Can Empathy in Patient Care Be Taught?

By Niki S. Mehdizadegan, Pharm.D., PGY1 Pharmacy Resident, Union Memorial Hospital 

I entered a patient’s room in the Anticoagulation Clinic.  A middle-aged lady wearing a colorful scarf was sitting quietly in her wheelchair. “Hello Miss. M! How are you doing today?” I said with a smile.  She remained quiet and barely raised her head. In the three seconds between saying hello to her and pulling the chair to sit in front of her I thought to myself: “Oh, she is so friendly! (sarcasm). Let’s see how this goes.” 

We often form our opinion of individuals in the first few minutes of meeting them.  Malcolm Gladwell, the author of the book Blink defines our ability to make a decision or form an opinion within a limited period of time of facing a situation as “thin-slicing.” ¹  He explains that although in most instances having a limited amount of information can be sufficient in decision making, sometimes our unconscious prejudice and stereotypes can bias that decision. 

In a society with significant cultural and socioeconomic differences, it is inevitable that  as healthcare professionals we will interact with a diverse group of patients whose behavior, expectations, and lifestyles are vastly different from ours. The question is: can we teach health care professionals to be empathetic towards patients in spite of these differences? Empathy has been defined as the “ability to behave in a caring manner toward a patient while demonstrating to the patient that his feelings are understood.”² 

In one study that was a joint collaboration between two schools of pharmacy, the authors employed Patient Empathy Modeling (PEM) pedagogy to teach pharmacy students  empathy towards underserved patients.³  The students were enrolled at two schools of pharmacy located at a rural and an urban site in the United States (Purdue University School of Pharmacy and University of Connecticut School of Pharmacy).  Students were given a patient scenario simulating the life of a patient with multiple chronic illnesses who was coping with a socioeconomic, cultural, or communication barrier. The student then had to live the life of that patient for ten days.  For example, one student role-played “Jamie Illiterate” - a patient who had multiple chronic illnesses, had financial problems, and had a learning disability that prevented her from learning how to read. The student was given prescription vials labeled in unintelligible texts. Assignments during the 10 days included: (1) having a one-time counseling session with a pharmacist (role-played by another pharmacy student) which simulated the challenges a patient might encounter, (2) setting up pillboxes or other reminder systems to take medications (vials containing placebos were provided), (3) observing the surroundings and attempting to read signs and other everyday objects for half an hour each day and recording feelings in a journal, (4) preparing a list of resources for illiterate patients in the area where the student lived, and (5) developing a medication brochure for illiterate patients. 

The effectiveness of this pedagogical approach was quantitatively and qualitatively assessed using the Jefferson Scale of Physician Empathy for Health Care Professionals (JSPE).  In addition, the authors assessed student journal entries as well as a final reflection paper. JSPE is a validated tool which analyzes 3 factors related to empathy: perspective taking, compassionate care, and the ability to stand in a patient’s shoes. The scores of the students participating in patient scenarios improved after completing the assigned activities.  Three major themes were identified from student’s journal entries and reflective papers: (1) greater appreciation for the difficulty in medication adherence, (2) increased empathy for patients from different backgrounds, and (3) improved ability to apply the lessons learned to real patient scenarios during their advanced experiential rotations. 

My first impression of the lady that I saw that day in the anticoagulation clinic was perhaps not the most positive. However, during that office visit I discovered that she was diagnosed with acute deep vein thrombosis (DVT) that day and that she had been scheduled to have knee replacement surgery. Due to the DVT diagnosis, her surgery would now be postponed.  This meant that she would suffer from continued pain from severe arthritis. She also needed treatment for her DVT.  This would require an injectable medication for a few days followed by an anticoagulant that required frequent blood tests and monitoring for the next few months. That day I tried my best to be empathetic towards her. I told her that I realized how painful her arthritis can be (perspective taking) and that my mother suffers from arthritis too (the ability to stand in a patient’s shoes).  I told her that I was more worried about her going into surgery with a new clot in her leg than postponing the surgery.  It was important that she receive the best possible treatment so that she can recover and be the healthiest she can possibly be prior to her surgery (compassionate care). She smiled and nodded her head and said that she understood.

As the study I have cited demonstrates, pharmacy students can be taught to be empathetic by engaging in role-play and facing difficulties from a patient’s perspective.  Schools of pharmacy across the country have designed various activities to teach empathy in their curriculum. Empathy does not require a genetic predisposition, but rather facing situations similar to those faced by our patients.  It is through these experiences that we can learn to relate to the similarities that bind us together rather than the differences that divide us.

