The Flipped Classroom – Turning Student Engagement Around

by Amanda R. Bertele, Pharm.D., PGY-1 Pharmacy Practice Resident, Frederick Memorial Hospital

Imagine that you are a second year pharmacy student enrolled in a pharmacokinetics course. Your professor assigns readings prior to the class. She then spends the two-hour lecture period with her back to the class deriving equations. You are dismissed from class with 20 practice problems for homework. The topic seems understandable during class and you think that your note taking skills are adequate.  But when you arrive home and begin working on the first problem, you soon realize that you understand very little about the information covered during lecture.  Moreover, your notes are incomplete because you could not type or write as quickly as the teacher was speaking. As you wade through the 20 problems assigned the homework grows increasingly frustrating.  You feel defeated and you decide that pharmacokinetics just isn’t “your thing.”

Source: http://elearningindustry.com/flipped-classroom-2012-infographic

How can this scenario be avoided? The answer may be the flipped classroom. The flipped classroom is a learner-centered teaching model that reverses or “flips” the order in which learners are exposed to new material.¹ In the model, new course material is covered prior to class using common instructional methods such as videos, readings, podcasts, or powerpoint slides with recorded audio. Presenting new material to students prior to class provides the opportunity for learners to view and review the material as many time as necessary until it is understood.² The scheduled class period is dedicated to hands-on activities requiring higher levels of cognition (analyzing, evaluating, and creating). Activities may include discussions, exercises, projects, or cased-based role playing.² Instructors often use class time to monitor student’s progress, guide them in their approach to learning, and revise course content based on student response.

One of the potential advantages of the flipped classroom is that the model facilitates the implementation of in-class activities that can appeal to multiple learning styles. During in-class activities the teacher is better able to spend one-on-one time with each student and to provide immediate feedback.³ Additionally, providing new course material in formats that may be viewed more than once can be especially helpful for students with barriers to learning (English as a second language, attention deficit disorder, hearing impairment).¹ To be successful, students are required to be self-motivated and active learners.

The flipped classroom is not a new instructional model as it contains elements similar to the Socratic method (5^th century BC) and has been implemented in traditional undergraduate courses like physics for decades.⁴ However, it is a model that gaining more attention in pharmacy education. Until recently there was little evidence demonstrating its effectiveness. In 2012, the University of North Carolina Eshelman School of Pharmacy assessed the effect of implementing a flipped classroom model in a pharmaceutics course on student academic performance, engagement, and perception.⁴ The intervention consisted of pre-class assignments including readings and pre-recorded video mini-lectures.  During each class period, four active learning exercises were implemented. The effectiveness of the active learning exercises were assessed using several methods including clicker questions, think-pair-share, student presentations and quizzes. The assessments allowed instructors to gauge students’ knowledge in real-time and deliver micro-lectures (1-3 minutes) to clarify key concepts. Students were also assigned 2 course projects, given multiple quizzes, a mid-term exam, and a cumulative final exam. Based on data collected using pre and post course surveys it was determined that learning foundational content prior to the scheduled class period significantly enhanced student learning of course material in class (p = 0.001) and interactive in-class activities significantly enhanced student learning overall (p = 0.01). After completion of the course, more students indicated that they preferred the flipped classroom structure over the traditional classroom structure (p = 0.001). Despite positive outcomes related to student engagement and perception, student academic performance based on examination scores was not significantly improved using the flipped classroom model when compared to the traditional model (p = 0.31).

While there are potential benefits of the flipped classroom, there are potential pitfalls that educators should be aware. The first is student workload.⁴ If careful consideration is not given to the length of videos or volume of reading required prior to class, students may become overwhelmed, show up unprepared for class, and unable to engage in the in-class learning activities. Educators should also consider the time and effort required to re-design lesson plans to fit the flipped classroom model.⁵ Educators will need to dedicate more time to evaluating activities and projects designed to assess student learning. Lastly, educators and students must have access to certain technology, like high speed Internet.

The flipped classroom method will probably never eliminate the need for traditional models of teaching but, it is a method that should be added to the teacher’s repertoire in higher education. When educators observe that lecture attendance is low, students seem bored during class, or when course material needs to be refreshed, the flipped classroom may be an effective strategy for re-engaging learners and teachers alike.

