evaluation of Clinical Competence and Clinical Competence and Communication Programs. Project Professionalism [Internet]. Philadelphia, (PA): American Board of Internal Medicine; 1995 [updated 2001; cited 2011 Oct 2]

3.     Chisholm MA, Cobb H, Duke L, McDuffie C, Kennedy WK.  Development of an Instrument to Measure Professionalism. Am J Pharm Educ. 2006;70(4):1-6.

4.     Duke LJ, Kennedy WK, McDuffie C, Miller M, Sheffield M, Chisholm M. Student attitudes, values, and beliefs regarding professionalism. Am J Pharm Educ. 2005;69:1-11.

Grades! Do They Help or Hinder Learning?

By Jennifer Yen, Pharm.D., PGY-1 Pharmacy Practice Resident, The Johns Hopkins Hospital

Students are taught to value grades at a young age.  Even from something as simple as a gold star to the A+, grades are viewed as an indicator of how knowledgeable one is on a topic.  But are grades really a good proxy for learning?   Grades do not necessarily reflect the knowledge a student has gained and may actually impede learning if a student is single-mindedly focused on achieving that A+. Grades might be necessary in order to efficiently classify a student’s progress; however, there is a fine balance between earning a grade and acquiring the knowledge.

Grades are traditionally seen as “the sticks and carrots of a classroom,¹” which makes them nearly impossible to discard.  Many people believe that assigning grades cultivates self discipline and motivation, driving students to achieve higher marks because they either see them as rewards or as a sign of failure.¹ However, grades are an extrinsic satisfaction: when the grades no longer matter then the motivation disappears. Students who are more intrinsically motivated are more invested in the outcome of their learning. For example, students who are expected to teach the material they learn may have an intrinsic motivation to understand the material. Having students actively engaged increases their focus on higher-level learning.¹ According to a review by Lowman¹ regarding motivational strategies, a way to de-emphasize grades is to avoid using them to penalize students. Instead, he suggested using formative feedback, having ungraded assignments, and stressing personal satisfaction. However this might not always be feasible or practical in a setting with a larger number of students. With a large class of students there would not be enough time or resources for a teacher to give everyone this kind of individual attention.

Another approach is to adopt a pass-fail system.  This system is often used by medical schools and in some pharmacy curriculum as well. A pass-fail system de-emphasizes grades, removing the external motivation for students to strive for that A+.  In theory, it encourages students to study to satisfy their intellectual curiosity. Gold and his colleagues² studied college students who took all of their courses or one course on a pass-fail basis too determine how it affected their academic performance. Their findings showed that students who took at least one course on a pass-fail basis versus those who took all of their courses for a letter grade, tended to get significantly lower grades after returning to a letter-grade course.  While the results suggest that students may be harmed by pass-fail courses, it is not clear that the students in this student learned how learn for the sake of learning rather than for a grade.  Also, the study did not look into how invested these students were in their course of study or how subsequent course work related to their future professional goals.  Thus, the results may not be applicable to students who enrolled in health professional education programs.  A study done at the Mayo Clinic College of Medicine³ showed that a pass-fail grading system significantly reduced stress and increased group cohesion in medical students. These benefits arguably improve their learning and professional careers.

Students with a strong interest in learning tend to see the classroom “as a context in which they expect to encounter new information and ideas that will be both personally and professionally significant.¹” On the other hand, students with a stronger interest in grades viewed the classroom as something they had to endure “as a necessary evil”¹ to achieve their professional goals.  Traditionally, teaching is often focused around the teacher, creating an environment where the essential motivator for students is getting good or avoiding poor grades.⁴ The classroom teacher has the opportunity to change this mentality and use grades as a tool for learning rather than the ultimate goal of learning, thereby encouraging students to use their intrinsic satisfaction to drive learning.⁴

Another approach to reduce a grade-oriented mentality includes developing a closer and more trusting relationship between teachers and students by abolishing the use of a syllabus.⁴  Proponents of this strategy argued that the large number of rules outlined in a syllabus convey the teacher’s mistrust of students. Others have proposed a student-centered model of instruction.  But such models often raise concerns about resources and minimizing the teacher’s role despite their considerable experience and knowledge.  Another model that de-emphasizes grades is the senior-junior partnership.  This model emphasizes collaboration between student while acknowledging that there is a hierarchical relationship. The junior partner (student) is required to respond to the senior’s instructions (teacher) and use the opportunity to learn. However, the senior partner takes responsibility for and is committed to the success of the junior. It is believed the mutual responsibility between the two encourages learning.⁴

There are several models proposed to encourage students to learn. Though, they all have their nuances, one theme is common: to encourage a better relationship between teachers and students where each invests in mutual success. Grades are practical in the sense that they define a certain standard that must be met and easily allows others to determine the qualifications of a student or applicant. Indeed, many pharmacy schools and residency training programs have a minimum GPA requirement they use in order to narrow the number of applicants they have to interview. However, in terms of learning, grades do not seem to be necessary and can take the focus off what’s most important.  There are methods teachers can utilize to de-emphasize grades and encourage deeper learning.

