An Interprofessional Approach to Teaching

by Raymond F. Lamore III, Pharm.D., PGY1 Pharmacy Resident, the Johns Hopkins Hospital

The strategy of treating patients as a part of a “multidisciplinary team” has become common in many progressive medical centers. Utilizing the various skills of different members of the medical team can lead to significant improvements in patient care. Recently, literature has been published demonstrating the impact that pharmacists can have on patient outcomes as a part of the multidisciplinary team.^1-3  Based on this body of literature, there has been a surge of opportunities for pharmacists to participate in point-of-care treatment as a part of an  inter-professional team.   

As a part of the medical team it is a necessity for the pharmacist to be able to appropriately interact with the other members and understand their point of view. This expansion in our “job description”, begs the question: Are we trained to do this!?  I am not questioning a newly trained pharmacist’s ability to answer pharmacological questions and make clinical decisions, rather asking if we have been properly trained to be an effective member of the medical team. Unless you have had a job within a hospital as an intern, your interaction with various members of the medical team was probably minimal; with most occurring during your final year in school during advanced pharmacy practice experiences (APPEs). Many have concluded that the difficulties encountered in working with multiple professions stem from a lack of knowledge regarding the different roles and a relative absence of teamwork skills.⁴ In 2007, the American Association of Colleges of Pharmacy (AACP) Professional Affairs Committee advocated that “all colleges and schools of pharmacy provide faculty and students meaningful opportunities to engage in education, practice, and research in interprofessional environments to better meet the health needs of society.”⁴

This leads to a second question.  Should students be introduced to the different members of the medical team during classroom-based instruction. Interprofessional education can add many benefits to a college of pharmacy’s curriculum.⁵  The World Health Organization defines interprofessional teaching as “…students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”⁵ An expert panel from the Interprofessional Learning Collaborative suggested the following key objectives for interprofessional teaching:⁶

·       Relationship focused

·       Process oriented

·       Linked to learning activities, educational strategies, and behavioral assessments

·       Able to be integrated across the learning continuum

·       Sensitive to the systems context/applicable across practice settings

·       Applicable across professions

·       Stated in language common and meaningful across the professions

·       Outcome driven

Interprofessional teaching would also add depth to the students’ ability to perform analysis, as different members of the medical team utilize a variety of thought processes in clinical decisions.  These perspectives and processes differ from a pharmacist’s. Educational researchers have found benefits to this teaching modality, as it helps students to recognize bias, think critically, tolerate ambiguity, and acknowledge and appreciate ethical concerns.⁵  Introducing students to different members of the medical team may also increase their confidence when communicating recommendations. This interprofessional model of teaching and learning could seamlessly progress from the classroom into experiences partnered with students from many health professional programs.

In 1995, a nursing and pharmacy school completed an interesting clinical collaborative project, in which students from each school were paired so that they could utilize their “profession specific” skills in patient care situations.⁷ During the project, students met weekly in the hospital to jointly present at case conferences to their peers. The students worked in pairs, one from each discipline, in selecting a patient case, plan a case study, and present the results to the group. This experience required the students to collaborate, utilizing negotiation skills and critical thinking processes. Common issues that were addressed by the nursing students, included: physical signs and symptoms, medication administration, laboratory values, discharge needs, and self care abilities. Whereas, student pharmacists would address pharmacological therapy, allergies, polypharmacy, pharmacokinetics, contraindications, route of administration, and adherence.

After the completion of the project student comments were positive.  They expressed appreciation for a collaborative approach to patient care. This project demonstrated great success as both groups of students expressed an appreciation for the complementary nature of the two health care professions.  This early experience lead to expanded implementation of these experiences in the respective curriculum.⁸ This form of interprofessional education is a great way to collaborate with other members of the team and gain an early appreciation for their roles in patient care. The only foreseeable complication in this approach would be possible scheduling complications between academic institutions and having resources (hospital, staff, etc.) to allow for team meetings and collaboration.     

Taking a interprofessional approach to teaching and learning is a tool to enrich the curriculum of any college of pharmacy. Utilizing this approach to educate pharmacists will open the doors for early interaction and collaboration with the various members of the health care team and broaden learning experiences for students.

References:

1.  Marshall J, Finn C, Theodore A. Impact of a clinical pharmacist-enforced intensive care unit sedation protocol on duration of mechanical ventilation and hospital stay.  Crit Care Med. 2008;36:427-433

2.  Cohen V, Jellinek S, Hatch A, et al. Effect of clinical pharmacists on care in the emergency department: A systematic review. Am J Health-Sys Pharm 2009;66:1353-61.

