The Socratic Method - Asking the Right Questions

by Whitney Chaney, Pharm.D., PGY2 Critical Care Pharmacy Resident, University of Maryland Medical Center

If you are like most pharmacy students or residents completing clinical rotations, you have probably come into contact with a preceptor whose main teaching strategy is to fire questions, one after another.  This can be a good learning experience or a very bad one.  Imagine going on patient care rounds with a preceptor.  As you discuss various diagnoses and treatments, you are asked a series of very pointed questions to which the preceptor is looking for very specific answers.  You may know a few answers.   Some questions you are unsure what the preceptor is asking.  And sometimes you have no idea what the correct answers are.  As this goes on you get more and more nervous, blurting out a few too many "I don’t knows," and the scenario ends with the preceptor giving you a long lecture about the disease state … very little of which you remember because you have become so flustered, frazzled, and distracted by your thoughts.  The strategy of teaching through questions is often called the “Socratic teaching” method.  The Socratic method can be very useful and effective, but all too often it is misused and abused. 

Defining the Socratic teaching method is challenging – there is a lack of consensus on the exact definition.  Much of the information describing Socrates' teaching comes from the writings of his students.  They describe conversations with deep inquiry and intense debates on philosophical topics.  Generally speaking, the Socratic method involves asking a series of questions in a logical manner until a common “truth” is reached.  The goal of this type of inquiry is to stimulate critical thinking and lead to discussion in which the learner must use their baseline knowledge and analytical skills to reach a well supported conclusion.  This method is also meant to point out unsubstantiated, preconceived notions and gaps in knowledge.  In this process of inquiry, less emphasis was placed on the final answer, and more was placed on the thought process.  While Socrates generally used his method to explore and answer moral concepts, this strategy of questioning can be and often is applied to clinical teaching.

As pharmacy students and residents complete their pharmacy practice experiences, this method of questioning and discussion can be a very effective learning tool.  One key way in which it applies to healthcare is that good clinical practice (so called "truths") must be critically evaluated and supported by good evidence.  Teaching with Socratic questioning forces the learner to not only know the "answers," but also to understand the background and reasoning to support them.  Thus, the learner must be able to defend her/his recommendations and conclusions.  Furthermore, as the Socratic method helps build critical thinking skills, it prepares the learner to become an independent practitioner in an environment where the standard of care continues to change as new information becomes available.  Lastly, this method is very useful in experiential clinical settings because questioning and discussion can occur as situations arise in practice.

In order to effectively use the Socratic method, it is important to make sure that teachers and preceptors are asking the right questions – ones that stimulate discussion.  Questions should be asked in a thoughtful and logical manner in order to guide the learner to appropriate conclusions.  Using a variety of question types is more likely to achieve the learning objective.  Questions can be exploratory ... these types of questions probe for basic knowledge.  Challenge questions are intended to scrutinize conclusions and assumptions.  Diagnostic questions probe for causes, connections, or cause-and-effect relationships.   Extension questions are meant to expand on the discussion.  It is often useful for the instructor to use priority questions to help identify the most important points and, at the conclusion of the discussion, ask summary questions.  Questioning can also be categorized by the type of cognitive level following Bloom’s hierarchy of cognitive skills: knowledge, comprehension, application, analysis, synthesis, and evaluation.  In addition to the type of question, another strategy is to think about the order of the questions.  Specifically, are the questions going from general to specific, simple to complex, or convergent to divergent?  Finally, as the teacher probes the learner, the teacher’s response to the answers also impacts the learning process.  It is important for the teacher to listen to the entire answer and use non-verbal cues that signals that he/she is interested in the learner’s thoughts.  Correct or well-reasoned answers should be appropriately praised, while partially correct answers should be accepted and the learner should guided down the correct path with additional inquiry.  Incorrect answers should be tactfully corrected in a non-judgmental manner. 

The Socratic method of questioning and discussion can be a valuable teaching tool, especially in the setting of clinical pharmacy training.  The secret to using this teaching tool is the appropriate use of questioning strategies and responding to the learner’s answers.  The Socratic method should be used to facilitate an open dialog and the instructor must take care to create a non-threatening learning environment, where learners are free from fear and anxiety.  Its important to keep an open mind, accept feedback, and be prepared to adjust the questioning strategy to ensure that every student and resident gets the best learning experience.   

