Role Modeling: The Forgotten Influence

by Ashley Janis, Pharm.D., PGY1 Pharmacy Practice Resident, the Johns Hopkins Hospital

The role of an educator, in the classroom and in practice, is to foster learning and serve as a role model.  Role modeling can be defined as teaching by example and influencing people in an oftentimes unintentional, unaware, informal, and episodic manner.¹ Thus, we all serve as role models for learners in our field through our routine actions.  Role modeling has often been referred to as the “hidden curriculum” of professional education as we often lack understanding regarding the influence role modeling has on learners.¹ Students learn behaviors that appear successful to them in light of their personal goals and rewards.  This is a foundational principle of social learning theory and how role models exert influence on others.

In a study published in 1997, researchers at the McGill University School of Medicine examined opinions of fourth year medical students using a questionnaire.³  Ninety percent of the responders identified one or more role models during their training.³ Many (35%) indicated that resident physicians were the most influential role models during the clinical portion of their academic training.² This finding demonstrates that pharmacy residents have a profound effect on student pharmacists.  As pharmacy residents, we have frequent interactions with students.  It may be easy to forget that we have an obligation to be a positive model of pharmacy practice.

Several common factors were consistently ranked high when students selected role models: personality, clinical skills and competence, teaching abilities.² Interestingly, position, academic rank, research experience, and publications were less important.² This finding suggests that is it not just the well-established, published, infamous leaders who are revered as models.  Instead, professionals of all age and rank may be influential.

Role models were not only important in helping students develop their knowledge and skill but 57% of students claimed their role model influenced their decision regarding their clinical specialty for residency training.²  Thus, the potential impact of a role model is very significant and can shape and inspire a career. 

While role models often influence learners in positive ways, it is important to discuss the potential for a negative impact.  In a study surveying students at the University of Texas Medical Branch in Galveston, the professional behavior of faculty and residents was examined.⁴  The authors found that the preceptors scored lowest on the following behaviors:  1) use of constructive criticism instead of backbiting about peers, and 2) consulting others when they lack the required knowledge.⁴  Prior research noted that students find bad-mouthing others as the most unprofessional behavior of faculty.⁴ Making negative comments about a specialty may discourage or decrease recruitment into that field.¹  And, it might incite pessimistic attitudes towards a learner’s chosen profession.¹  As we are emerging leaders and role models for future generations of pharmacists, we must hold ourselves to higher standards.  Negatively discussing colleagues sets a poor standard for ourselves and may also encourage bad habits.  In order to cultivate positive relationships between disciplines, we must refrain from voicing negative personal opinions in workplace conversations. 

To become positive role models, we must understand how our behavior affects others.  “Silent modeling is inadequate as a strategy.”¹ Where do we begin?  Role models must pay attention to their individual acts, encourage teamwork, and support others in their growth and development.⁵   Ideal role models inspire and teach by example.  The key is to be self-aware and self-critical.⁶

In order to change our behavior, we need to have the desire to improve and the insight to identify our strengths and weaknesses.⁶ Being self-critical of our current positive and negative actions in the workplace, allows us to develop personal improvement plans.  Self-reflection has two forms: “reflection-in-action,” thinking about changing the experience while it is underway, and “reflection-on-action,” critically evaluating an experience once it has passed.¹ Both are valuable tools to encourage change, and learner evaluations are a key source to identify areas of potential improvement.  Encourage your learners to critically evaluate you as a preceptor.  Skills to evaluate might include your ability to encourage teamwork and solve challenging problems with composure.  This may not be on the standard evaluation form, but it is appropriate to ask learners to evaluate you as a role model and as a source of clinical knowledge.  As you achieve positive marks, add new professional goals for learners to evaluate.  In this way, you have used your self-reflection and created a process to evolve and grow as a model.

Learners must learn to “talk the talk, and walk the walk.”¹ In this dynamic teaching method, role models talk through activities, explain their thought process, and allow for learners to discuss their own ideas and methods.¹ In this coaching method, students engage in the actions of their model, and receive verbal feedback.  For example, a preceptor on rounds may have a student observe the first day to familiarize with the experience.  After rounds, this preceptor can break down their thought process for recommendations by working through a patient with their learner.  In the following days, students learn how to model the appropriate behavior by presenting recommendations to both their preceptor and team, receiving feedback and constructive comments all the while.  We must set expectations.  If we fail to set appropriate guidelines for behavior, we have no basis for constructive criticism and students may feel lost without guidance.