3.  Gattis W, Hasselblad V, Whellan D, et al. Reduction in heart failure events by the addition of a clinical pharmacist to the heart failure management team. Arch Intern Med. 1999;159:1939-1945

4.  Page R, Hume A, Trujillo J, et al. Interprofessional Education: Principles and Application. A Frame Work for Clinical Pharmacy. Pharmacotherapy 2009;29(3):145e–164e.

5.  Romanelli F, Bird E, Ryan M. Learning Styles: A review of theory, application, and best practices. Am J Pharm Educ 2009;73:1-5.

6. Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative.

7. Science Education Resource Center at Carlton College. Starting Point: Teaching and Learning Economics. Why Teach with an Interdisciplinary Approach? Accessed: November 6, 2011.

8. Robertson K. Interdisciplinary professional education: A collaborative clinical teaching project. Am J Pharm Educ 1995;59:131-136.

Teaching Challenges in Religiously Diverse Classrooms

By Jennie Piccolo, PGY1 Pharmacy Resident, Carroll Hospital Center 

“We are a nation of Christians and Muslims, Jews and Hindus – and non-believers.”  In his inaugural address, President Obama used religious diversity as one of the many illustrations of diversity in America, proclaiming “our patchwork heritage is a strength, not a weakness.”¹ He did not address the challenges this often presents, however, in the classroom.  Sara Shady and Marion Larson of Bethel University ruminate on this ever present challenge to educators at American colleges and universities: “How should we handle the presence of different religious views in the classroom?  How can we best prepare students to constructively engage a world of competing religious truths?”² 

The pharmacy curriculum and curricula of other health professions are certainly not strangers to this concept.  Science and faith oftentimes clash when controversial topics, such as oral and emergency contraception, methadone clinics, and many others are discussed.  I will always remember my class on oral contraceptives, where our professor firmly proclaimed her views, disregarding the beliefs of many of my classmates.  When one of my fellow students confronted her, stating his views which contradicted her teachings, an argument ensued.  Each was firm in their views and the disagreement lead nowhere; neither side relented and both just agreed to disagree (and the class simply ended).  A similar disagreement occurred the following year during a class that discussed the use of methadone as treatment of drug abuse.  With so many controversial topics as essential components of a pharmacy curriculum, how can we avoid these conflicts? 

While few pharmacy professors approach this topic, Jan Worth, an English professor at the University of Michigan, admits that faith based topics “sometimes intersect in troubling ways with my own prejudices and personal history as a teacher and person.”³ She confesses to having trouble separating teaching from her personal beliefs and recognizes that educators often view faith as negative.  Career tracks that are strictly science based, such as pharmacy and other health sciences, tend to be even less open to combining scientific teachings with diverse religious views.  Many feel that logic and faith cannot coexist.  I can attest to feeling the need to downplay my religious upbringing and beliefs to gain respect from my teachers and peers.   Worth acknowledges “in teaching, we must respect our students—both the complicated personal histories and experiences with which they come to us.”³ She continues “it takes patience and fortitude, and, sometimes, conscious self-restraint.”³ College and universities strive to attract a wide variety of students, from a wide variety of cultures.  Pharmacy educators must be prepared to embrace this diversity when approaching a difficult subject.

You may be asking, what tactics can we use in such a volatile situation?  Pharmacy educators need to resist forcing what they see as truth on their students without taking into consideration the diversity of views in their classroom.² One of Worth’s tactics is to bring the conversation back to a text book, where the facts can be presented, hopefully free of cultural controversy.³ Other strategies could include phrases that do not over generalize, such as “some people..” or “in my experience…” to help prevent students from feeling that their cultures or beliefs are under attack.⁴ Allowing students to express their views in a low risk setting, such as an ungraded assignment or a small group discussion, helps to create a safe environment to express views on the subject matter.² By staying as unbiased as possible, a teacher can help promote healthy discussion rather than fuel arguments and controversy. 

In a world where pharmacists have refused to fill prescriptions based on their personal, moral, and religious beliefs, controversy will continue to fill the curriculum of pharmacy schools as well as other health professions.  Our college and university classrooms are full of cultural and religious diversity.  If pharmacy educators can remain unbiased in their teachings and prevent imposing their own views on their students, they can help foster a safe learning environment. 