References:

1. Gladwell, M. Blink. New York : Little, Brown and Co., 2005

2. Lonie JM, Alemam R, Dhing C, Mihm D. Assessing pharmacy student self-reported empathic tendencies. Am J Pharm Educ. 2005; 69:Article 29.    

3. Chen JT, LaLopa Jb, Dang DK. Impact of Patient Empathy Modeling on Pharmacy Students Caring for the Underserved. Am J Pharm Educ. 2008; 72: Article 40.

Teaching Across Generations

by Joshua Fleming, Pharm.D., PGY-2 Ambulatory Care Pharmacy Resident, The Johns Hopkins Hospital

“There are three things to remember when you are teaching:  know your stuff, know who you are stuffing, and then stuff them elegantly.” – Lola May

When you take a look at many pharmacy schools, you’ll notice students from different generations present within each class.  We are likely to see the middle-aged adult who has decided to go back to school. This middle-aged adult has made pharmacy their second career.  And they are likely to be sitting next to a 20-something student. This younger student has gone straight from high school, to college, and now pharmacy school.  This presents a challenge to us as we face a student body from multiple generations.  Their expectations in terms of preferred learning methods and teaching styles are often different. 

The generations we are most likely to encounter in our teaching careers include Generation X and Millennials.  Each of these generations differs slightly in their preferences and overall attitudes toward assignments.  In order to understand some of the differences between each generation, it is important to take a step back and review the events that shaped each generation.

Generation X (1964-1979)¹:  People from this generation are the product of the work-driven Boomer generation.  They experienced single parent homes, the advent of MTV, the Challenger explosion, and were the first generation of latch-key children.  This is the first generation to use computers in their homes and to experience the Internet.  Gen Xer’s are driven by money, crave balance in their lives, are self-reliant, and value free time. 

Millennial (1980-2001)^1,2:  This generation is also known as the “Nexters” or Generation Y.  This generation encompasses the majority of the pharmacy students today.  The events that shaped this generation include the Columbine shootings, Oklahoma City bombing, and September 11^th tragedy.  This generation has grown up with technology and expects it in every aspect of their daily lives.  Millennials are self-reliant, mobile, addicted to media, brand-conscious, and family-oriented in times of crisis.   

A study that examined the attitudes of Generation X students in pharmacy school found that these students have a higher preference for professors that are friendly and warm.³  They also believe that grades should be based on knowledge and performance of a subject, and believe that the average grade for a course should be a B.  In a follow up study, researchers found that Generation X students were:  technologically literate, independent problem solvers, and more likely to believe that learning should be fun, crave stimulation, personal contact, follow rules after explaining significance.  Moreover, they were more likely to desire learning relevant to work, experiential leaning, feedback, evaluation, and expect immediate answers.⁴  The authors then designed a course that would meet many of these desires.   During the course the used games, engaged the students in small group and individual activities, provided an online site to support the course, learned students’ names, communicated via email, and provided ways for students to obtain instant feedback.  They then evaluated their performance in the “re-designed” course and compared the results to a traditionally designed course.  They found that when the course met as many of these expressed desires as feasible, the students performed better and student feedback was more favorable.

A meta-analysis published in 2009 focused on the challenges of Millennial students in the classroom.⁵  Millennial students have a slightly differing attitude towards learning and formal education.  These students have high expectations and have a tendency to be over-confident. They have been told to “shoot for the stars” by their parents and may come to class with a sense of entitlement.  Millenials have a strong desire for connection and will generally “multi-task” through assignments and during lectures.  Strategies used to reach this generation in the classroom include adding more hands-on learning activities, delivering lectures in short chunks, and using technology such as YouTube.

In a study by Borges and colleagues, a 16 personality factor assessment was given to 809 medical students at a single institution.⁶  The students’ responses were compared based on their generational cohort.  Millennial students scored higher in areas of rule consciousness, social boldness, and perfectionism.  Generation X students scored higher in self-reliance.  An additional study by Borges and colleges focused on the differences in motives of Generation X and Millennial medical students.⁷  In this study they found that Generation X seemed be driven more by power.  Millennial students were driven more by achievement and affiliation.

So, how can we best approach different generations of students and achieve our desired educational outcome?  Unfortunately, there is little literature about how best to meet the needs of a generally diverse classroom, but its seems wise to make sure that rules (e.g. course policies) are clearly defined and learning objectives are measureable.  Both Generation X and Millennials are comfortable with technology and expect to use it in the classroom.  On demand podcast lectures (and vid-casts) have been used at some universities followed by classroom case discussions.  This would meet the desire for technology and independent learning as well as giving the student an opportunity for social learning in the classroom.   Both of these generations have a strong desire to succeed.  As future educators its going to be challenging to provide the best education to students that have demanding expectations, but if you “know who you are stuffing”, it makes the task much easier. 