References

1. EDUCAUSE: uncommon thinking for the common good [Internet]. Washington, DC: EDUCAUSE. 7 things you should know about flipped classrooms; 2012 Feb 7 [cited 2014 Jan 26].
2. Vanderbilt University Center for Teaching [Internet]. Nashville, TN: Vanderbilt University. Flipping the classroom [cited 2014 Jan 26].
3. Knewton [Internet]. New York, New York: Knewton Service. Flipped classroom a new method of teaching is turning the traditional classroom on its head; 2011 [cited 2014 Jan 26].
4. McLaughlin JE, Griffin LM, Esserman DA, et al. Pharmacy student engagement, performance, and perception in a flipped satellite classroom. Am J Pharm Educ 2013; 77(9): Article 196.
5. Edutopia: what works in education [Internet]. San Rafael, CA: The George Lucas Educational Foundation. The flipped classroom pro and con; 2012 July 10 [cited 2014 Jan 26].

Sailing Towards a Port of Personal Goals

By Gloria Kang, Pharm.D., MBA, PGY1 Pharmacy Practice Resident, Shady Grove Adventist Hospital

“If one does not know to which port one is sailing, no wind is favorable” - Seneca

Source:  http://www.cepolina.com/photo/people/job/fisherman/b/fisherman-rowing-lost-boat.jpg

How many times have we lived without knowing what our purpose was? How easy is it to do something when we’re unaware of its importance? At these times we’re like a boat sailing around aimlessly to no end. So how do we get some direction? The Continuing Professional Development (CPD) model² can help put things into perspective.

The CPD model is a process that can be used to teach learners to improve any area of their life. There are five stages to this model that are interconnected: Reflect, Plan, Act, and Evaluate with Record and Review at the center.

Source:  https://www.acpe-accredit.org/pdf/images/CPDCycle2011Color.jpg

To set personal goals using the CPD model:

1. Reflect on living your life for your personal purpose and no one else’s. (Figure out which port(s) you want to sail to)

Goals derived intrinsically are more likely to be achieved when compared to extrinsic goals.³ When your goal is actually the goal set by someone else, intrapersonal conflict can arise, causing resentment and displeasure in attempting to achieve it.³ Do a self-appraisal of where you want to be, not where someone else thinks you should be.²

Think about “approach” and “avoidance” goals. (Do you know which ports you want to sail toward and the ones you don’t?) Approach are prevalent in individualistic cultures such as the United States (“the West”) and avoidance goals are more common in collectivist cultures such as Japan (“the East”).⁴ In the West, goals are focused on desired outcomes and how to move towards them (approach). In these cultures, each individual is expected to “stand out” and do their best.⁴  In contrast, in the East, individuals work to assimilate themselves and embrace unity.⁴ Thus, goals are based on what actions should be avoided so as to remain unnoticed.⁴  I am someone who was raised in the West with a heritage from the East. I believe any changes initially consider to be avoidance can be easily converted into approach goals. For example, instead of thinking I should avoid gossip, my goal could be to speak directly to individual with whom I have conflict.

2. Plan to make your goals S.M.A.R.T.² (Goals often go unachieved because the boat sails without a map to a destination port³)

Goals should be:

a.    Specific – this brings forth action towards the dream²

b.    Measurable – without this, how will you know you have grown closer to or reached your goal?²

c.     Achievable – with the limited resources we have, can the dream goal be reached?²

d.    Relevant – is the dream goal pertinent to you and your desired area of life?²

e.    Timely – without this critical piece, a dream goal will continue to be one²

Make separate changes for each important domain you live in. Domains of life include activities of daily living, professional, financial, social life, close relationships, physical health, emotions, and spirituality/se­nse of community.¹ For example, in activities of daily living, my lifestyle changes could be clean dishes after eating, vacuum every week, or throw away the trash before it piles above the top of the can. Whereas a SMART professional goal might be to read three articles in professional journals every week.

3. Put plan into action and avoid feeling happy simply because you accomplished a goal.^1,5 (Use your map, get sailing, and don’t let reaching that port be the end of your sea adventure)

Typically, goals are based on a hierarchy: at the top of a pyramid are peak goals – the furthest one can imagin­­­­e oneself from the present state. In the middle are distant goals that bridge lofty peak goals to task goals – those things that are accomplished daily to reach the peak goal.⁶ While a feeling of accomplishment may be appropriate in certain situations (e.g. completing a project for a class), it may not create the best mentality.⁶

In a study by Hadley et al, the investigators discovered that clinically depressed patients have goals and thoughts about the future; however, they tend to be conditional.¹ Conditional goals predicate individual happiness and self-worth on goal achievement.  Thus mental anguish can result from attempting to reach the goal through daily tasks.¹

Instead, do away with focusing on a goal and instead focus on daily commitment to change. Eventually, you will surpass that goal without creating cognitive pressure and anxiety to achieve it.  Moreover, you will benefit from the change you’ve adopted.⁵  For example, I want to run at least one marathon in my lifetime. This requires training by scheduling runs and increasing slowly until day of the race. After the marathon, I may not feel as motivated to stay in shape. What if, instead, I set a goal to run five miles three times weekly and made it a healthy lifestyle habit? In one year, I will have run nearly 30 marathon-equivalents with no artificial goal “event” that might trigger me to stop.