Think back to the people who had a positive influence on your development and career choices.  Let their strengths serve as guide in your career.  When we become the person to be emulated, we have a profound effect on others.

References:

1.  Kenny NP, Mann KV, MacLeod H. Rolemodeling in physicians’ professional formation” reconsidering an essential butuntapped educational strategy. Academic Medicine 2003; 78: 1203-1209.

2.  Asghari F, Fard NN, Atabaki A. Are weproper role models for students? Interns’ perception of faculty and residents’professional behavior. Postgrad Med J. 2011;87:519-523.

3.  Wright S, Wong A, Newill C. The impact ofrole models on medical students. J Gen Intern Med. 1997; 12: 53-56.

4.  Szauter K, Williams B, Ainsworth MA, et al. Student perceptions of the professional behavior of faculty physicians. MedEduc Online. 2003; 8: 17.

5.  Macaulay S. Are you a good role model? Think:Cranfield. Feb 2010. Accessed 24 Nov 2012. 

6.  Ray S. Role Models. BMJ Careers. 13 Mar 2010. Accessed 24 Nov 2012.

Teaching Student Pharmacists to Be Patient-Centered

by Jenna Klempay, Pharm.D., PGY1 Community Pharmacy Practice Resident, University of Maryland School of Pharmacy

When teaching students how to provide pharmaceutical care, pharmacy educators have emphasized providing personalized, patient-centered care.  It is no longer acceptable to paternalistically tell patients how to take their medications and manage their disease states.  Student pharmacists are being taught to listen to the patient and tailor therapy to suit the patient’s lifestyle.  Evidence shows there is a positive correlation between patient-centered communication and improvement in health outcomes.¹  But given the subjective nature of the topic, it can be challenging to teach “patient centeredness.”  I believe pharmacy schools need to do a better job teaching this concept and emphasizing it throughout the curriculum.

Explaining terms to students like “empathy”, “compassionate care”, and “active listening” and role-playing how to provide patient-centered care is a good start.  But it’s not enough.  In order to really open the eyes of the student to the humanism of pharmaceutical care, the curriculum needs to include reflective learning activities.  One pharmacy school has developed a course that utilizes reflective and discovery learning to explore how pharmacists can improve interpersonal connections with their patients and facilitate healing, both physically and mentally.¹

The University of California-San Francisco (UCSF) School of Pharmacy offers a one credit elective course titled, The Healer’s Art.  It is modeled after a course developed for medical students taught by Dr. Rachel Remen of the UCSF School of Medicine.  The course is offered at medical schools across the nation, but UCSF is the first pharmacy school to offer it to student pharmacists.²  

The course includes three major instructional methods:

• Case studies shared by guest health care practitioners
• Student/faculty reflection in small groups
• Journaling between sessions

The course includes five sessions covering different topics intended to meet the course goal: understanding the “value of being ‘fully’ present and attending with heart” to patients:²

• Session 1:  “Tending to Our Patients” focuses on being fully present and attentive to patients in an appreciative and non-judgmental way.²
• Session 2: “Tending to Ourselves” challenges the students to reflect on the importance of caring for oneself and having a balance in life in order to offer “mindful, heart-based work”.² 
• Session 3:  “Tending to Life Changes” reflects on physical, mental, and emotional effects of life and how being present and listening with heart can be meaningful in healing.²
• Session 4:  “Tending to Appreciation and Alignment” offers an opportunity to recognize the joy of the profession in giving to others and also serves as a reminder of the impact pharmacists can have on the well-being of their patients.²
• Session 5:  “Translating Heart Matters into Practice” allows students to reflect on their experience and recognize the value of creating “safe places” for patients when developing a pharmacist-patient connection.²

Students are evaluated on their competency based on faculty observations during small group sessions, a review of each student’s reflective journal, and a questionnaire at the end of the course.

Students indicated that the course was a positive experience, they learned how to listen ‘with heart’, and they felt more comfortable dealing with emotional situations.  In addition, this class enriched their view of professional practice.²  Students felt empowered to “address the emotional needs of patients and their families” and understood that emotional needs can contribute to and complicate a patient’s condition.²  This class is an excellent example of how to teach students to be more patient centered and facilitate their growth as professionals.