References

1.  King D. Defining a Generation:  Tips for Uniting Our Multi-GenerationalWorkforce. Career Planning and Management, Inc. Accessed 20 November 2011.

2.  Oblinger D. Boomers, Gen-Xers, and Millennials: understanding the new student. EDUCAUSEReview. 2003;July/August:37-47.

3.  Romanelli F, and Ryan M. A Survey and Reviewof Attitudes and Beliefs of Generation X Pharmacy Students. Am J Pharm Educ. 2003;67(1):72-79.

4.  Ryan M, Romanelli F, Smith, K, and Johnson MMS. Indentifying and Teaching Generation X Pharmacy Students. Am J Pharm Educ. 2003;67(2):1-6.

5.  Twenge JM. Generational Changes and theirImpact in the Classroom:  TeachingGeneration Me. Med Educ. 2009;43:398-405.

6.  Borges NJ, Manuel S, Elam CL, and Jones BJ. Comparing Millennial and Generation XMedical Students at One Medical School. Acad Med. 2006;81:571-576.

7.  Borges NJ, Manuel S, Elam CL, and Jones BJ. Differences in Motives between Millennial and Generation X Medical Students. Med Educ. 2010;44:570-576.

To Record or Not To Record

By David E. Zimmerman, Pharm.D., PGY1 Pharmacy Resident, The Johns Hopkins Hospital

The video recording of lectures was implemented during my P3 year at the Philadelphia College of Pharmacy. At first I did not see a need for the technology because I was one of the students who always went to class. But I felt that it might benefit some students to see and hear the lecture for a second time. It did not occur to me that students might routinely skip class and simply watch the recorded lecture online. This soon became the norm … and my class of approximately 220 dwindled to only 50-100 student during most lectures.

A recent article published in the American Journal of Pharmaceutical Education, the authors discussed the pros and cons of recording lectures.¹ Some of the proposed benefits include repeated exposure to lecture material, the capability of reaching students at satellite campuses, and re-purposing the videos for other uses. I believe the first point can be a significant benefit. Recording lectures is perfect for students who may need repeated exposure to the material or who missed a key concept. Moreover, there will always be times when a student cannot attend a lecture due to illness or an unexpected event.

The main disadvantage to using this technology is decreased student attendance. Would students come to class if they had the opportunity to watch lectures within the comfort of their own apartment or dorm room?  Many students won’t.  I saw this first hand at my college … but this need not happen. To “encourage” attendance, instructors started using an audience response system, a polling technology that collects and displays aggregate responses.  The technology is often used to assess the audiences’ understanding of the material or to generate discussion.  The instructors also used the technology to record attendance and the data was used to determine the participation component of each student’s course grade.  This worked fairly well (in terms of improving attendance) but it required all students to purchase a clicker device and register it with the course.  A downside to this method was the occasional technological malfunction that can occur.  In addition, there is the potential problem of a student’s clicker being lost or stolen. This would require the student to purchase another clicker and re-register it with the course. Another option would be to take attendance manually (the old fashioned way) but this may not work for large classes as it would take away from valuable class time. A third option is to stop the video recording before class ends and then discuss material that would be appear on an exam.

A study was conducted by Bollmeier and colleagues at the St. Louis College of Pharmacy evaluated the performance of pharmacy students (P2) after they had been given access to recorded lectures in a therapeutics course.²  The recorded lectures were available online for a period of 72 hours after the lecture.  Attendance at each of the lectures, student scores on the final exam, overall course grades, the number of times students accessed the recorded videos, and the length of time that the videos were viewed were recorded. Although students performed better on the final exam when compared to historical norms, there was no correlation between a student's final course grade and the number of lectures he/she accessed online. In addition, there was no correlation between class attendance and the number of minutes that videos were viewed online. The authors also noted that the use of the online lectures was far less than expected. Overall, the study showed that video recording did not have a negative impact on lecture attendance. 

In the end, it is about students learning and not about showing up to class. We can all agree that students learn differently and for some, watching a recorded lecture may be the best method. The best way to determine if class attendance  impacts learning is to measure grade performance (short term) and by examining the NAPLEX/MPJE pass rates.  Unfortunately, assessing the impact on NAPLEX/MPJE pass rates would take several years and can be confounded if there are significant changes in the curriculum.

The decision of whether or not to record lectures should be addressed at each academic institution.  The course instructors should determine if there are particular class sessions where attendance would be of particular benefit to students. Examples might include guest speakers or the use of active learning techniques that require in-class participation. The course instructors and the pharmacy administration should also evaluate the cost, available IT support, and predicted use of the recordings.