References:

1.    Joseph Lowman. Promoting Motivation and Learning. College Teaching, Fall 1990,Vol. 38, No. 4  pp. 136-139.

2.   Gold RM, Reilly A, Silberman R, Lehr R. Academic Achievement Declines under Pass-Fail Grading. The Journal of Experimental Education, Vol. 39, No. 3 (Spring, 1971), pp. 17-21.

3.    Rohe DE, et al. The Benefits of Pass-Fail Grading on Stress, Mood, and Group Cohesion in Medical Students. Mayo Clin Proc. November 2006 81(11):1443-1448.

4.    Farias G, Farias CM, Fairfield KD. Teacher as Judge or Partner: The Dilemma of Grades Versus Learning. Journal of Education for Business. 2010. 85:6, 336-342.  

Learning in a Digital World

by Michelle Then, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland School of Pharmacy

I still remember my high school days when the back-to-school list consisted of pens, pencils, and notebooks.  But my back-to-school list for pharmacy school consisted of a laptop and a list of operating system and software requirements.  All of this seemed like a bogus language to me. When I came to class the first few days, I brought a pen and notebook and left the laptop at home, not realizing that the professors expected us to follow the slides and even do real time polls using my laptop during their lectures. This was my first dose of technology in the classroom.

According to a recent New York Times article about technology in the classroom, questions have been raised as to whether the use of technology helps to increase learning and a student’s understanding of concepts.¹  Proponents argue that this technological upgrade for classrooms is inevitable, but that’s a good thing because “digital devices let students learn at their own pace, teach skills needed in a modern economy, and hold the attention of a generation weaned on gadgets.”  Opponents believe that, “absent clear proof, schools are being motivated by a blind faith in technology and an overemphasis on digital skills — like using PowerPoint and multimedia tools — at the expense of math, reading, and writing fundamentals.”  Technology advocates, the opponent say, have it backward – acquiring new technology first and asking questions later.  Indeed, opponents contend there is no strong data to show that technology in the classroom improves learning.

In the Kyrene, Arizona, the school district made a big investment in a futuristic vision of technology in the classroom with laptops and big interactive screens. However, since 2005, reading and math scores have stagnated in Kyrene, even though statewide scores have increased. “But to many education experts, something is not adding up — here and across the country. In a nutshell: schools are spending billions on technology, even as they cut budgets and lay off teachers, with little proof that this approach is improving basic learning.”¹

The NY Times article explains how the concept of technology in the classroom is continuously “sold” to educators. This is evident by the science and technology committee assembled by President Clinton that urged schools to equip themselves with technology without evidence of benefit. It also talks about how the role of a teacher in this environment is becoming less of a teaching entity and more of a guide or facilitator to the technology.

I think this article brings up a lot of great points to play devil’s advocate in our technologically advancing world and is relevant to our course since we are learning in a virtual classroom. As a future educator and a past student who lived through an era of technology conversion, I can definitely see the pros and cons of technology.   Technology is constantly evolving and as users, we must constantly keep up with it.  Going through pharmacy school at the University of Maryland, I was part of the first class with a new satellite campus (Shady Grove) and all the technology delivering the curriculum to two physically separated groups of students entailed. Just like our Educational Theory and Practice class, we had live, synchronous and asynchronous classes. However, the technology didn’t always work as planned - many lectures started late or were interrupted because of technology glitches. Even in this class, we have experienced several difficulties related to the technology.

On the other hand, the convenience of being able to participate from different locations increases access. I also love the utility of Powerpoint and Blackboard for our coursework because it makes note taking and reviewing lecture materials simpler.

The use of technology may not have enough data to support its benefit in learning, but as future educators we can develop ways to gain from it and use it as a teaching assistant, instead of allowing it to become the teacher. An ABC Nightline piece entitled “The $50 Billion Gamble: Will computers improve public school education” highlighted a school with improved student performance, but “the 20 million dollars worth of technology had little to do with the school's improvement. Rather it was an old fashioned commitment to hiring, developing and providing necessary resources for teachers that was the source of the student success.”²  This highlights the importance of having quality teachers as a priority over spending money on more technology.