References
1.  Oh RO.  The Socratic Method in Medicine—The Labor of Delivering Medical Truths.  Fam Med. 2005; 37:537-9.
2.  Lewis DP.  Using the Socratic Method in Office-based Teaching.  Fam Med 2004; 36:162-3.
3.  Edwards S, Bowman MA.  Promoting Student Learning Through Questioning: A Study of Classroom Questions. Journal on Excellence in College Teaching.1996; 7: 3-24.

Practicality and Relevance in Pharmacy Education

By Sarah R. Thiel, Pharm.D., PGY-1 Pharmacy Resident, the Johns Hopkins Hospital 

It’s an eye-opening experience when a student steps out of the classroom and into a real-world work environment. The ideals of how things should be done (as taught in the classroom) do not always reflect the way they are actually done. This is because there are often workplace barriers, such as the financial and political issues, that hinder the best practices from being fully implemented. The modern-day pharmacy curriculum has put a great deal of emphasis on developing and practicing clinical skills. Relying on experiential learning as the only mechanism to learn about issues that arise in the day-to-day practice of pharmacy may be putting students behind their other health-care professional colleagues. In order to develop pharmacists with a more solid foundation and critical thinking skills, it is absolutely necessary to bring practical issues into the classroom! 

As adult learners, information that is relevant and useful is more likely to be retained and applied. Therefore, teaching students practical information and practical ways to apply the information, appeals to the needs of the students without sacrificing content. I’m sure many of us have experienced a class where we think to ourselves “Why am I here? How is this relevant to me? I’m never going to use this information anyways!” Wouldn’t it be wonderful if instead students would think to themselves “Wow! This information is important! I may not need it tomorrow, but I’ll at least appreciate and understand how to use it when I do.” As our profession continues to strive to be patient-centered instead of product-focused, shouldn’t our pharmacy curricula follow suit and be student-centered? Shouldn’t we be developing our students to identify workplace practices that are not up to the standards taught in school? And by doing so, give students the foundation to help improve the practice of pharmacy? As future teachers and preceptors, we should do our students the favor of bringing more practical and relevant examples, experiences, and stories to their attention. Other professional curricula, such as law, have already started to do this.¹ 

William Lubawy, Ph.D., a faculty member at the University of Kentucky College of Pharmacy, suggests that demonstrating relevance of the presented material to students is one of many ‘Best Practices’ in teaching.²  Specifically, the best practice is to:

“provide evidence of the relevance of course material. Do the students understand why it is important to learn the material? Are real world, practical, contemporary examples presented? Is basic science presented in the context of application to practice-related problems, commonly used drugs, common disease conditions, etc? What does the instructor do to provide evidence of relevancy?”

Furthermore, Dr. Lubawy considers relevancy a key for developing critical thinking and problem solving abilities in students.² 

While there may not be many resources that explore the concept of practicality in didactic training, it’s an important one to think about. For example, Think Watson, an affiliate of Pearson Learning, reports that employers rated critical thinking skills of four-year college graduates as “excellent” in only 28% and as “adequate” in 63%.³  Do you think pharmacy graduates would be rated much higher? I think that increasing practicality and demonstrating relevance in classroom-based instruction could help improve this critical thinking skill statistic.  Teaching students practical questions to ask and evaluate will improve their ability to handle similar issues in the future. While there may need to be a ‘right’ answer for an exam, adding practical, real-life twists will help improve student knowledge and application of skills. For example,the best therapy for a patient may be a medication only available as an intravenous formulation. But what if the patient does not have IV access? Community pharmacists know all too well that the ‘best’ therapy can turn into no therapy if that patient’s insurance won’t cover the medication.  Introducing students to practical issues, questions, and approaches while they are still in the classroom can help get our students ahead when they begin introductory and advance practice experiences.

I was inspired to delve into the topic after reading my college of pharmacy alumni announcement about the 2011 recipient of the Teaching Excellence Award.  This award relies heavily on student input regarding the impact of the instruction provided by the nominees. I went back through the previous winners and thought to myself, what is one attribute that each of these teachers share? They all strived to make instructional practical and relevant!⁴  The 2011-2012 President of the American Association of Colleges of Pharmacy, Brian Crabtree, Pharm.D., considers relevance an important component in evaluating teaching excellence.⁵  Shouldn't we make it a priority to bring practicality and relevance into the classroom?