References:

1.  Romanelli F, Cain J, and Smith KM. To record or not to record? Am J Pharm Educ  2011; 75(8): Article 149.

2.  Bollmeier SG, Wenger PJ, and Forinash AB. Impact of online lecture-captureon student outcomes in a therapeutic course. Am J Pharm Educ. 2010; 74(7): Article 127.

Mentoring: Give Back and You’ll Get More

By Jasmine Shah, Pharm.D., PGY1 Pharmacy Resident, Suburban Hospital

In middle school I joined a community tennis program which met every weekend year-round. For the first few years, my only focus was to improve my tennis skills and endurance … until one day my coach asked me to become a mentor for the new students that had just joined the program. I agreed, not really knowing what my responsibilities would be.  I thought it would be fun! Little did I know I would be tutoring, counseling, assigning “homework,” and (of course) teaching tennis! I was starting to feel like I was becoming a role model for these students, especially when they would come to me seeking advice from anything related to tennis, school, friends, family, and more.

Mentoring can be simple or complex, depending on the situation and commitment from both the mentor and the mentee. Research from the University of Glasgow describes mentoring as “a supportive relationship; a helping process; a teaching-learning process; a reflective process; and a career development process.”¹ Clearly, this definition exhibits complexity, but that’s the beauty of mentoring. Mentoring can be basic counseling to career development and spans across many fields from the educational setting to work.

There are different types of mentoring including: classic mentoring (one-to-one), individual-team mentoring, friend-to-friend mentoring, peer-group mentoring, and long-term relationship mentoring.¹  After reading about these definitions, our tennis mentoring program exhibited the qualities of all these types of mentoring. Mentoring is all about making a difference in someone else’s life, and the research from University of Glasgow states that “the more experienced shall care for and train the less experienced, in a non-judgmental manner.”¹   I can honestly say that after I became a mentor, I learned more about myself and how to be a better role model.

Research published in Advances in Health Sciences Education² explored mentoring in health care educational programs.  The researchers specifically focused on the professional development of medical students. The authors of this study wanted to explore one-to-one mentoring of medical students and examined its influence on theoretical knowledge and clinical competencies. This was a voluntary program with 122 medical students.  Mentors were able to meet with their mentees 1-3 times per semester. The authors concluded that students enrolled in the program had a positive experience and the mentors were able to facilitate their professional development. Students felt a sense of security because they had a mentor to talk to and gain support when needed. Personal issues were also addressed. Lastly, the authors commented that the students enrolled in the program exhibited increased professional competence by “handling relationships, interacting with colleagues, patients and others in a good way and gaining insight into social codes associated with the profession.”²

Mentoring programs in grammar and high school can change a student’s life. The Department of Education designed a mentoring program to expand and improve mentoring for children with special needs.  There are several examples of how these programs help students all over the nation. For example, students interested in medicine are able to shadow a plastic surgeon in San Diego. In another program, students are able to enroll in SAT mentoring programs to improve their scores. If one is fortunate to have a supportive mentor, education and professional development can positively be influenced. You never know when your advice and leadership can lead to someone else’s success.³

How does one become a mentor? I hate to break it to you, but you do not become a mentor overnight.  A good mentor must first believe in themselves and believe that they can make a difference. The best mentor is someone who has been in situations similar to those faced by the mentee and can relate to their situation. A mentor must have a plan regarding how they will help their mentee and how they will help them acquire new knowledge, skills, and attitudes. I would recommend reading teaching and mentoring books in order to gain insight on how to be a great mentor. Most importantly, a mentor must consistently be in contact with their mentee in order to establish a lasting relationship.  Phone calls or regular face-to-face discussions are a must.

Some experts say that mentoring is not well-defined and is poorly-researched. This may be true, but I strongly feel that mentoring has as much to offer.¹ After being part of the tennis program for nearly 7 years, I started a tennis program with two of my colleagues. We are still in touch with every one of our students that we mentored. The best part is that these students have now become mentors to a group of newer students. It’s a rewarding to see new mentors for a new generation!

References:

1.  Hall JC. Mentoring and Young People: ALiterature Review. Research Report 114 (2003). Web. Date Accessed: 5 Nov 2011.

2.  Kalén S, Ponzer S, Silén C. The core ofmentorship: medical students'experiences of one-to-one mentoring in a clinicalenvironment. Adv Health Sci Educ Theory Pract. 2011 Jul 27.

3.  About the U.S Department of EducationMentoring Program. U.S Department of Education. Web. Date Accessed: 6 Nov 2011.

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.