Problem-Based Learning in Pharmacy Education: Effective or Problematic?

by Kelly Parsons, Pharm.D., PGY1 Pharmacy Resident, Union Memorial Hospital

Problem-based learning (PBL) is a teaching strategy used among many pharmacy and medical schools that strives to teach students using realistic scenarios. The purpose behind this educational approach is to increase retention of learning by having students think independently and problem solve. There are two key features of PBL. The first feature is student-centeredness. Learning takes place in small groups and is facilitated by instructors. The second feature is problem solving.  The goal is to have students solve specific problems and thereby enhancing the skills necessary to perform well throughout the curriculum (and in life). When PBL is successfully implemented, the presentation of clinical material serves “as the stimulus for learning” and this “enables students to understand the relevance of underlying scientific knowledge and principles in clinical practice.” ¹

Many research studies have analyzed PBL and compared this teaching strategy to more traditional approaches such as a series of didactic lecture. Leslie Nii and Alfred Chin compared PBL to lecture-based instruction by randomly assigning students to these two forms of instruction during their third year of pharmacy school and assessing the mean grade point averages (GPA) of each group.²  The goal of the course was to help students acquire the skills necessary to manage patients’ drug therapy.  Faculty members served as resources for students during PBL class sessions and facilitated meaningful discussions, with emphasis on skills necessary for pharmaceutical care. Students assigned to the traditional didactic lecture group were taught via presentation-style lectures. At baseline the GPA of two groups was not statistically different during the first two years of school when all students received traditional didactic lectures.  However, there was a significant difference in GPA during the third year of school when PBL was implemented.  Students who received PBL instruction had significantly higher GPAs during fourth year rotations than students received traditional didactic instruction. This suggests that PBL gives students a set of skills that enable them to more quickly become competent and self-sufficient, and may be more effective than traditional lectures. ²

Robert Cisneros and his colleagues completed a systematic review of PBL in pharmacy education based on research articles published between 1980 and 2000.³ In their review, several examples of PBL were described including the use of PBL in an introductory pharmaceutical care course, a therapeutics course, as well as throughout the second and third years of a pharmacy curriculum.  Most examples in the systematic review incorporated PBL after students had completed introductory science courses where they received didactic instruction.  In only one case, where PBL was used in an introductory pharmaceutical care course, that students were introduced to PBL early in the pharmacy curriculum prior to receiving other forms of instruction.  The results of these studies indicated that PBL was an effective method of instruction and could be successfully implemented during any year of pharmacy education.³  Given these positive findings, it is not surprising that PBL continues to be implemented in many pharmacy school curriculums today. Pharmacy education programs have placed more emphasis on patient care and PBL is well suitable to teaching students the skills needed in practice.

When considering Grasha’s Five Teaching Styles, PBL is best matched with the facilitator teaching style.⁴ Instructors guide students through the learning process while encouraging independent thinking and responsibility.  Students are perhaps more engaged because “real life” scenarios are presented.  Students are expected to consider the “whole patient” as opposed to one specific issue.

As a recent pharmacy school graduate, I have experienced PBL first-hand during a therapeutics course.  My experience was similar to the one described by Calvin Meaney in the “Creating a Critical Learning Environment” blog.⁵  Students were divided into groups of ten and each group was given several patient case scenarios to research, identify pertinent medical problems, and develop a therapeutic strategy. This approach fostered critical thinking and was an effective teaching method when group members reviewed material prior to attending the group sessions and actively participated during scheduled class times. However, in my experience, attendance was poor at many sessions and many students worked independently on the case studies.  Thus, the opportunity to capitalize on the strengths of PBL were often lost. Many students elected to forego attending PBL sessions when exams were scheduled in close proximity. Students wanted to use the time to study. In order to overcome this problem, it’s important to schedule PBL sessions at least two or three days apart from exams to encourage student attendance. As an alternative, teachers could make attendance a requirement.  In general, I found that pharmacy students appreciated the PBL sessions and benefited from the learning experience when they were focused on the material.

PBL is an instructional method that can, should, and does play a significant role in pharmacy education.  It fosters strong critical thinking skills.  Although initial findings seem to have positive, there is need for more research to evaluate the effectiveness of PBL in pharmacy education. Challenges will arise as PBL is more frequently used, but these can be overcome as educators become more experienced in this teaching strategy.

