Professional Education in < 140 Characters: A Tweetorial

by Emily Wiener, PharmD, PGY1 Pharmacy Practice Resident, Sinai Hospital

The internet has changed nearly every aspect of our lives. The way we communicate, shop, and learn has fundamentally changed. Websites abound with information which can be accessed nearly instantaneously. Social networking sites and instant messaging applications allow us to connect with people worldwide with a simple click of the mouse or tap on the screen. Although many social media tools were originally developed for, well, socializing, many of them can be used for professional and educational purposes as well. I was first introduced to the idea of Twitter for professional education during my first advanced pharmacy practice experience (APPE). My preceptor (@PharmERToxGuy) along with a number of the medical residents and attending physicians actively sent and received messages on Twitter. They used Twitter as a means of sharing clinical pearls, staying up to date on literature, and connecting to others in their specialty worldwide. I, in jest, joined Twitter as my "final project.” Since then I have been surprised by what I’ve learned. But the use of social media sites is not risk free, especially in educational settings. It can compromise the authority of the teacher-learner relationship and blur the lines between professional and personal life. In health professional education, there’s the added risk of compromising patient anonymity. Twitter use, as with most things, is all about the risk/benefit ratio. How does one minimize these risks and maximize the quality learning opportunities available through Twitter?

Twitter has been adopted in various educational settings as a means to dialogue with and engage learners as well as a forum for sharing knowledge.  This practice has been slowly adopted in health professional education. The first paper regarding Twitter’s use in health professional education was published in 2009.¹  Several reports have been published since. Most are descriptive in nature. They address a variety of uses including "Tweeting the Meeting", evidence based tweeting, learner engagement, blog dissemination, and networking.^1-6

With the increased use of social media, many journals have added social media editors to their editorial team in an attempt to increase readership. The Journal of Continuing Education in the Health Professions appointed Alexander M. Djuricich, MD to this position in 2014. In an article he wrote describing his position, he explained that one goals is "to connect with the continuing education and continuous professional development community beyond the traditional peer-reviewed publication format."² Other well-known journals including the Journal of the American Medical Association (JAMA) and the British Medical Journal (BMJ) regularly send evidence-based tweets (EBT) to their followers.² These tweets generally contain a brief description or pearl along with a link to the original source. The link provides followers direct access to primary literature from an array of journals which are relevant to practice. Learning who the right people, organizations, and journals to follow is key to finding quality Tweets.  Strategically employing hashtags is another tactic to maximize learning.

“Tweeting the meeting” has increased substantially over the past few years at national conferences. Many medically related conferences now have their own hashtag(s) including the largest pharmacy conference, the ASHP Midyear Clinical meeting (MCM). Audience members can interact with speakers, ask questions, make comments, and archive information for retrieval after the meeting. At the ASHP MCM in 2013, 31% of postings were related to specific educational sessions.³

The use of Twitter in conferences isn't limited to large, national gatherings. Local conferences such as grand rounds and weekly resident conferences have also created hashtags and taken to tweeting the meeting.⁶ This allows clinicians with similar interests in different geographic locations to share experiences and improve their practice. In March 2012, a hospital in Indiana started tweeting grand rounds. There were 613 tweets sent from 17 consecutive grand rounds presentations.⁴ Tweets came from users physically attending as well as those following asynchronously. This breakdown of geographical barriers engages learners and maximize learning opportunities.

There are a few simple tips to maximize your Twitter experience. The quality of your Twitter feed is directly related to who you follow. Be selective!  Identifying experts in your specialty area is key to increasing the quality of the Tweets you read. Even when following the “right” people (the so called twitterati), it’s important to maintain a skeptical eye. Remember, Tweets are not always evidence based and they certainly aren’t peer reviewed literature. They are often opinions or über brief summaries of primary literature or anecdotal reports. It is important to read the literature and draw your own conclusions. If you disagree with the Tweeter, respectfully respond and engage in a discussion. Just like face-to-face dialog, the best learning often comes from professional differences of opinion. But it’s important to remain professional.  Don’t be a TrashTweeter! And don’t use your professional title or credentials without first checking your institution’s policies regarding social media use. Recently, the Royal Pharmacuetical Society published a guidance document.⁷ Once you’ve built your Twitter network and start meeting people at conferences, it can be difficult to keep use strictly professional. If you want to use Twitter for social purposes too, consider creating a separate personal account. This helps to keep a clearer division between the two.

