Social-Class Achievement Gaps in Higher Education: Can Values Affirmation Interventions Help?

by Lily Van Cheng, PharmD, PGY1 Community Pharmacy Practice Resident, University of Mississippi School of Pharmacy

As an underrepresented minority (URM) and first-generation (FG) college student, the psychosocial factors that influence one’s success at the collegiate level of education is both fascinating and frightening. FG college students comprise roughly 15-20% of students in American universities today.¹ FG students are more likely to come from working-class backgrounds and face significant economic and psychosocial barriers that create performance discrepancies called the “social-class achievement gap.”² The performance gap might be the result of poverty, the rigor of high school preparation, parenting practices, and/or cultural mismatches. None-the-less, it is arguable that the gap between FG students and continuing-generation (CG) students are merely the results of differences in baseline academic preparation or readiness.

Martin Leon Barreto for The Chronicle Review

A tool that some educators have used to address these challenges has been the values affirmation (VA) intervention.^3,4 VA interventions are designed to address the students’ perceived “stereotype threat.”  FG students are more likely to be confronted with stereotypes that threaten their identity and self-esteem which affect their academic performance. The VA intervention technique addresses stereotype threat by asking students to reflect and write about their most important values. It is hypothesized that this practice enhances the student’s ability to cope with internal identity threat and reaffirms their core values to reestablish their personal integrity and worth. In one study conducted with middle school students, a VA intervention significantly improved the grades of Latino students. The grades of white students were not impacted. The VA intervention thereby partially closed the achievement gap for URM students.⁵

In a more recent study conducted at the University of Wisconsin – Madison, researchers evaluated the role of a VA intervention comparing the performance of FG versus CG college students in a double-blinded randomized experiment in an introductory biology course.⁶ Outcome measures included confidence in their innate academic abilities and perceived concern about their generational background on academic success.  In addition, the researchers compared final course grades, overall GPA in other courses (excluding the biology course), and rate of continuation in the second-semester biology sequence. Students were randomized in blocks based on a variety of characteristics, including generational and URM status. In both the VA intervention and control groups, there were FG and CG students.  All students in the VA intervention were instructed to identify and write about values that were most important to them.  Students in the control group were instructed to identify values least important to them and write about why these values would be important to someone else.

The results?  The researchers found a significant generational status effect. While FG students obtained lower grades than their CG counterparts in the same biology class (p < 0.01), the VA intervention led to significant improvements in the FG students grades (p < 0.05), resulting in a 50% reduction in the social class achievement gap. In terms of progression into the second-semester biology course, in the control group, CG students (77.7%) were significantly more likely to enroll in the second course in comparison to FG students (66.2%).  Conversely, in the VA intervention group, FG students (85.7%) were more likely to enroll than CG students (74.8%). This represents a 20% increase in enrollment for FG students (p < 0.01) who participated in the VA intervention.  In contrast, CG students were no more likely to enroll regardless of whether they were in the intervention or control group (p = 0.41). The results suggest that a VA intervention can indeed narrow the social class achievement gap, improve the success for FG students in an introductory biology course and other college classes, and help keep them on track to progress in the science sequence.

Factors that threaten a student’s motivation or ability to learn vary from classroom to classroom, but it is vital that educators identify the variables that might influence a student’s success. In addition to the generational differences, other variables such as ethnicity, sex/gender, stress, and cultural mismatch may influence a student’s ability to academically succeed.^7,8 Learners come from different backgrounds and have individual struggles. Some are pretty obvious such as ethnicity and language. But others, like generational differences in educational attainment, are harder to identify and trickier to address. Supporting our learners so they can succeed to the best of their ability starts with acknowledging that barriers exist and doing our best to address those barriers. Whether an achievement gap is the result of stereotype threat or a cultural mismatch, VA interventions can play a positive role in influencing our learners’ success.