References:

1.  Novak S, Shah S, Wilson J, Lawson K, Salzman R.  Pharmacy students’ learning styles before and after a problem-basedlearning experience.  Am J Pharm Educ  2006; 70: 1-8.

2.  Nii L, Chin A.  Comparative trial ofproblem-based learning versus didactic lectures on clerkship performance.  Am J Pharm Educ  1996: 60: 162-164.

3.  Cisneros R, Salisbury-Glennon J, Anderson-Harper H.  Status of problem-based learning research in pharmacy education:  a call for future research.  Am J Pharm Educ 2002; 66: 19-26.

4.  TeachingStyles and Instructional Uses of the World Wide Web [Internet].  Terre Haute (IN): Indiana State University; 2011.

5.   Meaney C.  Creating a critical learning environment [Internet].  Educational Theory and Practice Blog.  Baltimore (MD): University of Maryland; 2011.

Teaching Communication Skills to Pharmacy Students

by Eamonn J. Murphy, Pharm.D., PGY1 Pharmacy Practice Resident, Georgetown University Hospital 

A key concept that I learned during pharmacy school is the importance of communication.  Several classes in the pharmacy curriculum put a strong emphasis on communication.  There were therapeutics labs that incorporated one-on-one counseling of mock patients on medication adherence, side effects, and techniques for using inhalers and medical devices.  However, working with various students and teachers in lab is quite different than practicing as a pharmacist.  This practice was a great stepping stone, but it is vital that students get structured counseling and feedback while interacting with actual patients.

I recently read an article, Improving communication skills of pharmacy students through effective precepting, by McDonough and colleagues.¹ This article emphasizes the importance of students developing and practicing their communication skills during their advance pharmacy practice experiences (APPEs), especially their community-based rotation. This article brings up an interesting concept, “see one, do one, teach one”.  A pharmacy student is going to shadow a preceptor and follow their example.  Every interaction a pharmacist has on a daily basis goes back to the principles of communication, and the student will be influenced by these observations.  Whether talking to a patient, a physician, a nurse, or another pharmacist, these skills will used every day.¹ 

To help develop and teach professional communication during the APPE, it would be beneficial to students to have the preceptor introduce all staff members and their respective roles (or position) in the pharmacy.  This would be the first step in creating professional relationships in which the student would feel comfortable relaying information and asking questions to staff.¹ 

Now that I am in the fifth month of my pharmacy residency, I have had precepting experiences and I will be responsible for co-precepting P4 pharmacy students in the future.  I have been thinking about some lessons that a preceptor should teach to a student.  Even though this article by McDonough focuses on community pharmacy, several of the lessons are equally applicable in hospital pharmacy and precepting in that setting.  A pharmacist in an institutional setting should perform medication reconciliations every day and go into patient rooms to discuss new medications that have been prescribed. One style of teaching is through direct observation of a preceptor conducting medication reconciliations and discharge counseling.  While conducting medication reconciliations and discharge counseling on new medications, it would be appropriate to use the Indian Health Service questions. A pharmacy preceptor should make sure to teach these questions to their APPE student.  Before the student first observes the preceptor patient counseling, time should be spent discussing and rehearsing the Indian Health Service questions with the student. These questions focus on the patients understanding of what medications they are taking, why they are taking them, and what they can expect.

Indian Health Service questions:¹

Prime Questions to ask patients who are receiving a new prescription:

• What did your doctor tell you the medication is for?
• How did the doctor tell you to take it?
• What did the doctor tell you to expect?

Final verification or asking the patient for feedback

• Just to make sure that I didn't leave anything out, please tell me how you are going to take your medication.

Strategy when a patient is receiving a refill

• What do you take the medication for?
• How do you take it?
• What kind of problem are you having?