Twitter can be a great resource for connecting with experts in your field, staying up to date on primary literature, and engaging at conferences. If you are a twewbie, learning twettiquette can help you navigate the Twitosphere. Getting started is easy. Fly on over, create an account, and start reading what people have to say. You might be surprised by what you learn.

[Editor's note:  For more detailed instructions on how to create a Twitter account and some recommended twitter feeds for health professionals, visit Using Twitter for Professional Development on the iForumRx.org website. Follow us at @iforumrx.]

References

1. Williams, SA Terras, M Warwick, C. How Twitter is studied in the medical professions: A classification of Twitter papers indexed in PubMed. Med 2.0. 2013;2(2):e2 DOI: 10.2196/med20.2269.
2. Djuricich, AM. Social Media, Evidence-Based Tweeting, and JCEHP. JCEHP 2014; 34(4): 202-4.
3. Awad, NI Cocchio, C. Use of Twitter at a major national pharmacy conference. Am J Hosp Pharm. 2015;72:65-9.
4. Djuricich, AM Zee-Cheng, JE. Live Tweeting in medicine: 'Tweeting the meeting.' International Review of Psychiatry. 2015;27(2):133-9.
5. Jalali, A. "Why do you Tweet, Anyway?" A glance into medical education tweeting. [Internet] AM Rounds: Beyond the pages of academic medicine. 2015 June - [Cited 2015 Sept 20].
6. Joshi, N. Introducing #EMConf Twitter hashtag. [Internet]. Academic Life in Emergency Medicine. 2013 Aug - [cited 2015 Sept 20].
7. Royal Pharmaceutical Society. Social media guidance for pharmacists. [Internet]. Royal Pharmaceutical Society. Accessed 2015 Sept 27.

Losing Sleep Over Poor Performance

by Zak Cerminara, PharmD; PGY2 Oncology Pharmacy Resident, University of Maryland School of Pharmacy

I realize the irony of this essay as I write it with only five hours left until I have to wake up. Personally I struggle with the daily decision between staying up to work on a project or finishing homework or catching up on the emails and going to bed at a reasonable time. While I am sure that most people, me included, are aware that the lack of sleep is not healthy for your body or mind, does everyone really understand how detrimental sleep deprivation can be?

A lot of people are cognizant of the fact that young adults should get seven to eight hours of sleep every night, but how many people actually accomplish this? A Gallup survey in 2013 found that 59% of Americans get seven or more hours of sleep each night.  This means that over 40% get less!  And 14% of Americans say they get less than five hours of sleep per night. This is a substantial difference when compared to the original survey conducted in 1942. Back then 84% of Americans reported getting seven or more hours of sleep each night with the average person getting almost eight hours per night. While you might expect that people today willingly sleep fewer hours and are satisfied with the amount of sleep they get, 43% of people in the 2013 survey said they would be happier if they got more sleep.¹

Knowing that there is this large gap between the amount of sleep we get compared to what we should be getting is one thing. But how does the lack of sleep impact our performance? Sleep is important for our bodies — it's the time when our bodies repair and grow. But sleep also important for our mental state, including memory and cognitive function. During sleep our brains consolidate the memories and experiences from the day — and this facilitates learning as we process the day’s events.  Students may think that staying up to study for a big exam will benefit them (e.g. spending additional time learning the material) but, in actuality, they are doing themselves a disservice.

Sleep loss not only causes fatigue and sleepiness but it also leads to neurocognitive and psychomotor performance impairments. One meta-analysis found that sleep-deprived individuals performed at a level comparable to the ninth percentile of those who had adequate sleep.² Lack of sleep has been shown to impact the prefrontal cortex, which is responsible for higher brain functions including memory, reasoning, and language. One study found that shortening sleep duration lead to decreased memory encoding and knowledge retention, suggesting that the hippocampus may be affected.³

A study conducted with first-year college students found that for every hour delay in sleep, the predicted GPA decreased by 0.13 on a 4.0 scale. This study sought to determine favorable and negative health related variables and their relation to GPA. The study found that the variables that had the highest correlation to poor GPA were later weekday and weekend wake up time as well as later weekday and weekend bedtimes.⁴ Another study compared the sleep habits of the lowest and highest quintile of performers base on their GPA. They did not find any significant difference in total hours of sleep between the two groups, but they did find that students with the highest GPAs went to bed earlier and woke up earlier when compared to students who performed less well academically.⁵

I know that some of you might be saying: “I’m in [law / medical / pharmacy / graduate] school. There aren’t enough hours in the day to get everything done. Plus, I think I am smart enough to know if I were experiencing the detrimental effects of sleep deprivation on my academic performance.” Actually, you probably don’t.