References: 
1. Obama B. “Inaugural Address.”  January 21,2009.
2. Shady S. and Larson M. Tolerance, Empathy, or Inclusion? Insights from Martin Buber. Educational Theory. 2010; 60:81-96. 
3. Worth J. Hot Spots and Holiness: Faith-Based Topics in Freshman Composition.  2002. Paper presented at the Annual Meeting of the Conference on College Composition and Communication. 
4. Liggett T. and Finley S.  Upsetting the Apple Cart: Issues of Diversity in Preservice Teacher Education. 2009

Breaking down the primary literature: the role of the journal club

by Emily C. Pherson, Pharm.D., PGY1 Pharmacotherapy Residency, the Johns Hopkins Hospital 

As pharmacy students, we have courses where we are instructed on the key elements of a research study and we are tasked with trying out our literature evaluation skills by writing evaluations of major drug trials. As pharmacy residents, we are faced with reviewing multiple pieces of primary literature nearly every day in order to find the best data we can to inform the drug treatment decisions we are making for our patients. Leading journal clubs has helped me develop the skills I need to break down the primary literature.

As a pharmacy resident at Johns Hopkins, I was excited to discover that the first record of a medical journal club was one founded in 1875 by Sir William Osler, a renowned physician with Hopkins roots. He originally described the journal club as facilitating the distribution of unaffordable periodicals, and later evolved it into a book and journal club that met over dinner to discuss the latest in medical research.¹ 

A journal club is a teaching tool that helped me digest large amounts of information in limited amounts of time. When I started to think more about how I could conquer breaking down the necessary information in a journal article for a journal club, I realized that an easy way to do this would be to apply Gagne’s 9 events of learning, one of the many educational strategies we have been exploring in the Educational Theory and Practice Course.

To really engage participants in a journal club, you need to gain their attention. I find that applying the journal article to a patient case is a good way to get participants to relate to the content. It is also important to emphasize that at the end of the journal club, all attendees should understand the clinical implications of the data presented. This is always a recurring key objective for a journal club. It also important to give a bit of background on the disease state or therapy being addressed in the article as a way to stimulate recall of prior learning and help the attendees draw on information they already know about the topic. As far as presenting the content, a 2004 overview in the American Journal of Health-System Pharmacy points out three key steps to providing adequate discussion about an article.² First, the presenter must determine the relevance of the study (something I accomplish by laying out my objectives). Next, the validity of the trial must be determined. This is where the patient population, the study design and how the study was conducted are all evaluated. Lastly, the results must be evaluated. Askew suggestions that you list all of the efficacy endpoints of the study and then calculate the relative risk reduction and the absolute risk reduction.² Other important things to look at include the statistical analyses. It may be helpful to calculate the number needed to treatment (NNT) and/or the number needed to harm (NNH). It is also important to consider if the study was adequately powered to assess the defined outcomes.² 

In order to provide learning guidance and engage learners, its helpful to prepare some discussion questions to get the conversation started. These questions should be focused on the application of key study findings. If you started the journal article with a patient case, this can be a good time to bring the case back into discussion.

Its also important to have an evaluation tool available to assess the learners performance and provide feedback on the presentation. A 2007 article in the American Journal of Pharmaceutical Education provides an extensive evaluation rubric that was piloted with pharmacy students. In addition to the rubric, the students were also provided with an outline of important considerations for each section of the study. The authors provide a truly comprehensive tool that’s very useful for providing feedback to learners.³ 

The last event that Gagne proposes is that we must enhance retention and transfer knowledge. At the conclusion of every journal club, its important to summarize the discussion and talk about how the information can be applied in practice.  Some days later, I invariably find myself applying what I’ve learned during a journal club to specific patient cases I see on my rotations.  I encourage participants to think about when they might use the information in the journal article again.

I would challenge any educator who is faced with the task of discussing the primary literature with learners, to considering using a journal club format and applying Gagne’s 9 events of learning when conducting them. 

References:

1. Greene WB. The role of journal clubs in orthopaedic surgery residency programs. Clin Orthop. 2000;373:304–310.
2.  Askew JP. Journal club 101 for the new practitioner: Evaluation of a clinical trial. Am J Health-Syst Pharm. 2004;61:1885-1887. 

3.  Blommel ML and Abate MA. A rubric to assess critical literature evaluation skills. Am J Pharm Educ. 2007;71:1-8.

Pharmacists Education: B.S.Pharm to Pharm.D. — the Evolution of a Profession

by Ashley McCabe, PharmD, PGY1 Community Pharmacy Resident, University of Maryland School of Pharmacy 

If you or someone close to you has recently graduated from pharmacy school, you know the Doctor of Pharmacy (Pharm.D.) degree is the degree that all pharmacists now earn.  However, not every pharmacist in the pharmacy world has a Pharm.D.  In fact, the education of pharmacists has evolved as the profession has transformed.  The Pharm.D. degree is a relatively new standard in the profession.  As someone who works in a community pharmacy setting, where more pharmacists have a Bachelor of Science in Pharmacy (B.S.Pharm) rather than a Pharm.D., I am intrigued by the differences between the two degrees and how professional education has changed over the years.  I intuitively understood that the doctorate required more years of school but, why did the doctorate become the standard? As a student of education, I wondered what drove educators to alter the curriculum so drastically.  More importantly, as we are undergoing another phase of healthcare reform, it is vital to look at that process, in the event that education will need to transform again based on the needs of the profession and the patients we serve. 