As healthcare providers, we strive for ways to bridge the health disparities that exist between people of different social classes. As health professional educators, shouldn’t we be striving for ways to bridge the academic disparities that exist? Taking a 10-minute check-in with our students using a VA intervention could be the difference that a student needs to succeed. I challenge every educator to try this in their classroom. Take 10 minutes at the beginning of class every month to have your students identify and write about what positive traits they value. Is it empathy? Compassion? Athleticism? It doesn’t matter if it’s for a grade or not. But portray it in a way that the students realize it is important to really give it honest thought. We spend so much time teaching what they lack or don’t know. It’s time we start reminding and reaffirming our students that what they currently know or possess is just as important. When we help our students reaffirm interdependent values they perceive as integral to their self-worth, we will see positive improvements in and out of our grade books.

References

1. Saenz, VB.; Hurtado, S.; Barrera, D.; Wolf, D.; Yeung, F. First in my family: A profile of first-generation college students at four-year institutions since 1971. Los Angeles, CA: Higher Education Research Institute; 2007. http://www.heri.ucla.edu/PDFs/pubs/TFS/Special/ Monographs/FirstInMyFamily.pdf
2. Snibbe AC, Markus HR. You can’t always get what you want: Educational attainment, agency, and choice. Journal of Personality and Social Psychology 2005; 88:703–720.
3. Cohen GL, Garcia J, Apfel N, Master A. Reducing the racial achievement gap: A social-psychological intervention. Science 2006; 313:1307–1310.
4. Sherman, DK.; Cohen, GL. The psychology of self-defense: Self-affirmation theory. In: Zanna, MP., editor. Advances in experimental social psychology. Vol. 38. San Diego, CA: Academic Press; 2006. p. 183-242.
5. Sherman DK, Hartson KA, Binning K, Purdie-Vaughns V, Garcia J, Taborsky-Barba S, Tomassetti S, Nussbaum AD, Cohen G. Deflecting the trajectory and changing the narrative: How self- affirmation affects academic performance and motivation under identity threat. Journal of Personality and Social Psychology 2013; 104:591–618.
6. Harachiewicz JM, Canning EA, Tibbetts Y, Giffe CJ, Blair SS, Rouse DI, Hyde JS. Closing the Social Class Achievement Gap for First-Generation Students in Undergraduate Biology. Journal of Educational Psychology 2014; 106(2): 375-389.
7. Smart-Richman L, Leary MR. Reactions to discrimination, stigmatization, ostracism, and other forms of interpersonal rejection: A multimotive model. Psychological Review  2009; 116:365–383.
8. Steele CM, Aronson J. Stereotype threat and the intellectual test performance of African Americans. Journal of Personality And Social Psychology 1995; 69:797–811.

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Values Affirmation: Reducing the Gender Gap in STEM Disciplines

by Samantha McBryde, Pharm.D., PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

Policy makers and the educational community have debated for decades ways to address the underrepresentation of women in science, technology, engineering, and mathematics (STEM) disciplines. In high school, male and female students enroll in advanced science courses at about the same rates. Indeed, females are slightly more likely to enroll in some STEM courses than males.¹ However, the rates of women taking science and engineering courses drop in college and significant disparities begin to emerge in the workplace, especially for minority women.¹

The gender disparity in the STEM fields in the United States is wide! In 2016, women made up half of the total college-educated workforce, but only 29% of the science and engineering workforce.¹ While women receive over half of the bachelor’s degrees awarded in the biological sciences, they receive far fewer in the computer sciences (17.9%), engineering (19.3%), physical sciences (39%), and mathematics (43.1%).¹

One issue of concern that could jeopardize women’s decisions to go into these fields is that in some STEM disciplines men outperform women on in-class exams and standardized tests.^2,3 Numerous interventions, such as tutorials, peer instruction, and context-rich problems have been used to address the gender gap in STEM courses. While these approaches likely work, a novel approach known as values affirmation was recently studied in a college-level introductory physics class.²