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As a preceptor, you could demonstrate the use of these questions in front of a student, and then have them counsel patients once they are ready. Through discussion, memorization, practice, and then observation, an APPE student can become comfortable using these Indian Health Service Questions. Other important aspects of communication that could be focused on and discussed with P4 students while precepting is using open ended questions, good eye contact, and active listening.  The responses to these open ended questions will help show what the patient truly understands about their medication and help direct a student or pharmacist toward what should be addressed.² This is especially important because, as Kripalani and colleagues state, only 12% of adults in the United States are proficient health literacy.³

Additionally, in an institutional or hospital setting it is important at the beginning of the APPE to discuss appropriate interactions with physicians. As a pharmacist, there may be several medication-related interventions that need to be communicated directly to the prescribing physician.  A preceptor should spend adequate time discussing how the APPE student should interact with a physician. One method to teaching this type of communication is for the students to write up a series of hypothetical scripts they would use during telephone calls or face-to-face interactions.  Hasan⁴ describes this method of teaching where the pharmacy students writes three scripts for telephone interaction with physicians.  The script types including: passive, aggressive, and assertive.  The purpose of this is for the student to think critically and to explore the various types of communication skills and determine which would be most effective.  Once the student writes these, a preceptor can discuss the pros and cons of each of these styles. Having a student listen to several phone calls and interactions with physicians would also be appropriate.  McDonough includes a brief list of things that should be discussed with a student.

How to Communicate Information to Physicians:¹

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• Keep patient focused
• Provide the physician with meaningful background information
• Clearly and concisely outline the problem the patient is experiencing with the drug therapy
• Propose a solution
• If face-to-face, request physician feedback regarding the solution

In order to be a pharmacist today, effective communication with patients and all members of the interprofessional team is vital.  Preceptors play an important role by helping APPE students acquire the knowledge and skills needed to be effective communicators.

References: 

1. McDonough RP, Bennet MS, et al. Community pharmacy improving communication skills of pharmacy students through effective precepting. Am J of Pharm Educ. 2006; 70 (3) Article 58. 1-12.

2. American Society of Health-System Pharmacists. ASHP guidelines on pharmacist-conducted patient education and counseling. Am J Health-Syst Pharm. 1997; 54:431–4.

3. Kripalani S, Jacobson KL, et al. Strategies to improve communication between pharmacy staff and patients: a training program for pharmacy staff. AHRQ Publication No. 07(08)-0051-1-EF. 2007

4.  Hasan S, et al. A tool to teaching communication skills to pharmacy students. Am J Pharm Educ. 2008; 15; 72(3): 67.

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Students Teaching Themselves: The Unschooling Movement

By David Ngo, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

In our traditional schooling culture, there is a belief that children must be taught how to read, and most learn how to do so at a certain pace. In addition, the children who do not stay at the school curriculum’s pace are often looked down upon, while those who read at a higher grade level are applauded.¹ However, Peter Gray, a psychology research professor at Boston College, discusses the “unschooling” movement and the Sudbury “non-school” movement.²  He claims that children can teach themselves how to read and will enjoy the process, rather than resent it like those who struggle with the conventional schooling system. The Sudbury “non-school” movement focuses on allowing the students to learn at their own pace, with no set syllabus or curriculum, among peers of various ages. Moreover, Gray summarizes the following principles:²

1)    For non-schooled children there is no critical period/best age for learning to read

2)    Motivated children can go from apparent non-reading to fluent reading very quickly.

3)    Attempts to push reading can backfire.

4)    Children learn to read when reading becomes a means to some valued end or ends.

5)    Reading, like many other skills, is learned socially through shared participation.

6)    Some children become interested in writing before reading, and they learn to read as they learn to write.

7)    There is no predictable course through which children learn to read.

Gray brings up several salient points.² For example, his seventh principle discusses how each student is different; therefore, the method and time required to learn how to read will be different. This not only applies to children, but to learners of all ages.  Everyone has a unique approach to learning. This is related to learning styles including Visual, Auditory, Reading, and Kinesthetic. Learners may dominantly learn best in a certain way or a combination of these styles. VARK and the “unschooling” movement are related because it shows that not only does everyone learn at their own pace, but also that they will learn best in their own specific way. A child may learn best visually, by associating the word with the visual image of the object; or a child may learn by hearing the word aloud and associating that with the word; or a combination of both. Through the “unschooling” method, the child will approach the parents/teachers and will learn how to read in the manner that suits them best. Therefore, the “unschooling” or Sudbury movements have implications for learning because it allow students to learn in their own way rather than following a set curriculum that forces each student to learn in one specific way.