Through my investigation, this is what I discovered.  The B.S.Pharm degree was the norm until 1997 when the Accreditation Council for Pharmacy Education (ACPE) re-evaluated the needs of entry-level pharmacists and patients.¹   The changes made were based on recommendations for healthcare provider competencies identified by the Institute of Medicine (IOM).  In 2000, the new ACPE standards went into effect.  Therefore, if you graduated pharmacy school in 2003 or later, the doctorate became the entry-level degree.  As the profession and medical care in general evolved, so did the education of the pharmacist.  The doctorate of pharmacy put more emphasis on medication management – and this proved important when the Medicare Modernization Act passed in 2003.¹ Pharmacists needed to employ their cognitive skills to an ever expanding population in need.

 Pharmacy practitioner Paul W. Abramowitz clarified this concept perfectly in his Harvey A. K. Whitney Lecture by describing the transition of pharmacy practice throughout his career.² He painted a picture of pharmacy practice in 1974, the start of his career, as more humble clinically with limited inter-professional exchanges.  He continued with how the profession morphed as pharmacists became more involved in acute care settings and as the repertoire of medications expanded along with medication-related problems and the pressure to make cost-effective decisions.  Moving into the current practice model, he expanded his story by describing how curriculums now require one year of advanced practice experience in order to fit into the new healthcare model of inter-professional care.  Thus, Mr. Abramowitz helped answer how the doctoral degree evolved, but there is definitely more to it than that.  What were the educators thinking? 

In a recently published article by former dean of the University of Maryland School of Pharmacy, Dr. David A. Knapp, highlighted the thoughts of educators, policy makers, alumni and other stake holders at the time of the transition.³ The article illustrates the lengthy debate and political upheaval that the all-Pharm.D. inspired.  Support from research studies and practice analyses done by both sides of the debate exemplified how difficult the transition really was.  Faculty and staff members at the school were burdened by trying to put additional requirements into a 5 year program.  Adding 2,000 supervised practice hours and 6 months of externship into a packed course load with limited elective opportunities stressed an already bloated curriculum.  However admirable it was, an all-PharmD was despised by many employers, pharmacists, and state legislators who saw a doctoral education as costly and unnecessary, amongst many other perceived undesirable characteristics. But as we all know, in the long run, the all-Pharm.D. transition occurred. 

From an educator perspective, the necessity of transitioning from 5 years to 6 years of education was related to a needs analysis.  The transformation was inspired by the evolving advance clinical roles pharmacists were taking on.  These roles were first explored by practitioners and educators in the 1960’s, 70’s, and 80’s.  In the current economic and political climate, the pharmacy profession is facing different challenges.  Educators and practitioners are sure to have opinions on the topic, but none are as potentially influential as the current students who will become the future of the profession.  Therefore, a needs analysis of the current students could hold the key to where professional education needs to go. 

With the transformation of pharmacy education in mind, as highlighted by Mr. Abramowitz and Dr. Knapp,^2,3 I believe it is fair to question where this evolutionary trend in pharmacy education will lead.  This is especially vital when considering the perceived needs of current students as they begin their careers in pharmacy.  Will it be residencies for everyone in order to enhance the retention and transfer of the advanced knowledge and skills first taught in school?  I believe that assessing the needs of the learner, in this case pharmacy students, as well as the needs of our patients should provide the data we need to make informed decisions about the future of pharmacy education and training. 

References

1. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Accreditation Council for Pharmacy Education. Chicago; 2006.

2.  Abramowitz PW. Harvey A. K. Whitney Lecture: The evolution and metamorphosis of the pharmacy practice model.  Am J Health-Syst Pharm. 2009; 66:1437-46.

3. Knapp DA. The rocky road to educational change: Adopting the entry-level Pharm.D. at Maryland, 1989-93.  J Am Pharm Assoc 2011; 51:712-719.