Values affirmation is a psychological intervention whereby students engage in structured reflection on self-defining values. In this study, 399 students (283 men and 116 women) were randomly assigned to either a values affirmation group or a control group. Students in the values affirmation group were asked to select their most important values from a list and write an essay about why these values were important to them. This group would write about things such as friends and family in response to a series of structured prompts. The control group selected their least important values from the same list and were instructed to write an essay about why these values might be important to other people. Therefore, both groups wrote about values and their importance, but the exercise was self-relevant only for the values affirmation group.²

This assignment was completed twice during the semester, in the first week of the course and shortly before the first midterm exam. Both groups were given 15 minutes for this writing exercise during the physics class. Students were assigned to the same group for both essays. The course instructor and teaching assistants were unaware of students’ group assignments. Moreover, the teaching assistants and students were blinded to the purpose of the writing exercises.¹

To assess the effect of values affirmation on learning, the researchers examined scores on three in-class exams, the in-class final, and a nationally-normed standardized test [the Force and Motion Conceptual Evaluation (FMCE)].²

 Previously, men substantially outperformed women on the exams in this course and the FMCE.³ Specifically, 58% of females versus 35% of males fell into the lowest two pretest quintiles on a FMCE pretest, while 22% of females and 44% of males scored in the highest two quintiles.³ After taking the course, the post-test scores for males and females increased, on average, 10.7 points. Moreover, 64% of the males and 49% of the females scored above 60% on the post-test.³ If the difference in the FMCE scores after this intervention shrank, values affirmation might prove to be a promising way to address the STEM gender gap.²

The FMCE exam was administered twice during the introductory physics course, once during week 1 of the semester and once at the end of the semester. In the control group, men improved their FMCE scores more than women. However, in the values affirmation group, the gender performance gap disappeared.²

Stereotype beliefs also appear to impact student performance. In the first weeks of the introductory physics course, students were asked to indicate their endorsement of the stereotype: men perform better than women in physics.² Women in this study, as a whole, did not strongly endorse the stereotype; however, even a moderate level of stereotype endorsement was costly for women in the control group. Their FMCE exam scores were significantly lower as a function of stereotype endorsement.² The values affirmation activity buffered women against this identity threat.² The intervention eliminated the negative relationship between the exam scores and stereotype endorsement.² On the other hand, men’s FMCE exam scores were not impacted regardless of whether they endorsed the gender stereotype or not.²

The results suggest that female students positively benefited from the values affirmation activity. Among women in the control group, there was a negative relationship between stereotype endorsement and end-of-semester FMCE scores.²  In other words, as stereotype endorsement went up, FMCE scores went down. Among women in the values affirmation group, this relationship was not found.²

Looking at the average of the four exams in the course, men substantially outperformed women. However, the difference in the average scores between men and women was much smaller in the values affirmation group. The improvements in performance was also evident in the distribution of final letter grades. More women earned B’s in the values affirmation group than in the control group. Conversely, more women in the control group earned C’s than women assigned to the values affirmation group.²

The results of this study suggest that the values affirmation activity reduces the gender gap and women who endorsed the gender stereotype benefitted the most.² Values affirmation is an intervention that could be used in an effort to lessen evaluative stress and also improve the performance of stereotype-threatened students.² Values affirmation activities offer a promising intervention to reduce the gender achievement gap in STEM courses.

References:

1. Britsch B, Carter G, Gustafson J, et al. “Statistics.” National Girls Collaborative Project. 2016. Available from: https://ngcproject.org/statistics. Accessed April 6, 2019.
2. Miyake A, Kost-Smith LE, Finkelstein ND, et al. “Reducing the Gender Achievement Gap in College Science: A Classroom Study of Values Affirmation.” Science 2010; 330: 1234-37.
3. Kost LE, Pollock SJ, Finkelstein ND. “Characterizing the gender gap in introductory physics.” Physics Review Special Topics - Physics Education Research. January 2009. Available from: https://doi.org/10.1103/PhysRevSTPER.5.010101. Accessed April 8, 2019. 