In a slightly barbaric study, investigators examined the impact of sleep deprivation on performance.⁶ They found that after just one night of sleep deprivation, college students (n=44) scored significantly lower on a cognitive task when compared to a group of students who were not sleep deprived. Amazingly, the sleep deprived students ranked their concentration, effort, and estimated performance significantly higher than those students who were not sleep deprived.⁶ This suggests that while you feel like you are performing well, you lack an awareness of how detrimental sleep deprivation impacts your performance!

A recent study looked at the sleep patterns of pharmacy students.⁷ Not surprisingly, the investigators found that students who reported sleeping an average of 6 hours or less each night were statistically more likely to report feeling tired when waking up and throughout the day.  Those who got less sleep were also more likely to feel excessively sleepy during class and when studying course materials. When looking at actual academic outcomes, comparing the grades of those who slept more or less than an average number of hours during the week was not statistically different. This finding mirrors previous studies. However, it is important to note that most of the students in the study slept well under the recommended number of hours each night, averaging about six hours of sleep per night.  Thus most of the students were sleep deprived! The most compelling finding of this study was the relationship between the number of hours slept the night before an exam and academic performance. The authors found that those with a GPA less than 2.5 slept an average of 4.60 hours the night before a test, while those with GPAs above 3.5 slept an average of 5.53 hours before the test.⁷ There is one caveat. While one might assume that these students are studying when they stayed up late the night before an exam, the author’s acknowledge they don’t know with certainty what these students were actually doing.

So what can educators do to help learners get more sleep? The most obvious solution is to make certain the amount of work students are expected to do outside the classroom is reasonable. While homework and outside projects are certainly beneficial to learners, paying attention to the amount as well as the sequencing of assignments is key. Overburdening the learner with a bunch of assignments all due the same week is a recipe for disaster! Parsing out big assignments into small chunks helps learners stay on task. Furthermore, ensuring that concepts are taught well during class sessions (e.g. using active learning strategies) is another way educators can help. If learners spend hours of time outside the classroom trying to relearn or memorize concepts because they were poorly understood in class, it’s a waste of time. Using audience response questions and working through practice problems in class can help the teacher gauge student learning. Lastly, explicitly coaching students about how to manage their time is another strategy – including encouraging learners to get a good night’s sleep!

So the next time you are considering staying up late to finish work, consider a few things: Could it wait until tomorrow? What level of cognition does the work require? And is it worth staying up to finish if there is a strong likelihood that you won’t perform as well or may need to redo parts of it tomorrow? Maybe you should get a good night’s of sleep instead.

References

1. Jones JM. In U.S., 40% Get Less Than Recommended Amount of Sleep. Gallup, Inc. December 13, 2013. [Internet]  Accessed September 20, 2015.
2. Pilcher JJ, Huffcut AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep 1996;19:318–26.
3. Alhola P, Polo-Kantola P. Sleep deprivation: impact on cognitive performance. Neuropsychiatr Dis Treat. 2007;3:553-567.
4. Trockel MT, Barnes MS, Egget DL. Health-related variables and academic performance among first-year college students: implications for sleep and other behaviors. J Am Coll Health 2000;49:125–30.
5. Eliasson AH, Lettieri CJ, Eliasson AH. Early to bed, early to rise! Sleep habits and academic performance in college students. Sleep Breath. 2010;14:71-5.
6. Pilcher JJ, Walters AS. How sleep deprivation affects psychological variables related to college students' cognitive performance. J Am Coll Health. 1997;46:121-6.
7. Zeek ML, Savoie MJ, Song M, et al. Sleep duration and academic performance among student pharmacists. Am J Pharm Educ 79(5): Article 63.

Meeting the Unique Needs of Non-traditional Students

by Imran Chughtai, Pharm.D., PGY1 Pharmacy Resident, Holy Cross Hospital 

The National Center for Education Statistics (NCES) states non-traditional students have one or more of these characteristics:¹ 

• Entry to college delayed by at least one year following high school
• Having dependents
• Being a single parent
• Being employed full time
• Being financially independent
• Attending part time
• Not having a high school diploma

Institutions of higher education have seen an increasing number of adult learners with life demands returning to school.¹ These non-traditional students experience social and financial burdens more than the traditional student. Due to non-traditional students’ life experience, they frequently have a keen understanding of the economic, professional, and social success that can be gained from higher education.¹ Non-traditional students require a unique approach to teaching and need to be taught differently than traditional students. 