Moreover, pushing the conventional reading method upon a child may breed resentment and disdain throughout a lifetime, doing more harm than good. Children will learn more easily and find it more enjoyable once they find their own motivation to read.  Young learners may develop the desire to read because they want to know what a video game says, to write a story, or to emulate family and friends. This is related to the educational theory known as cognitivism. Cognitivism is interested in understanding how the brain functions, how learners think, and the influences of mood, feelings, motivations, and past experiences on learning.  In Sudbury schools, children learn with other students of various ages. Gray talks about how the younger children wanted to learn to read to be like their older peers. Once a child is motivated to read, he or she can learn the skill quickly and fluently. Although unconventional, the “unschooling” movement provides some interesting insights about how best to educate young students, and these are strategies that traditional schools and teachers should incorporate.

If children are able to teach themselves to read, adult learners can successfully teach themselves as well. Self-directed learning is becoming more important particularly as online schools and degree programs are becoming more established.  And more adults are going back to school. As a Shady Grove student at the University of Maryland School of Pharmacy, I was skeptical about how I could earn a Pharm.D. primarily through distance education and web-based strategies.  I’ve seen through personal experience that “unschooling” can apply to pharmacy students.  Personal motivation plays a major role in how well students learn in a self-directed, online learning format.  Shady Grove students are able to watch lectures whenever they want — not restricted by set class times. I have seen that this works well for some and poorly for others.  It works well for students that are motivated and set their own learning schedule. I found this freedom to be great, as I learn better in the afternoon and night.  So I schedule myself to watch my lectures during the afternoon. Other adult learners with families also find this method to be great because they can take care of their family and set aside time to learn. However, some students have difficult with this level of freedom and do not do any work until an exam looms.  Under extreme pressure, they have marathon lecture sessions, binging on as much materials as possible.  This may be effective for short-term learning but this method does not work very well for long-term retention.

“Unschooling” applies to medical residents as well. A qualitative analysis regarding self-directed learning among medical residents found that they believe self-directed learning skills serve as the basis for a physician’s lifelong learning.⁴  Moreover, they found that most residents viewed self-directed learning as important to themselves and their patients.  However, most medical residents felt that they lacked the skills to engage in self-directed learning and valued teacher-centered teaching approaches. Therefore, although self-directed learning has a lot of potential, motivation is important for it to be effective.

References

1.  Anderson R. Junior Knows Best. Utne Reader. 29 Jun 2006 [cited 2011 Oct 17]

2.  Gray R. Children Teach Themselves to Read. Psychology Today [Internet]. Freedom to Learn. 24 Feb 2010 [cited 2011 Oct 17]

3.  Gray R. Nature’s Powerful Tutors; The Educative Functions of Free Play. Eye on Psi Chi. Psi Chi, The National Honor Society in Psychology. 12(1):18.

4.  Nothangle M, Anandarajah G, Goldman RE, Reis S. Struggling to Be Self-Directed: Residents' Paradoxical Beliefs About Learning. Academic Medicine. 2011 Oct 25;Published Ahead of Print.

Teach Me How to Teach

By Mallory Onisk, PGY1 Pharmacy Practice Resident, VA Maryalnd Health Care System 

How many of you took a course in pharmacy school that taught you how to be a good teacher?  I’m going to guess not many.  I know at my college of pharmacy we weren’t given any teaching tools or tips aside from what we learned by modeling our professors.  Nor were we trained on how to be a preceptor, give a lecture, engage a classroom, or evaluate students’ learning. I recently attended the ASHP Resident Visit Day where a poll was taken as to who was taught how to be a preceptor in pharmacy school.  Not a single hand in the room (fifty residents) went up.  At least I wasn’t alone.  But how are recent graduates supposed to become the future leaders of the profession when we haven’t been given the tools to educate those following us?  Unless you were fortunate enough to match to a residency program in a city that offers a teaching certificate program or a residency at a college of pharmacy, you might be on your own.  But surely there has to be a better way…

The Southern Illinois University Edwardsville (SIUE) School of Pharmacy has developed “concentrations” or tracks for their students to focus learning on career interests.  One track is an education concentration where students take 3 elective courses during the P3 year and an elective APPE in the P4 year with a teaching emphasis.¹  Drs. Poirier & Santanello describe this unique curricular concentration and evaluate its impact on students’ knowledge and attitudes in an article that recently appeared in the American Journal of Pharmaceutical Education.¹  The first course, Orientation to Teaching, explores learning theories and teaching philosophies.  Students compose their own teaching philosophy and discuss with professors what they believe constitutes teaching excellence.  The second course, Instructional Design and Strategies, highlights active learning strategies and different instructional methods.  Students take turns facilitating class discussion using these different instructional methods.  The third course, Assessment Strategies, familiarize students with various assessment strategies including learning portfolios, multiple-choice exams, and grading rubrics.  During the APPE experience, students lead 2 small group discussions, give 2 lectures, maintain a teaching portfolio, and present an manuscript during an educational journal club.¹  An evaluation of this education concentration was done with knowledge tests and an attitudinal survey.  The authors found that both attitudes and knowledge increased after completing the three elective courses.¹  Positive attitudes correlated with positive feelings about the subject matter and an increased likelihood of pursuing a career in academia.