The Connection Between Confidence, Knowledge, and Experience

by Madalyn Van Valkenburg, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

During my first hospital pharmacy experience, I remember being awe-struck by the confidence exuding from the pharmacist when she gave her recommendations to the attending physicians and other members of the interprofessional team. She seemed at ease discussing the evidence supporting the recommendations. And when there was uncertainty about the next steps, she asked explicit questions to develop a more accurate assessment. I wanted to have this level of confidence in my clinical decision-making, but I was unsure about how to achieve it. I think every student (and resident) seeks to gain a high level of confidence but how can educators assess and cultivate it?

Before measuring confidence, we need to define it. Therein lies the initial problem. Confidence is tricky to define because it is not concrete – you can’t actually see it. It is a belief the action taken is right, proper, and effective.¹ Clinical confidence is the certainty that a decision or action undertaken in the clinical setting is correct and will lead to the best outcome.

One of the interesting aspects of confidence is that it doesn’t always match with knowledge. This mismatch is known as the Dunning–Kruger effect whereby, based on our perceived knowledge, we overestimate our ability. In other words, some knowledge of the subject matter leads us to conclude we are more competent than we actually are when measured using objective tests.²

In a 2006 study, Valdez and colleagues compared second-year pharmacy students’ self-confidence scores regarding the treatment of dyslipidemia and hypertension to their scores on a multiple-choice exam. Confidence was measured using a 12-item questionnaire and rated on a 5-point Likert scale (1=low confidence and 5=high confidence). Each confidence question was linked to a critical concept on the 21-item multiple-choice test. For example, students were asked to rank their confidence “identifying causes of resistant HTN” and this concept was evaluated on one or more items on the multiple-choice test. The confidence assessment (administered first) and multiple-choice test (administered second) were given immediately after students had received didactic instruction about the treatment of patients with dyslipidemia and hypertension. For most items on the test, there was little or no correlation between the students’ level of confidence (mean scores typically = 3.5 to 4.2) and whether (or not) they correctly answered the question. In other words, students who incorrectly answered questions about a concept were just a likely to rate their confidence as a 4 or 5 (moderate-high or high) as students who correctly answered the question. The same confidence and knowledge assessments were administered 4 months later. Interestingly, student confidence remained relatively high (despite the passage of time); however, their retention of the knowledge decreased significantly, by about one letter grade.³ Since the multiple-choice exam was administered after the confidence assessment, it seems clear that students were not able to accurately judge their knowledge. Moreover, as we all know, in the absence of use, knowledge diminishes over time as the “use it or lose it” phrase implies. And yet, students continued to be quite confident in their knowledge even after doing poorly on an exam and with the passage of time.

While learners may over-estimate their knowledge and skill, is it possible to increase their confidence using novel teaching techniques? In a pharmacotherapy laboratory course, teachers at the University of Wisconsin-Madison School of Pharmacy compared the use of paper-based patient-case narratives to the same cases deployed in a simulated Case Scenario/Critical Reader (CSCR) Builder program. The hypothesis was that the simulated environment would increase student engagement, knowledge, and confidence. Each group – paper-based and simulation— completed a 13-item pre-experience confidence survey (0-39 score) regarding their self-perceived ability to manage a patient with osteoarthritis. The simulated-case students had access to an electronic medical record (EMR), could navigate through a series of multiple-choice questions, and could gather information from the simulated patient and physician. The simulation group reported significantly increased confidence in their ability to assess the medication regimen and document the encounter (p < 0.05) when compared to the paper-based group. However, the mean SOAP scores were not significantly different. So, the instructor’s effort (> 20 hours) put into creating a simulated patient case may have increase student confidence but its impact on skill appears to be marginal.⁴

Similarly, instructors at the University of North Carolina at Chapel Hill School of Pharmacy designed a rigorous third-year pharmacy elective where students gained experience with exercise counseling. The students created pamphlets and monitored a patient over a 4-week period. Students who took the elective were more confident counseling patients about exercise and remained more confident 6 months later when compared to students who did not enroll in the course.⁵ Thus, engaging students in practical, hands-on experiences appear to be an important aspect of developing confidence.⁶