Preparing Pharmacy Students for Residency Training

by Diane E. Hadley, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Maryland School of Pharmacy

Over the past few years, I have been asked at three different pharmacy schools by first year students “What can I do to become the perfect residency candidate?”  Perhaps the better question is, what we can do as pharmacy educators and schools of pharmacy to prepare students to “put their best foot forward” for the ASHP Midyear Clinical Meeting (ASHP MCM) and residency interviews?  As the demand and the competitiveness for pharmacy residency training increases, acquiring accurate information about residency training and preparing students for the interview process becomes increasingly important.  In most doctor of pharmacy programs, students learn about residency training and preparation methods primarily by informal methods through peers as well as preceptors during advanced pharmacy practice experiences (APPE’s). Although beneficial, it may leave the prospective residency candidate with incomplete information regarding the type of residency to pursue and may not adequately prepare students for the interviewing and matching process.  Would a more formal approach, such as a pre-residency curriculum, be more effective than the current informal methods?

Experiential learning is a crucial part of the doctor of pharmacy curriculum that exposures students to current pharmacy practice models.  Ideally, APPE rotations should serve as an introduction to residency training.  Unfortunately, schools don’t control the “hidden curriculum” taught during APPE rotations.¹  An article published in Academic Medicine, observed that values such as professionalism was often taught informally more often by peers during off hours instead of traditional methods from an instructor.²  This article illustrates how the “hidden curriculum”  is often driven by peer influence.  This notion is further supported by an article published in Clinical Orthopedics and Related Research Journal.³   Indeed, informal one on one and group interaction can impact opinions, most often in a negative way.³  Thus information and attitudes about residency training may be acquired through a “hidden curriculum” and these may be driving decisions related to residency training that are not envisioned or endorsed by the school.^1,2,3  Thus a formalized pre-residency curriculum may help diminish the potentially negative influences of the “hidden curriculum.”

An article published in American Journal of Pharmaceutical Education supports the potential benefits of developing structured pre-residency instruction at the University of Buffalo School of Pharmacy.⁴ The author surveyed sixty-eight pharmacy students that attended either the ASHP MCM in 2007 or 2008  or both.⁴ Prior to attending ASHP MCM, students attended a one hour presentation and receive a handout regarding the residency process.⁴  The educational seminar included information about residency terminology, benefits of attending the ASHP MCM, time management,  and the pre-during-post ASHP MCM meeting residency selection.⁴ The survey asked about the helpfulness of the structured educational event and had an impressive 97% response rate.⁴ A majority of the students, 73%, ranked the educational event as extremely helpful in preparation for the ASHP MCM.⁴   A 2010 survey of seventy-one colleges of pharmacy showed that sixteen pharmacy institutions now have a pre-residency program in their pharmacy cirriculum.⁵   Of these sixteen schools, nine provided information on their pre-residency curriculum.⁵  The curriculums offered a variety of traditional and non-didactic learning activities including: lectures on residency training, pre-residency pathways, mentoring programs, and research project development.⁵

Schools of Pharmacy should provide residency information using a structured approach.  Such instruction has become crucial because the American College of Clinical Pharmacy has proposed that residencies become mandatory for pharmacists who work in direct patient care roles by the year of 2020.⁶  As leaders in our profession, we need to take action to formalize the instruction about residency training to keep students well informed.  We need to reduce the likelihood that students will make ill informed decisions based on misinformed that practitioners or peers may have given.  Ideally a pre-residency curriculum should be created that incorporates didactic presentation on the ASHP MCM meeting and residency interviewing process, encourages experimental learning rotations that increases a student’s preparedness for residency training,  a pre-residency mentor, and opportunities to get involved with clinically oriented research projects.  A combination of all these elements would provide a sturdy foundation for students to become the “perfect residency candidates.”

References:

1. Gardner S. Car Keys, House Keys, Easter Eggs, and Curricula. Am J Pharm Educ. 2010; 74 (7) Article 133.

2. Stern DT. In Search of the Informal Curriculum: When and Where Professional Values are Taught. Acad Med. 1998:73:S28-S30.

3. Gofton W and Reghr, G. What We Don’t Know WE Are Teaching: Unveiling the Hidden Curriculum.  Clin Orthop Relat Res. Number 449. Augest 2006. Pages 20-27

4. Prescott WA. Program to prepare pharmacy students for their postgraduate training search. Am J Pharm Educ. 2010; 74 (1) Article 9.

5. Dunn B, Ragucci K, Garner S, et al.  Survey of Colleges of Pharmacy to Assess Preparation for and Promotion of Residency Training. Am J Pharm Educ, 2010. 74 (3) Article 43.

6. Murphy JE, Nappi JM, Bosso JA et al. American college of Clinical Pharmacy Vision of the Future: Postgraduate Pharmacy Residency Training as a Prerequisite for Direct Patient Care Practice. ACCP Position Statement. Pharmacotherapy 2006; 26 (5): 722-733.