Problem-based Learning …Does It Work?

by Omayma Kishk, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

As the field of pharmacy has shifted towards patient care, re-structuring of pharmacy curricula has occurred.  What once seemed like a foreign concept, problem-based learning (PBL) has become a common theme in not only pharmacy education but in the curricula for many other health professionals.

PBL is a teaching strategy in which the teaching and learning is focused around a specific problem (usually a patient case).  There are six main characteristics of PBL:¹

1.   Learning is student-centered
2.   Learning occurs in small groups
3.   Teachers act as facilitators
4.   The problem (or case) is the base for organized focus and learning
5.   The problem helps to develop and use problem solving skills
6.   New knowledge is gained through self-directed learning.

The beauty of problem-based learning is that it helps portray what a student pharmacist will encounter in the real world.  PBL allows students the luxury to develop and fine-tune their skills; to practice how they would approach these problems without risking patient harm.  Some may argue that students may not be ready for PBL because they will not know where to look or what to focus on.  I personally have a great deal of experience with PBL because my entire pharmacotherapy year as a P3 student at the  University of Mississippi School of Pharmacy used the PBL methodology.  I had a lot of these same concerns and couldn’t understand how I was supposed to teach myself subjects I was not yet familiar.  I was skeptical.  It seemed the student was forced to assume the teacher’s responsibilities.


Student-centered learning is a key characteristic of PBL. PBL is very flexible and can cater to many different learning styles.  Each student can learn in the manner that works best for the individual.  For instance, I enjoyed lectures and liked to hear the teacher talk about things.  I was terrified of PBL because I didn’t think I would get to hear the information.  But, I was mistaken. I soon realized that I could learn about the disease state by listening to my classmates.  I gained so much from our conversations.  I didn’t feel intimidated to ask questions.  Together we shared charts, resources, and ways to better understand the material.

Having a facilitator to help guide the discussions is important to keep the group focused and help direct the students with the case, especially the first part of the case.²  Only when the group is going in a completely wrong direction or developed a significant misunderstanding about the topic or the problem should a facilitator step in. Without this guidance, it would be difficult for students to know where to focus their efforts. In a study examining PBL learning strategies and outcomes among second year medical students at the University of Nebraska, student performance on examinations did not differ when students or faculty members served as facilitators.  However, students said they took more short cuts when a student facilitated the group.³  I recall some of my facilitators that “kept” the group for the entire two hours, forcing us to discuss every detail.  These were some of the group sessions where I learned the most.

PBL can be a daunting experience for students because the student really has to push him/herself to locate the material and study it.  You have to become a more skilled self-directed learner.  Students that have gone through PBL have said it is much harder than conventional didactic instruction.  But it is also more stimulating, engaging, and relevant than those boring, passive conventional lectures.⁴ PBL helps the student, early on, learn interpersonal skills and how to keep the patient’s needs in mind when developing treatment and monitoring plans.

For me, PBL was difficult but now that I have done clinical rotations both as a P4 student and as a PGY1 pharmacy resident, I truly appreciate all of the tools and skills I gained from PBL.  PBL cannot prepare students for every case or problem they will encounter, but it does build the skills needed to help solve problems.

References:

1.   Kilroy DA. Problem based learning. Emerg Med J. 2004; 21:411-3.

2. Ross LA, Crabtree BL, Theilman GD, Ross BS, Cleary JD, Byrd HJ. Implementation and refinement of a problem-based learning model: A ten-year experience. Am J Pharm Educ. 2007;71: Article 17.

3. Steele DJ, Medder JD, Turner P. A comparison of learning outcomes and attitudesin student- versus faculty-led problem-based learning: an experimental study. Med Educ. 2000;34:23-29.

4. Nandi PL, Chan JN, Chan CP, Chan P, Chan LP.  Undergraduate medical education: comparison of problem-based learning and conventional teaching. Hong Kong Med J. 2000; 6:301-6.

Teaching Pharmacy Students to be Excellent Communicators

By Allison Lardieri, PharmD, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

After completing four years of undergraduate education, four years of pharmacy school and now six months of PGY1 pharmacy residency training, I’ve come to the realization that communication skills are perhaps the most important skill I need – and I continue to work on them!  Being a skillful communicator does not require one to know the mechanism of action of a specific drug, disease pathophysiology, or the most recent CHEST guidelines – not that these concepts aren’t extremely important.  But, I have found that the importance of effective, clear, and assertive communication by pharmacists surpasses drug knowledge.