4. After every stage, evaluate how well Reflection, Plan, and Action, was completed. (Constantly evaluate how effectively you are sailing towards your port)

Repeatedly reflect and decide if what you are doing is contributing toward your goals. If so, give yourself some praise. If not, re-assessment and re-planning is warranted.²

5. Lastly, Record and Review your progress constantly. (Remember the paths you sailed for future reference)

This serves as documentation to help plan future actions.  You may wish to include some of your accomplishments on your curriculum vitae. During each evaluation step, this can be useful as a guide to help you remember where you are in reaching your goals. This record must be easy to understand and up-to-date.²

If you use the CPD cycle wisely, any wind will be favorable because you know to which port you are sailing, have a plan on how to get there, and will continually evaluate your progress.

References:

1. Hadley SA, MacLeod AK. Conditional goal-setting, personal goals and hopelessness about the future. Cognition and emotion 2010;24:1191-8.
2. Dopp AL, Moulton JR, Rouse MJ, et al. Continuing professional development (CPD). Written 2009. Accessed 11 Feb 2014.
3. Downe M, Koestner R, Horberg E, et al. Exploring the relation of independent and interdependent self-construals to why and how people pursue personal goals. J Soc Psychol. 2006;146:517-31.
4. Elliot AJ, Sedikides C, Murayama K, et al. Cross-cultural generality and specificity in self-regulation: avoidance personal goals and multiple aspects of well-being in the United States and Japan. Emotion. 2012;12:1031-40.
5. Clear J. Forget setting goals. Focus on this instead. Written 17 Dec 2013. Accessed 8 Feb 2014. 
6. Masuda AD, Kane TD, Shoptaugh CF, et al. The role of a vivid and challenging personal vision in goal hierarchies. J Psychol. 2010;144:221-42.

Is Continuing Education Really Worth It?

by Brittany Palasik, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

My parents are both pharmacists practicing in the state of Maryland.  Over the years, I have attended many continuing education sessions with them.  I have snored through most, but was intrigued by some of the topics discussed.  Some pharmacists are so specialized now, that it seems useless to spend time learning topics that don’t directly pertain to their specialty. How essential is it to learn topics that seem unrelated to your scope of practice?

Continuing education (CE) is required by law for many health professionals.  The Accreditation Council for Continuing Medical Education describes the importance of maintaining knowledge for health professionals.¹  Indeed, knowledge has been moving forward increasingly fast and health professionals need to continually learn the latest information in science and medicine. However, many healthcare professionals complain about the extra work required and wonder if CE is actually beneficial.  I decided to investigate the pros and cons of continuing education.  Is it really necessary?  After all, aren’t we all supposed to be learning on the job every day? 

Why Require CE?

Fact:  CE has been directly correlated to positive health outcomes.²

In a study completed by the American College of Surgeons, continuing education resulted in reduced morbidity and mortality rates for surgeons performing segmental colon resections as well as repair of ruptured abdominal aortic aneurysms.  Additionally, rates of myocardial infarction were lower in cardiologists who had participated in continuing education, than those who had not.²  

Fact: CE can improve knowledge in the short- and long-term.³

Twenty eight different studies were examined by the Johns Hopkins Evidence-based Practice Centre to determine the efficacy of continuing education.  Twenty-two (79%) of the studies showed knowledge improvement, whereas only 4 (14%) of the studies showed no difference in knowledge (2 studies [7%] had mixed results).  These same 28 studies were evaluated through follow-up and resulted in 15 studies (68%) demonstrated long-term knowledge retention.³

Why shouldn’t we require CE?

Fact:  CE programs can be biased.

        

All too often health professions will obtain most of continuing education funding from pharmaceutical companies.  This can introduce bias, as each company can influence the subject matter.  Additionally, this can reduce the availability of content that may be relevant for contemporary practice but which is not within the business interests of the sponsor.² For example, a new guideline that is important for the healthcare community may not be promoted through continuing education because the guideline does not favor the use of more expensive brand-name products.   

Fact:  CE is time-consuming.