This is not the first time I have heard about curricular tracks or pathways for students to follow their professional interests in pharmacy school.   Giving students the opportunity to take multiple classes that focus on a particular career interest can be a great way to accelerate learning prior to graduation.  The education concentration implemented at SIUE is a unique way to give interested students insight into the career of academia.  Many students in school might think they want to teach but don’t actually know what being a faculty member entails.  Giving a lecture may look easy enough, but what kind of time and preparation actually goes into creating the lecture? Prior to my experience with Educational Theory and Practice course I had very little understanding of educational theories.  I’ve come to learn that active learning strategies and instructional designs are core concepts that aid in creating effective educational sessions.  To students who may choose to pursue a career in academia, learning some of these fundamental models is beneficial and will help them become successful scholars. 

But a career path towards academia still doesn’t meet the needs of students who will become future preceptors.  What about the students who become clinical pharmacists working at hospitals or managers in community pharmacies?  Surely many (if not most) at one point or another will become preceptors.  A preceptor’s role is to create a positive environment where learning can be effective and efficient.²  A pharmacy preceptor should convey “enthusiasm, professionalism, and knowledge.”³ There are many factors that have increased the demand for quality pharmacy preceptors including the increased number of pharmacy schools and the increasing experiential requirements for ACPE accreditation.⁴  Whether by interest or demand alone, chances are we will need most pharmacy students to become preceptors.  Knowing these odds, shouldn’t we prepare students to be become dynamic preceptors? 

There are more reasons to teach students how to teach.  One of the most important roles of pharmacists is to serve as a patient educator. Being able to give effective, concise, and useful advice to patients is vital to aiding in their understanding of their disease process and the importance of their medications.  Communicating information to patients requires that we assess audience characteristics through needs analysis, identify learning objectives, and employ effective teaching strategies.  While we all might have been taught the basics of patient counseling in pharmacy school, my guess would be that most classes focused on what to say to patients (knowledge dumping) and less on how to do educate (assessing learning needs, selecting appropriate teaching strategies, and promoting self-directed learning).

I propose that students should have the opportunity in school to learn how to be successful preceptors and patient educators.  This could be done through a classroom-based course, seminars, or other learning methods.  Metacognitively students would benefit from understanding the role of a preceptor prior to advanced practice experiences.  If students are taught how to teach, they could develop awareness and reflect during courses and APPEs on ways to improve as a learner and as a future teacher.  Learning about who people learn and how to address learning barriers would make us better health professionals.  With knowledge and experiences, students would be more prepared to precept students and educate patients.  Incorporating such instruction into pharmacy school is important to strengthen the leaders and teachers of tomorrow.

References:

1.  Poirier TI, Santanello C. Impact of a Pharmacy Education Concentration on Students’ Teaching and Attitudes.  Am J Pharm Educ 2010; 74(2) Article 23: 1-8.
2.  Kleffner JH. Becoming an effective preceptor [Internet]. Austin (TX): The University of Texas at Austin College of Pharmacy; 1998 [revised 2001, 2004, 2007, 2010; cited 2011 Oct 22]. Available from: Becoming an Effective Preceptor.
3.  Skrabal MZ, Kahaleh AA, Nemire RE, et al. Preceptors’ perceptions on benefits of precepting student pharmacists to students, preceptors, and the profession. J Am Pharm Association 2006; 46(5): 605-612.
4.  AACP: American Association of Colleges of Pharmacy [Internet]. Alexandria: American Association of Colleges of Pharmacy; c2011. Academic Pharmacy’s Vital Statistics 2011 July [cited 2011 Oct 20]. Available from: Academic Pharmacy's Vital Statistics.