References 

1.  University of Michigan Law School. The Practicality of the Practicum.

2.  Lubawy, WC. (2003). Evaluating Teaching Using the Best Practices Model. Am J Pharm Educ. 2003; 67(3):1-3.

3.  Applied Critical Thinking: A 3-Phase Approach to Developing Problem Solvers and Efficient Thinkers.

4.  University of Michigan School of Pharmacy.  2011 Teaching Excellence Award Winner.

5.  Crabtree BL. Excellence and Relevance. Am J Pharm Educ. 2011; 75: Article 173.

Fears of the Nontraditional Student: A Focus on E-Learning

by Jennifer Dress, Pharm.D., PGY2 Psychiatric Pharmacy Resident, University of Maryland School of Pharmacy 

Non-traditional adult learners inevitably face barriers related to pursuing a college degree. These barriers tend to differ from those experienced by traditional learners. Essentially, non-traditional adult learners (i.e. part-time students, full-time workers, parents, and those not pursuing a college degree immediately after finishing high school) may encounter limited access to classes at a convenient time and place. A recent blog published by Dr. Flemming highlights some of the issues encountered when “teaching across ages.”¹ However, there seems to be opportunities to develop strategies to increase course access and overcome these issues. Some may think the answer is at our fingertips. What better way to solve the problem than to offer online courses! 

Online courses may overcome some of these situational and dispositional barriers. Specifically, they may circumvent situations in which adult learners find it difficult to attend classes on campus. Non-traditional students may also feel segregated from traditional learners because of differences in age, responsibilities, and energy levels. This may be overcome by the anonymity and flexibility that online courses offer. Consequently, nontraditional learners may begin to feel their opportunities and educational experience align with traditional students. Or don’t they?

Although online courses may prove beneficial for busy adults, a new barrier may surface: fear. Instead of reducing the limitations facing non-traditional students, e-learning may bring forth fear of the unknown, fear of technology, and fear of losing control.² A recent study conducted at a college in Boston highlighted some fears students have regarding e-learning. A survey sent to 64 faculty members and 234 part-time students taking courses in the summer of 2008 revealed that students and faculty members were least comfortable with online courses and social media sites when compared to websites that were used for informational purposes or had transactional tools.² 

However, only 74.4% of students and 33.3% of faculty had actually taken/taught an online class.² Furthermore, those individuals who had not participated in an online class were significantly more likely to rank the online classes as more difficult than face-to-face courses (p<0.05). Despite the small sample size and pooled analysis of both teachers and students, an inference can be made from the study. E-learning naive respondents seem to be afraid of losing control over their learning environment and the means of communication.

Evidence from a study conducted in 2008 shows a benefit from blending both an online and face-to-face teaching component for students in an interprofessional team development course.³ The students, majoring in pharmacy, medicine, nursing, and other health care fields, were divided into groups attending traditional face-to-face lectures and those enrolled in the blended classes. Results from pre/post tests, in-class observation, and student polling showed no significant difference between the team process skills both groups acquired. Therefore, the quality of blended classes and face-to-face classes appear equal, but the importance of carefully considering the percentage of each component needed to satisfy learning objectives is crucial.³ 

Despite the new obstacle introduced by technology, there is hope. First, we need to address the lack of confidence and fear of technology exhibited by students and faculty.  Faculty can receive support through instructional designers and pedagogical training in order to gain confidence and develop interesting and appropriate course designs.^2,4 We can also learn by example from the University of Maryland, who successfully implemented a strategy to increase innovation of online teaching tools in early 2000 through provision of mini-grants for support and incentive.⁵ Finally, a less costly idea would be to develop a mentoring program to provide support to faculty and students involved in e-learning. Coming from someone who has feared technology at times, I feel these ideas are a good start to get all students united in their pursuit of a college degree.   In conclusion, the hope is that students, including myself, taking online courses will begin to feel the same as the learner captured in the following quote:

“I feel that I am able to express myself more effectively when
I have more time to think about the issues and questions.
I know that I will be able to contribute more to class and to the discussions.”²

References

1.  Fleming, J. Teaching Across Generations. Baltimore (MD): Educational Theory and Practice; 2011 Nov 27.

2.  Sendall P, Shaw RJ, Round K, Larkin JT. Fear Factors: Hidden Challenges to OnlineLearning for Adults. In: Kidd T, editor. Online Education and Adult Learning: New Fronteirs for Teaching Practices. Pennsylvania: IGI Global; 2010. P. 81-100.

4.  Carbonaro M, King S, Taylor E, Satzinger F, Snart F. Integration of e-learning technologies in an interprofessional health science course.  Med Teach 2008; 30:25-33.

5.  Educause Learning Initiative (2008, August). Educause. Fritz, J. Lessons learned from a faculty incentive grant program. Educause Mid Atlantic Regional Conference (MARC); 2004; Baltimore, Maryland. Educause; 2004.