The key to providing patient-centered care is not merely recognizing the illness, but also understanding the attitude or perception the patient and creating a way to provide care in a manner that is conducive to healing.³  By teaching students from the beginning how to provide this type of care, we can stop them from developing poor patient care habits.  All too often, students are taught by preceptors who have become cynical, burnt out, and accustomed to suppressing their emotions and treating patients more like disease states than humans.  It is important for educators to teach students how to keep their hearts alive in settings where many lose heart.  When students begin experiential learning, they will encounter patients suffering and dying.  Students need to be prepared to face these realities and help patients, families, and caregivers.  The pharmacy curriculum should teach humanism just as much as it prepares students to be knowledgeable about pharmacotherapy.

Effectively teaching students to practice with their hearts requires a different approach.   Typical didactic teaching won’t work.  Patient centeredness cannot be taught through a series of lectures.  It requires reflection.  Reflection is more likely to lead to deeper learning and meaningful change.  Reflection can be prompted through stories about one’s experiences, journaling, and small groups discussions.  Students should be encouraged to express their feelings.  This can only be fostered by creating a safe classroom environment where students feel comfortable opening up and sharing personal thoughts.  The classroom environment should emulate the type of environment the student should one day create for his or her patients.  Finally, an affirmation activity during the last class session will facilitate the transfer of the classroom experience to the clinical setting.  An affirmation activity consists of each individual sharing positive remarks about how the student can make a difference in the lives of patients.  This activity will give students confidence in their ability to care compassionately for patients and encourage them to take what they have learned into practice.

UCSF provides a great model for how to teach a topic that is not easy to teach.  While this class is a great start, a one-credit course is not enough.  If we want to mold our students into patient-centered practitioners, this kind of reflective learning should occur during all four years of pharmacy school.  Yes, the curriculum is already crammed full, but one potential solution is to hold a yearly class retreat for students to revisit important concepts of humanism.  Clinical faculty and preceptors should be invited to this retreat to renew their hearts and reaffirm the qualities that make them caring practitioners.  Since these pharmacists are mentors and role models for students, it is important that they model for students patient centeredness in their words and actions.

Dan Pink, keynote speaker of the 2007 AACP Annual Meeting, advised pharmacy educators to “challenge students to mature into holistically oriented healers, knowledgeable about the whole person with whom they soon will be establishing healing relationships.”⁴  Students need to be taught that the pharmacist-patient interaction is just as important as the technical services and the medications we provide.  Medications are not enough.  By providing compassionate care, we have the ability to heal with our hearts as well.

References

1.  Stewart M. Towards a global definition of patient centered care. BMJ 2001;322:444-5. 

2.  Vogt EM and Finley PR. Heart of pharmacy: Acourse exploring the psychosocial issues of patient care. Am J Pharm Educ. 2009; 73(8): Article 149.  

3.  Sánchez AM. Teaching patient-centered careto pharmacy students. Int J Clin Pharm. 2011;33:55-57.  

4.  Maine L. and Vogt E. The courage to teach caring. Am J Pharm Educ. 2009;73(8) Article 138. 

When we strengthen our weaknesses do we weaken our strengths?

by Roshni Patel, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Maryland School of Pharmacy

Let me use this musing to tell you about what’s right with people.  And why we should pay more attention to people’s strengths and less to perceived weaknesses.

As educators, we look to employ new and creative instructional strategies to help strengthen the weaknesses of our students to ensure competence.  The feedback and evaluations that we provide our students are typically aimed at addressing students’ deficits.  But perhaps we have it all backwards.  If we utilize all of our time developing weaknesses, what happens to the innate strengths that students possess?  Is there a possibility that if they don’t ‘use it’ they’ll ‘lose it’ as we claim applies to so many of our skills?  I think so.

Tom Rath is leading business consultant on Wall Street and one of the best selling authors over the last decade.  He has drawn attention to our fundamental weakness (no pun intended) for focusing so much of our time and energy on shortcomings rather than capitalizing on strengths.¹  In his book Strengths Finder 2.0 he encourages readers to redirect attention toward what they do well, which he believes is the key to a greater well being. Specifically, he believes that not enough people have the opportunity to do what they do best at work each day.  But they can…

This notion that Rath discusses within the context of business is relevant to the world of academia too.  In fact, paying greater attention to our strengths easily integrates with core educational theories.  For example, one of the guiding principles of constructivism is the search to understand the world in which we live in.  Within this theory of learning, students are encouraged to interpret and judge their own progress as they take ownership of their learning experience.  If we devote time to helping students to first understand their talents, they can then invest in those skills.   Rath argues that raw talent needs to be cultivated, and the student aware of his or her talents will be fully engaged, challenged, and interested in their own application of their strengths to their experiences. 