Communication skills are vital to pharmacists every day, regardless of whether they work in a community or hospital setting.  As pharmacists move from a medication-dispensing role to a patient-centered role, they must communicate regularly with other health care practitioners and patients.  In the hospital setting, a clinical pharmacist participating on interdisciplinary rounds needs to feel confident speaking up at the appropriate time and needs to know how to make recommendations in a manner that is well-received by the team.  I believe this is a skill that does not come naturally, but rather can be practiced and refined.  Whether in the hospital setting or community pharmacy, pharmacists have opportunities to counsel patients and need to master the best way to illicit pertinent medical information from patients.  Pharmacists in the community are often pressed for time, and it is important to convey the critical counseling points to patients in a caring and knowledgeable way.  Lastly, communication between pharmacists is another area where being open and assertive allows workflow to go smoothly.  Pharmacists and technicians working together should be constantly communicating about tasks that need to be completed and patient care issues that require resolution.

There are countless times where communication is critical, and as future pharmacy educators we need ensure we train students to become excellent communicator.   In the article, “A Tool to Teach Communication Skills to Pharmacy Students” by Susan Hasan, students developed scripts to illustrate interactions between physicians and pharmacists.¹  Three different scripts were developed based on three communication styles:  assertive, aggressive, and passive.  One of the scripts was turned into a multimedia CD and used for future students.  This activity allowed pharmacy students to explore different communication techniques and improve their communication skills. 

For a majority of pharmacy students, clinical rotations are where they refine their professsional communication skills.  Optimally students should model the behaviors and communication style of their preceptors.  McDonough and Bennett describe several effective strategies for preceptors to improve pharmacy students communication skills.  This includes a thorough orientation to the practice site, establishing pharmacist-patient relationships, and using a counseling model.²  They emphasize that students cannot improve communication skills by just observing, but rather must participate in communication encounters.  The authors point out that feedback immediately after the student-patient encounter is critical as this will help students to improve.  The authors recommend that preceptors think of students as an extension of themselves and train them to be an active participant in the workflow of the practice.

During my advanced practice experiences as a student and now as a resident, I have noticed that medical students are taught about communication skills and case presentations very early in their education.  Beginning in their third year, medical students are required to do a patient presentation daily to the interdisciplinary team and to work throughout the day on patient care issues.  I think pharmacy students would benefit from earlier exposure to inter-professional interactions.  Even as first or second year students, I think activities requiring students to discuss patients with each other and present their pharmaceutical plans to preceptors would help them to improve their communication skills.  This could also be accomplished by having students practice counseling patients in front of other students, where feedback is provided at the end of the session.  By incorporating these informal activities earlier in pharmacy students’ education, it will help students gain confidence. 

One interesting and creative communication activity involves the use of simulated patients and video review.  In a study conducted at the South Dakota State University College of Pharmacy, video review increased first year pharmacy students’ counseling skill achievement scores and helped to develop their self-assessment skills.³  Video review really helps when giving feedback to students.  I think it is important to have informal opportunities for students to learn from video review prior to using video recording for assessment purposes. 

Communication skills must be taught and students can only improve their communication skills through practice.  I recommend a mix of formal assessment activities and informal opportunities to practice communication beginning early in pharmacy students’ education.  Informal activities can include having students present a patient to a faculty member or counseling a simulated patient as part of a group activity.  The formal and informal use of video review is also helpful.  Feedback by the faculty member and peers can be provided to each student following the activity. I think we teach pharmacy student to be excellent communicators, but only if we start early!

References

1. Hasan S. A tool toteach communication skills to pharmacy students. Am J Pharm Educ. 2008;72(3): Article 67.

2. McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effectiveprecepting. Am J Pharm Educ. 2006;70(3): Article 58.

3. Mort JR, Hansen DJ. First year pharmacy students’ self-assessment of communication skills and theimpact of video review. Am J Pharm Educ. 2010;74(5): Article 78.

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.