Instructional methods that appeal to adult learners are most effective for non-traditional students. Methods that allow non-traditional students to talk about and use their past experiences, collaborate with peers, and reflect are often more successful.² “According to tacit theory, adult learners acquire their metacognitive skills from peers, teachers, and the local culture.”² An example includes mentoring where teaching occurs through role modeled behaviors. Educators of non-traditional students tend to gravitate to this framework because it facilitates learning in the absence of a traditional academic setting. In essence, the educator is meeting learning objectives by individualizing the “classroom.

A major problem faced by non-traditional students is the high risk of dropping out.³ In the study described by Gilardi and Guglielmetti (2011) the number one reported risk factor for dropping out was the student’s employment status -- 35% of students who dropped out had permanent jobs and 49% of students had temporary jobs. Evidence supports a negative relationship between the weekly hours worked and the rate of retention.³ 

A successful educator can mitigate the demands of employment by engaging students via non-traditional teaching methods, such as distance learning or “e-learning,” and thus increasing the “perceived quality of [the learning] experience.”³ By creating a flexible teaching/learning process the non-traditional learner is motivated to persevere through the rigors of higher education. The non-traditional student will meet learning objectives when he/she perceives the instructional will result in a meaningful learning experience.  This can be enhanced by the addition of social support from peers. For example, non-traditional student experience greater success with content that has “implications and applications of theoretical knowledge in their own professional context.”³ 

Learning assessment tools such as the Learning and Study Strategies Inventory (LASSI)² can be used to help adult learners identify their pre-existing learning strategies and preferences. The educator can use that information to introduce new learning strategies that may be more effective for the student and it encourages students to develop metacognitive strategies. Repetition, presenting information in similar, but not duplicate environments, is essential to strengthen course material.  Moreover, educators should force students to re-examine their pre-existing learning strategies (less than optimal strategies) and adopt new ones that will allow for optimal learning.

Non-traditional students are often self-directing and goal-oriented – and this can be used to the educator’s advantage! These attributes are key in promoting lifelong learning. Non-traditional learners often pursue higher education for professional development and advancement. This can provide motivation to increase engagement in the learning process.

When compared to traditional students, non-traditional students are more likely to⁴ …

• Ask questions in class or contribute to discussions (80% vs. 72%)
• Prepare two or more drafts of papers and assignments (61% vs. 40%)
• Come to class prepared (87% vs. 76%)

One study found that successful non-traditional students often used social supports, programs, and services to overcome time constraints.⁴ Social supports included study groups and online communication with teachers.  Face-to-face meetings are not always time friendly for non-traditional students. Non-traditional students also benefit from online-lectures or discussion boards which allowed remote participation without having to physically be present on campus.

The educator needs to use instructional methods that have fluidity in order to integrate the adult learners’ professional experience and individual learning preferences. The educator should use a student’s stated goals to tailor the learning objectives and activities so that the student has a more meaningful experience.  The non-traditional student has unique needs but they can be successful if educators employ appropriate methods and strategies. 

References

1. Ross-Gordon JM. Research on adult learners: Supporting the needs of a student population that is no longer nontraditional. Peer Review 2011; 13(1).
2. Kenner C., Weinerman, J. Adult learning theory: Applications to non-traditional college students. Journal of College Reading and Learning 2011, 41(2): 87-96.
3. Gilardi S., Guglielmetti C. University life of non-traditional students: Engagement styles and impact on attrition. The Journal of Higher Education 2011; 82(1), 33-53.
4. Wyatt LG. Nontraditional student engagement: Increasing adult student success and retention. The Journal of Continuing Higher Education, 2011; 59(1), 10-20.

Self-Assessment is Essential to Lifelong Learning

by Nkem P. Nonyel, Pharm.D., PGY1 Pharmacy Practice Resident, Holy Cross Hospital 

Self-assessment is the process of ongoing reflection, self-judgment, and self-monitoring to summarize one’s strengths and clarify areas for improvement. This includes learning from one’s experiences; judging one’s personal, educational, and professional performance; examining personal characteristics based on evidence, external standards, and explicit criteria for the purpose of future quality and performance improvements. Research has shown that self-assessment can improve learner's communication skills, and can result in behavior change.¹ 

Self-assessment skill is beneficial to every learner. McMillan and Hearn state “Students need to self-assess to know when they are learning, how much effort they must expend for success, when they have been successful, when they are wrong, and which learning strategies work well for them”¹ The reinforcement of one’s knowledge, skills, values, and behaviors can enhance one’s self-esteem and influence motivation by strengthening self-efficacy and readiness to change. Self-assessment is an essential for lifelong learning for students, educators, and professionals.