What about behaviorism?  Is an emphasis on strengths compatible with this theory?  We tend to reward our students when we recognize improvements in their behaviors, and there is tons of empirical data to show that we can train people to produce a specific response.  But why not change the stimulus?  Lets reward our students for recognizing their talents and condition the learners to respond appropriately to their own strengths.  Rath’s book does just that.  In addition to identifying the readers’ strengths, the book supplies ideas for action that help readers apply their strengths to every day living and practice. 

Critics of Strengths Finder 2.0 argue that it’s just another personality questionnaire, but I strongly disagree.  The raw personality of Bill Clinton does not show his strengths.  And, his strengths are not equivalent to his personality.  I also believe that so many of us do not truly know our strengths.  Sure, we all ramble off a laundry list of so-called strengths during professional interviews – ones we have written down and memorized, ones we feel will win us the job.

Let me be clear. I am not promoting the absolute disregard of evaluating our weaknesses. There is clear benefit in recognizing the skills we lack (and need).  And we should try to improve weakness that make less effective.  But what I’m recommending is a redistribution of our time and attention.  If we agree with David Kolb that individuals learn in different ways, then we have to acknowledge the baseline characteristics of our learners.²  And that should include their strengths.  If we understood the intrinsic strength of our learners better, we could facilitate learning experiences around their talents.  Ultimately, I believe, this strategy will prevent creating people who are a jack-of-all-trades and a master of none.  If the students are aware of their strengths, they can utilize their professional education to develop their application of those strengths. Have I said it enough, yet?

Teach with Your Strengths is a book written by educators who have devoted their lifetime to applying this simple philosophy into their own behaviors in the classroom.³  This book demonstrates the use of personal strengths to facilitate leadership in the classroom in order to avoid mediocrity.  Although many educators who follow this philosophy, not nearly enough do.  And if we are to encourage our students towards the application of their strengths, let us first lead by example.  Are you thinking social learning theory?  I am.

Let me leave you with this final thought:

“Most people think they know what they are good at. They are usually wrong… and yet, a person can perform only from strength.” – Peter Drucker

References:

Rath, T. Strengths Finder 2.0. New York: Gallup Press; 2007. 174 p.

Kolb AY, Kolb DA. Learning styles and learning spaces: enhancing experiential learning in higher education. Acad Manag Learn Edu. 2005 Jun;4(2):193-212.

Liesveld R, Miller J, Robison J. Teach with Your Strengths: How Great Teachers Inspire Their Students. New York: Gallup Press; 2005. 205 p.

Simulating Experiences in Pharmacy Education

By Xiaoxue Nehrbass, Pharm.D., PGY1 Pharmacy Resident, Johns Hopkins Bayview Medical Center

What is simulation? According to the Accreditation Council for Pharmacy Education (ACPE), simulation is an activity or event replicating pharmacy practice.¹ Simulation experiences may include the use of high- or medium-fidelity manikins, standardized patients, standardized colleagues, role play, and computer-based exercises.¹  Benefits of these experiences may include enhancements in student knowledge and clinical performance, improvements in critical thinking and student confidence, as well as reductions in medication errors.² In the latest version of its Accreditation Standards and Guidelines, ACPE states that colleges and schools of pharmacy may choose to incorporate simulation into introductory pharmacy practice experiences (IPPEs) but it can not exceed 20% (60 hours) of the total IPPE requirement (300 hours).¹