Going Paperless in the Classroom

by Kate D. Jeffers, Pharm.D., PGY1 Pharmacy Resident, The Johns Hopkins Hospital 

Over the past years, there has been a push to “Go Green.” Alongside this push, has been the revolution in digital publishing, with digital readers such as the Kindle and Nook, and the ability to digitally access digital material through Google Books or textbooks via the school library. But what does this mean for the classroom? Is there such a thing as a “required textbook” anymore?

The “green” classroom movement has taken an recent turn with the advent of the iPad. Apple and its affliated “app” developers have created increasingly sophisticated applications for use in education. iPads have been integrated into numerous schools around the country—from high school  down to kindergarten!^1,2 This push has begun to creep into medical education.  The teaching hospital at which I am completing my residency gave each of the medical interns an iPad and the Department of Pharmacy purchased laptops for each of the PGY2 pharmacy residents.

A high school English teacher, James Harmon, from the Cleveland area conducted an experiment to determine if the iPad actually improved learning in the classroom. His findings? His students learned better with the aid of iPads—when used correctly. He began the experiment after the school was provided 24 iPads by the school district. The school primarily serves a low-income population, and traditional approaches to teaching reading and writing weren't working. Harmon hypothesized that the iPads would help the school's English teachers find new, creative approaches to teaching the content.  He also wanted to justify asking for more iPads with data-driven evidence. 

Harmon divided the sophomore English class into two groups, one iPad-free control group, and one that had access to these tablet devices at school. He ensured that all sophomore English teachers taught the same curriculum for that school year. According to his end-of-year data, students with access to an iPad were more likely to pass both the reading and writing sections of the state standardized test. The teachers also reported that the devices made their lessons more engaging and helped them connect with students, adding that the iPads allowed them to give students "more frequent and timely feedback on writing." Additionally, student surveys revealed that the iPads increased students' motivation to learn. Of course, the excitement behind the use of novel technology might wear off with time.  Which would mean their value would diminish unless teachers take other steps to make their material engaging.³ 

In addition to motivation that new technology like the iPad can engender, the paperless classroom has other benefits. For starters, it cuts the cost of purchasing printed textbooks, which may or may not be used by students. By allowing students to access textbooks digitally, this allows them real time access to material. For example, if a student completes a lecture and has further questions regarding the topic, they are able to log onto the library website and read a textbook chapter immediately, rather than wait hours to return home (and perhaps forget to look up the material). This allows the student to formulate informed follow-up questions for the professor and quickly reinforces concepts covered in the classroom. Further, teachers are able to pick and choose what readings they require. Rather than requiring students to buy multiple textbooks and using isolated sections from each, professors are able to customize their reading requirements to the most relevant sections from various texts.⁴ 

A potential issue with all of this technology is the loss of the tactile sensation of pen to paper. Students learn in different fashions—some may be auditory, some may be visual, while still others may be tactile. Throughout my education, I have found it necessary to highlight and take notes on various book chapter or articles. Some technology, such as Adobe Pro, allows you to highlight and comment on electronic documents. During my first year of pharmacy school, I printed each slide set to take hand notes. As the courses got more difficult, I took notes on my computer, which I then had to convert into a word document alongside the slide information.  And then I printed it to study for exams.

An additional concern becomes the reliability of the technology itself. I watched many students loose all of their hard work during computer crashes.  This highlights the importance for backing up files regularly. Finally, with all of the computers in the classroom, it can be distracting for students. Students may be tempted to instant message, check out Facebook, or surf the web; all of these would be counterproductive to the purpose of being in the classroom.

Is it ever possible to “go paperless” in the classroom? Probably not. On the other hand, it is feasible to use “less paper,” bringing new meaning to the “Go Green” movement. 

References:

1. Hu, W. Math that moves: Schoolsembrace the iPad. New York Times 2011 Jan  4 [cited 2011 Nov 26]. 

2. Dwyer, L. iNsane? Auburn, Maine,is giving an iPad2 to every kindergarten student. Good Education 2011 April 11 [cited 2011 Nov 26]. 

3. Dwyer, L. Teacher’s iPadexperiment shows possibilities for classroom technology. Good Education 2011 Sept 9 [cited 2011 Nov 26].

4. Kupetz, AH. Is the paperlessclassroom possible? BizEd 2008 Jan/Feb: 36-40 [cited 2011 Nov 26]

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.