Who’s Who: Getting to Know Your Students in Large Classes

By Ashleigh Lowery, PharmD, PGY1 Pharmacy Resident, University of Maryland Medical Center

I walked into my undergraduate Organic Chemistry class ready to begin the semester.  I had a new notebook, pencils, and the large expensive textbook.  Our professor started by reviewing the syllabus, as expected, and then unexpectedly passed around a blank index card to each of the 120 students in the lecture hall.  “I want you all to write your name, where you are from, your major, and something interesting about yourself.  Telling me that you want to go to med school is not interesting.  I want a real fun fact – like you were on Who Wants to be a Millionaire.”

I was impressed and surprised at the next lecture when he told us all about some of the people in our class.  One had taught English in Thailand, one had just run his first marathon and one person, in fact, had been on Who Wants to be a Millionaire.  I was even more impressed when I had an appointment for office hours later in the semester and the professor began by asking me about my hometown and interests.  It was obvious he had pulled my index card.  Over the semester, it was clear that this professor had developed great communication with our class and was able to form relationships despite the class size.  He was not just teaching to anonymous faces in a crowd.  I learned a lot that semester and was never hesitant to approach our professor when I had a question.

In large lectures, getting to know your students does not come as easily as it may in smaller teaching settings.  However, it is just as important in order to create a positive learning environment for your students.  It just may take some more creative approaches, or 120 index cards.

In an article in College Teaching, Jan Armstrong of the University of New Mexico describes a similar approach to getting to know her students.¹  The article is titled, “Write me a letter: challenging anonymity in large-enrollment classes.”  Armstrong hands out sheets of lined paper and asks students to write an informal introduction letter, stating “Tell me a little bit about yourself and why you are taking this course.  Tell me whatever you think I should know about you.”  She then reviews all of the letters and spends a few minutes in subsequent class sessions introducing individual students to the class and incorporating noteworthy or humorous information.

The University of North Carolina Charlotte provides a “Survival Handbook for Teaching Large Classes,” which includes a section titled “How can I reduce the feeling of student anonymity.”²  This provides an assortment of ideas, from taking Polaroid pictures of your students to greeting each student at the entrance of the classroom.  Some of the other suggestions include:

-  Ask students to wear nametags so that you can call on them by name

-  Have students place name cards in front of them during exams so you can learn names while you wander the room

-  Hand back tests individually to associate names with faces

-  Arrive early to class and chat with students who are already there

-  Stay after class to answer individual questions

-  Invite groups of students to coffee to get acquainted

The University of Maryland Center for Teaching Excellence also provides a guide for teaching large classes.³  One of their interesting ideas is for professors to host an “open house” during the first class session when students have a change to meet and talk with the professor.  They also emphasize the importance of having frequent and flexible office hours in order to meet and help more students.

Without a doubt, these efforts to get to know your students are worth it.  A study at the University of Illinois at Chicago assessed the impact of student-faculty informal contact and college outcomes and found that significant positive associations exist between extent and quality of student-faculty informal contact and students’ education aspirations, their attitudes toward college, their academic achievement, intellectual and personal development, and their institutional persistence.⁴ 

Richard Tiberius of the University of Toronto described the importance of this relationship well by stating, “The relationship between teachers and learners can be viewed as a set of filters, interpretive screens, or expectations that determine the effectiveness of interaction between teacher and student…within [effective] relationships, learners are willing to disclose their lack of understanding rather than hide it from their teachers; learners are more attentive, ask more questions, are more actively engaged.”⁵ 

Regardless of your style, pharmacy education is bound to include some large lectures.  We should all remember to make our best efforts to get to know our students, for both our benefit and theirs.

References:

1.  Armstrong J. Write me a letter: Challenging anonymity in large-enrollment classes. College Teaching 2008; 56: 63.

2.  Ives SM.  A Survival Handbook for TeachingLarge Classes.  University of North Carolina Charlotte Faculty Center for Teaching; 2000.

3.  Large Classes: A Teaching Guide:Personalizing the Large Class.  University of Maryland Center for Teaching Excellence; 2008.

4.  Pascarella ET.  Student-faculty informal contact and college outcomes.  Review of Educational Research 1980;50:545-595.

5.  Tiberius RG, Billson JM.  The social context of teaching and learning.  In Menges RJ, Svinicki MD, editors.  College Teaching:  From Theory to Practice.  San Francisco:  Jossey-Bass Publishers, Inc; 1991.  p. 67-86.