Self-assessment can help learners “to discover their own learning potential” by developing self-awareness of their own beliefs and potential misconceptions. It may be used to promote ongoing appraisal of the qualities of one’s performance, and reinforce one’s cognitive abilities and skills. Through self-assessment, one can discover one’s likes and dislikes, knowledge gaps, and opportunities for self-improvement. Self-assessment may also be used to improve morale, strengthen commitment to competent performance, and enhance motivation to take responsibility for one’s professional growth. Self-assessment is facilitated by using and incorporation feedback from peers, teachers and/or preceptors as a learner sets goals and formulates action plans.

Self-assessment involves reflection, planning, acting, evaluating, and recording. Self-assessment could be completed using paper or electronic methods. Other self-assessment activities might include keeping a journal or diary of activities, proofreading and revising one’s work, asking questions to clarify doubts, recording and reviewing audiotape or videotape of one’s own performance.

Teachers should engage and assist learners as they perform their own self-evaluation. The teacher can do so by first explaining to learners how he/she sets and evaluates his/her own goals. Next, the teacher can use thought-provoking questions to stimulate the learners’ thinking about pertinent concepts that should be addressed during goal setting. Such questions allow the learners to assess their thought-process while completing a task, evaluate their strengths and challenges during the assignment/project, and assess the amount of time invested in the assignment/project versus what they gained from the assignment/project.

It is common for any learner to over-estimate their performance. Video recording a student’s performance, either during oral presentations or practical activities, allows students to view themselves and critique their performance.  An educator can either videotape the learners or encourage them to videotape themselves.  Videos should be reviewed in private or with the instructor to avoid shaming. The educator may have the students complete a written self-evaluation immediately following an activity before they view the video, and again after viewing the recording. This way, the student is able to differentiate between the perception and reality of their performance. The University of Maryland School of Pharmacy uses videotaping during Objective Structured Clinical Examination (OSCE).

An educator can also model self-evaluation and the need for continuous performance improvement by videotaping some of his lectures, and having learners watch and critique his performance and provide feedback on his communication skills and teaching style. The educator may intermittently hand out evaluation forms, or use a suggestions box to seek the learners' opinion on how well the class is going, what the teacher is satisfactorily engaging the learners well or not.

Assigning learners to write Personal Learning Plan may help them become active participant in their education since they can create goals based on their perceive personal and professional needs. A written Personal Learning Plan will also facilitate dialogue between educators and learners because learners will have the opportunity to meet with the educators to review the set goals and the activities to ensure the attainment of the goals. Educators may also assign reflection essays to students to prompt them to reflect on ways to bridge gaps in knowledge and skills.

Self-assessment is an essential metacognitive skill that learners use to gauge their general background knowledge but determine the best strategies to problem-solve.⁴ In a study to evaluated the implementation of self-assessment among student health care practitioners and its impact on learning, Dearnley and Meddings noted that self-assessment enhanced the student’s ability to think reflectively and to achieve their academic potential.⁶ 

Students can tell that they have learned when they can use self-testing, self-questioning, summarizing, repeating or explaining to improve their understanding of pertinent concepts.⁴ Teachers can tell that students have learned from self-assessment, not merely from grades, but when they “develop reflective skills to become self-regulated and lifelong learners”, consistently use analytical methods to approach problems, apply their knowledge and skills across a variety of situations, and require less prompting.⁴ 

Reference

1. McMillan J, Hearn J. Student self-assessment: the key to stronger student motivation and higher achievement. Educational Horizons 2008: 40-49.
2. Bose S, Oliveras E, Edson WN. How can Self-assessment improve quality of the healthcare. USAIDS Quality Assurance Project 2001; 2(4).
3. Krueger JL. Pharmacy students’ application of knowledge from classroom to introductory pharmacy practice. American Journal of pharmaceutical education 2013; 77(2) article 31
4. Kurnaz MA, Cimer SO. How do students know that they have learned? An investigation of students’ strategies. Procedia Social and Behavioral Sciences 2010; 3666-3672.
5. Sarget J, Armson H, Chesluk B, et al. The process and dimensions of informed self-assessment: aconceptual model. Academic Medicine 2010; 85(7); 1212-1220.
6. Dearnley CA, Meddings FS. Student self-assessment and tis impact on learning – a pilot study. Nurse Education Today 2007; 27; 333-340