In April of 2011, watching the first Inter-professional Critical Care Simulation that took place at Universities at Shady Grove, I was impressed by how high-fidelity simulation technology brought the health professional disciplines on our campus together.  I learned first-hand the importance of interdisciplinary collaboration in a healthcare setting to optimize patient care. High-fidelity simulation has been widely used in other health professional schools, such as medical and nursing education. The high-fidelity manikin mimics a real patient with computerized programmable physiological responses to disease states and medication treatments.² Similar to a real patient, the manikin can talk and breathe, has heart sounds and palpable pulses.  Simulations can include cardiac and pulmonary arrest, anaphylactic reactions, myocardial infarction, stroke and other scenarios.² In one recent study, a group of fourth-year pharmacy students (in a five year program) used high-fidelity simulation in a series of courses.³ The scenarios included various exercises such as drug-drug interactions, intravenous drip rate calculations, medication recommendation, physiological changes, as well as patient education.³ In addition to the patient (manikin) and pharmacy students, these scenarios also included role plays with physicians, nurses, and family members. Interestingly, the role of family member was played by a standardized patient, who displayed certain emotional responses during the simulation in response to the care provided to patient (manikin). The study showed that when compared to students who did not participate in the simulations, students who experienced the simulations felt more confident in making recommendations to other healthcare providers.³ Additionally, over ninety percent of students reported that simulation enhanced their learning compared to didactic lecture alone.³ As this study has shown, high-fidelity simulations can help to enhance clinical knowledge in various acute care scenarios, improve communication skills and build confidence.  But high-fidelity manikins aren’t cheap!  The cost can range from $16,000 to $90,000 depending on the model.²

Computer-based virtual patient technology offers another type of simulation experience. At the end of the ACLS/BLS training program I completed a few months ago, online simulation technology allowed me to practice the skills and knowledge I had learned, and to make assessments and decisions in a virtual environment. I valued the simulation component of the program because it allowed me to use newly acquired knowledge to create solutions during plausible situations. Throughout each simulation scenario, I learned quickly what I did wrong and the potential (positive or negative) consequences my decisions may have had on my virtual patient. According Jabbur-Lopes and colleagues, one advantage of using virtual patients in patient counseling is that a virtual patient can exhibit various psychological states, such as angry, anxiety, ambivalence, passivity, assertiveness, and persuasiveness.⁴ Through the use of virtual patient technology, students can practice counseling skills with a wide range of patients. Despite these benefits, Jabbur-Lopes and colleagues found that this type of simulation is underutilized in pharmacy education.⁴

For me, the most realistic patient counseling simulation experiences were my encounters with standardized patients. As actors who have been trained to play the role of real patients in specific scenarios, standardized patients not only perform, but in many cases, evaluate the student’s interviewing skills during the counseling session. My personal encounter with standardized patients came during the University of Maryland’s required Objective Structure Clinical Exam (OSCE), a comprehensive assessment that required students to use a wide range of knowledge and skills learned throughout pharmacy school. The counseling sessions were taped and standardized patients evaluated our performance.

To best serve students, programs must evaluate each type of simulation for its strengths and weaknesses. High-fidelity simulation may be an effective teaching tool in an urgent care scenario occurring in the acute care setting. It allows participants to enhance interpersonal skills through team building exercises. The high costs of this simulation tool may, however, be a barrier at some institutions. In addition, it may not be appropriate or efficient to use high-fidelity simulation in less acute situations which do not require close monitoring of the patient, such as counseling on management of chronic disease states. On the other hand, virtual patient technology offers an advantage of accessibility and convenience. It also provides hands-on experience students may need when learning a complicated concept or procedure. Finally, standardized patients may be most beneficial when used in assessing students’ interviewing skills and clinical knowledge. This experience will also prepare them to enter the profession and face real world situations.

With the continued expansion of pharmacy schools and ACPE’s increased acceptance of simulation has part of the IPPEs, simulation experiences should play a larger role in pharmacy education.  Using these types of teaching tools helps students gain the skills and confidence to enter advance pharmacy practice experiences.  Simulations are an innovative and effective way of providing training in an evolving academic landscape.

References:

1.  Accreditation Council for Pharmacy Education. Accreditationstandards and guidelines for the professional program in pharmacy leading tothe doctor of pharmacy degree. Chicago: Accreditation Council for Pharmacy Education; 2011. [cited 2012 Oct 29]

2.  Seybert AL. Patient simulation in pharmacy education. Am J Pharm Educ 2011; 75(9): Article 187. [cited 2012 Oct 29]

3.  Vyas D, Wombwell E, Russell E et al. High-fidelitypatient simulation series to supplement introductory pharmacy practice experiences. Am J Pharm Educ 2010; 74(9): Article 169. [cited 2012 Oct 29]

4.    Jabbur-Lopes MO, Mesquita AR, Silva LM et al. Virtual patientsin pharmacy education. Am J Pharm Educ 2012; 76(5): Article 92. [cited 2012 Oct 29]