In Maryland, 30 hours of approved continuing education must be completed by pharmacists within 2 years in order to renew licensure.  Two of these hours must be live sessions.⁴ Some pharmacists complain that 30 hours is a large amount of time to dedicate to continuing education.  Some pharmacists and other healthcare professionals believe that they learn every day through their work activities and this extra work should not be required.

For those who believe CE should be required, the evidence suggests, that under optimal conditions, continuing education is beneficial.³ But CE isn’t without problems.  Its potentially biased and requires an investment of time and money. I think we can all agree that poorly designed instruction that’s not engaging or relevant to the audience is unlikely to lead to improvements in practice or patient care outcomes.  How can we ensure that healthcare professionals are getting a snooze-free, informative, knowledge refresher that improves their skills and the care of patients? 

How can we improve CE?

A systematic review completed evaluated different forms of educational techniques including live sessions, computer-based instruction (off-line and online real-time), videos, audio recordings, handheld materials such as laminated cards, and printed documents (articles and monograph).³  Simulations and other interactive lessons, whether online or in person, were the most effective.  There was no differences found in any of the other instructional techniques when used alone. However, there was a significant difference when instructional techniques were combined.  So, by combining different techniques such as videos, hand-outs, and live simulations, continuing education can produce significant improvements in healthcare practitioner knowledge and skills.  It was also shown that repetition led to improvements in short and long-term knowledge retention.

There are many recommendations to reduce the potential bias due to commercialism.  Increasing awareness among healthcare providers regarding the potential bias within continuing education programming seems to be the best first step.  By revealing the possibility for bias, professionals may be more apt to critically evaluate continuing education programs.  Other suggestions include requirements mandated by the Accreditation Council for Continuing Medical Education (ACCME):⁵

1. Compiling a list of (that year’s) most important topics

2. Requiring proper disclosure of amounts received for funding

3. Limiting the amount of funding received from commercial entities or completely removing commercial funding.  

Lastly, there has been a lot of hype about implementing the Continuous Professional Development (CPD) Model.  The CPD differs from traditional CE in that it incorporates practice-based learning.  The goal is to improve performance of healthcare providers and to individualize objectives for a particular person or organization.⁶

Figure 1

Source:  https://www.acpe-accredit.org/pdf/images/CPDCycle2011Color.jpg

The CPD cycle (Figure 1) begins with self-appraisal: the individual reflects upon his or her own experiences, strengths, and weaknesses.  Then the individual creates a personalized learning plan, implements it (with documentation of course!), and evaluates the efficacy of what’s been learned.  The circle metaphorically represents the never-ending cycle of knowledge and skill development in healthcare.  As healthcare professionals, we have to continually learn new advances and skills if we want to make a positive impact in patients’ lives.⁶

References

1. Why Accredited CME is Important: CME That Supports a Lifetime in Medical Practice [Internet]. Chicago, IL: Accreditation Council for Continuing Medical Education; 2012 [cited 5 Feb 2014].
2. Ahmed K, Wang TT, Ashrafian H, et al.  The effectiveness of continuing medical education for specialist recertification. Can Urol Assoc J. 2013;7:266–272.
3. Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness of continuing medical education. Evid Rep Technol Assess 2007;(149):1–69.
4. Pharmacy Laws and Regulations for the State of Maryland. 14^th ed. Baltimore, MD: Maryland Pharmacists Association; 2014. P. 297
5. Harrison RV. The uncertain future of continuing medical education: commercialism and shifts in funding. J Contin Educ Health Prof. 2003;23:198-209.
6. Rouse MJ. Continuing Professional Development in Pharmacy. J Am Pharm Assoc. 2004;44:517-520.

Teaching e-Professionalism

by Katie Brant, Pharm.D., PGY1 Pharmacy Practice Resident, the Johns Hopkins Hospital

Facebook, Twitter, Pinterest, YouTube, Instagram, LinkedIn … the list goes on and on. Social media has an increasing presence in our society and professional students are not immune to this cultural shift towards information sharing and social openness. As the social media and online forums grow, health professionals and students have more opportunities to interact with colleagues, patients, and faculty online — whether it is via email, social networking, blogging, or tweeting. My personal experience with social media began as an undergraduate student when Facebook was first emerging, continued through pharmacy school, and into my residency training. As a professional student, I can remember wondering if social networking websites were appropriate, whether I needed to change my profile when applying to post-graduate residency programs, where the line between my personal and professional life existed online, and how I was representing myself and my profession via social media. Professional students and faculty must make decisions regarding online social media resources and online communication etiquette; decisions that could potentially impact their careers.