References

1.  Richtel, M. Grading the Digital School: In Classroom of Future, Stagnant Scores. The New York Times. 2011 Sept 4: Sect. A1.

2.  Ahern T. Will Technology Really Change Education? From Blackboard to Web. Teachers College Record. 2001 Nov 1;103:136-138

3.  Major CH. Do Virtual Professors Dream of Electronic Students? University Faculty Experiences with Online Distance Education. Teachers College Record. 2010 Nov 8;112:2154-2208.

Responsibility: Can it be Taught?

By: Emeri D. Potter, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, VA Maryland Health Care System

This past June, towards the end of my PGY1 Pharmacy Practice Residency, I had an administrative rotation at the Veterans Affairs (VA) Central Office. My preceptor posed a question to me: “Can you teach pharmacists accountability and responsibility?” My preceptor told me it would not be an easy question to answer.

I wondered, “What exactly is responsibility in pharmacy?” A responsibility is a duty for which you can be held liable.¹  Although the willingness to accept a responsibility ultimately resides within the individual, it does not alter the expectation.  Nonetheless, although responsibility exists, it can be a challenge to teach someone to feel responsible.  Pharmacy has changed in the last few decades.  Rather than concentrating primarily on chemistry, compounding, and dispensing, pharmacy now takes a more patient-centered approach.  Pharmacists today have a new set of responsibilities, in addition to the traditional ones.  As the profession is becoming more “patient-centered”, pharmacists make decisions and recommendations to improve patient care in addition to dispensing.  Some pharmacists may not feel comfortable in this new role depending on their training.  The management of patients requires us to consider what is optimal for the patient in terms of adherence, cost, and quality of life as well as what’s recommended by various practice guidelines.

After a comprehensive search, I did not find any data or research regarding how to teach responsibility to pharmacists. However, I did find a useful review that offers guidance on teaching responsibility to medical students.²  I believe this review can be extrapolated to pharmacy training.  Here are some of the best practices that are discussed in the article.   First, educational objectives relating to professional responsibilities should be included in each year of the pharmacy curriculum. It should be longitudinal, rather than a single elective or course.  Responsibilities can be taught in didactic format but, second, should also be taught during practice-based experiences.  For instance, a pharmacy student can be taught in a lecture about the responsibilities of a pharmacist in a hypertension clinic. This can be reinforced during an experiential rotation and/or health fair, where the student has to take and record blood pressures, and provide medication counseling.  The connection between both the didactic and professional experiences should be clear to both the faculty and students.  Evaluations by students and faculty are a key part of gauging whether the connection between didactic and experiential learning have been made.²

In pharmacy school, I listened to lectures and took exams relating to pharmacy laws, morals, and ethics. However, ”what students learn is not confined to what they learn in the classroom setting.”¹ These topics were reinforced during my pharmacy practice experiences in school, where I believe social learning and constructivism were the most common educational themes.  In addition, group discussions and class debates about topics such as Plan B were also helpful.  I learned a lot about myself and how to handle sensitive situations.  At the conclusion of these exercises, the faculty and students debriefed, exchanging feedback and evaluations.  I realize now that the process of accepting new responsibilities did not end at the conclusion of pharmacy school and will continue throughout my career.

I feel that I have learned more about responsibility since starting my PGY2 Ambulatory Care Pharmacy Residency.  As a student and a PGY1 resident, I did a lot of observing.  I was more passive.  In my PGY2 residency, I am expected to order laboratory tests and recommend changes in drug therapy.  I must take full responsibility for my actions based on the results.  In the past, when I made recommendations to practitioners, the ultimate responsibility was still theirs.

As pharmacy moves towards the Pharmacy Practice Model Initiative (PPMI) ³, taking responsibility will become increasingly important and it must be taught throughout the pharmacy curriculum. PPMI is an initiative from the American Society of Health-System Pharmacists (ASHP).  The goal of PPMI is to “significantly improve the health and safety of patients by capitalizing on pharmacists’ unique knowledge of the medication-use system, and professional acumen as direct patient care providers.”³ The pharmacy profession is more specialized and additional training is required to meet our new responsibilities.  Pharmacy practice is undergoing a mutation and I think everyone must be ready to adapt.

References

1.  Jacono BJ, Jacono JJ. A holistic approach to teaching responsibility and accountability. Nurse Educator. 1995;20(10):20-23.

2.  Faulkner LR, McCurdy RL. Teaching medical students social responsibility: the right thing to do. Acad Med. 2000 Apr;75(4):346-350.

3.  Hertig J. New practitioners and the pharmacy practice model initiative: our opportunity to define the future. Am J Health-Syst Pharm. 2011 Jun;15(68):1074-1076.