Professionalism in the online domain, or e-professionalism, has become a significant issue in health professions education as well as practice. One of the goals of professional education is to instill values and a sense of responsibility in students.  E-professionalism is no less crucial than more traditional forms of professionalism and should be taught in the professional curriculum. E-professionalism has been defined by Cain and Romanelli as “the attitudes and behaviors (some of which may occur in private settings) reflecting traditional professionalism paradigms that are manifested through digital media.”¹ E-professionalism not only encompasses professional behavior on social networking sites but also proper online communication etiquette, also termed “netiquette.” Netiquette includes using appropriate terms and tone when writing emails or posting on online discussion boards.¹

Through the use of social media sources, a professional student creates an “online persona” based on choice of photographs, group affiliations, posts, and comments.¹ Students digress from professional norms when they post derogatory comments about their educational institution, post pictures of drug or alcohol abuse, affiliate with groups that are disrespectful of certain races or sexualities, and post private patient information on public domains.¹

Many health care institutions including The Ohio State University Medical Center, Mayo Clinic, and University of Maryland are now instituting policies with guidelines regarding use of social networking by employees in order to protect the reputation and privacy of their employees and the institution.² The Ohio State University Medical Center now has Social Media Participation Guidelines which outline rules that employees are expected to follow when using social media sites. These rules prohibit using social media sites during work hours, using of a work email address on social media sites, and attributing any opinions or comments posted on a website to the institution.²

This then begs the question of how e-professionalism should be taught and when it should be introduced to professional students. Many universities already incorporate a professionalism course or module in their curricula.  Spending some time discussing e-professionalism would be a relatively seamless addition to these courses. Kaczmarczyk and colleagues recommend focusing on instruction regarding about e-professionalism and how it reflects professional values, ethics, and integrity. Educators can develop course materials that give students examples of what is acceptable online behavior and behaviors to avoid.² Instructors should have students to evaluate online posts, discuss aspects of professionalism with peers, and reflect on how postings may be interpreted by outside viewers.²  It is also important that the institution’s honor codes and policies include e-professionalism too.¹

Although there are limited data regarding best practice approaches to incorporating e-professionalism into the professional school curricula, there are many examples of how to effectively teach the general principles of professional behavior that could be applied.³ One example described in the literature comes from Auburn University’s Harrison School of Pharmacy (AUHSOP). This school promotes the development of professional behaviors from admission to graduation.  New students and recently hired faculty go through orientation to learn about the school’s culture as well as the values and expectations regarding professionalism and integrity. Professionalism behaviors are evaluated and acceptable performance is required for academic progression.  Severe professionalism lapses can lead to student dismissal. This curricular design instills the culture of professionalism and integrity at the very beginning of the students’ academic career.  Hopefully these behaviors and values continue beyond graduation.

I believe that incorporating e-professionalism instruction throughout the curriculum would be the most effective strategy for changing students’ perceptions and practices. New student orientation would be an ideal time to introduce the concept. Educators could discuss the importance of maintaining a professional online persona and conduct a workshop in which students evaluate social media profiles.  This would make the instruction more practical and relevant.  To reinforce what was taught in orientation, there could be an online module reviewing e-professionalism principles that students are required to complete annually. Finally, given that potential employers or residency directors may utilize social media websites when screening candidates, e-professionalism should be explored again a few months prior graduation.

Ness and colleagues conducted a study in which a survey was distributed to graduating pharmacy students at several Midwestern schools of pharmacy.⁴ A vast major (93%) of the pharmacy students used social media websites.  More importantly, 74% felt that they should edit their social media profiles before applying for jobs. Thus the prevalence of social media use is high among professional students and students understand the importance of censoring publically available information in order to portray a professional persona.

While social media and online communication is increasingly common, educating students about professionalism and role modeling appropriate behavior is not a new idea. Educators (and preceptors) should provide instruction on e-professionalism and online etiquette to help prepare the next generation of professional students for a successful career.

References:

1. Cain J, Romanelli F. E-professionalism: A new paradigm for a digital age. Currents in Pharmacy Teaching and Learning 2009;1:66–70.
2. Kaczmarczyk JM, Chuang A, Dugoff L, et al. e-Professionalism: a new frontier in medical education. Teaching and Learning in Medicine 2013; 25(2): 165-170.
3. Berger BA, Butler SL, Duncan-Hewitt W. Changing the culture: an institution-wide approach to instilling professional values. Am J Pharm Ed 2004; 68(1): Article 22.
4. Ness GL, Sheehan AH, Snyder ME, et al. Graduating pharmacy students’ perspectives on e-professionalism and social media. Am J Pharm Ed 2013; 77(7): Article 146.