Developing one’s confidence is an important step in becoming an effective clinician. Students may be misled by high exam scores into believing their clinical abilities are well developed. This can be problematic because overestimation may result in students inadvertently practicing beyond their level of competence, resulting in patient harm. However, providing students with opportunities to simultaneously employ their knowledge through concrete, real-life experiences improve their clinical confidence and competence.⁶

Recommendations to help students more accurately assess their confidence and competence:

• Measure confidence before administering knowledge and/or skill assessments
• Provide students with engaging ways to learn and test their skills
• If students overestimate their knowledge or skill, challenge them to identify where their knowledge or skill is lacking
• Personal experience, providing students autonomous practice, can help students grow their confidence and competence

Questions yet to be answered:

• What factors influence students’ perception of confidence?
• What is the relationship between clinical experience and confidence?
• What effect does problem-based learning (and other forms of classroom-based problem-solving) have on clinical confidence?

References

1. Confidence. Merriam-Webster's dictionary. 2019.
2. Kruger J1, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999; 77: 1121-34.
3. Valdez CA, Thompson D, Ulrich H, Bi H, Paulsen S. A Comparison of Pharmacy Students’ Confidence and Test Performance. Am J Pharm Ed. 2006; 70 (4) Article 76.
4. Barnett SG, Gallimore CE, Pitterle M, Morrill J. Impact of a Paper vs Virtual Simulated Patient Case on Student-Perceived Confidence and Engagement. Am J Pharm Ed 2016; 80: Article 16.
5. Persky AM. An Exercise Prescription Course to Improve Pharmacy Students’ Confidence in Patient Counseling. Am J Pharm Ed 2009; 73: Article 118.
6. Jih JS, Shrewsbury RP. Student Self-Analysis of Their Nonsterile Preparations and its Effect on Compounding Confidence. Am J Pharm Ed 2018; 82: Article 6473.

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Problem-Based Learning: Is It A Better Way To Learn?

by Brandon Hawkins, Pharm.D., PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

Howard Barrows, one of the earliest champions of problem-based learning (PBL), once defined it as “the learning that results from the process of working toward the understanding or resolution of a problem.”¹ Since its first use at McMaster University School of Medicine in the 1960s, PBL has been used by many other health disciplines including nursing and pharmacy.^2,3 PBL really took off in pharmacy education in the early 2000’s when the Accreditation Council for Pharmacy Education (ACPE) standards proclaimed that the Doctor of Pharmacy curriculum should promote “lifelong learning through the emphasis on active, self-directed learning and … teaching strategies to ensure the adeptness of critical thinking and problem-solving.”⁴ This theme continues today in the 2016 ACPE accreditation standards.⁵

As an instructional method, PBL is primarily designed to empower learners to solve a problem through the application of knowledge. Given its wide range of implementations, there is no universally agreed definition of problem-based learning. Traditionally, PBL usually involves a small group of students with an elected (or appointed) leader and scribe. A faculty member serves as the facilitator whose primary role is to observe the group dynamics and ensure the intended learning objectives are achieved but does not provide any direct instruction. The groups review “trigger material,” such as a patient case or clinical scenario with no prior exposure and without instruction by the facilitator.⁶ Some institutions like the University of Southern California implemented “assisted” PBL, whereby didactic lectures are used to enhance the students’ background knowledge, but the technique still contains elements common to a traditional PBL experience.⁷ However, despite some differences in their implementation in pharmacy education, there are several common themes: discussions in small groups; hypothetical or real case scenarios; facilitation focused on group progress; and self-direction combined with collaborative learning. PBL uses problems in order to develop problem-solving skills as well as reinforce existing and acquire new knowledge.^8,9 Thus, PBL was an obvious choice for many schools and colleges of pharmacy to meet their need for a self-directed form of active learning. However, despite the level of “deep learning” provided by PBL, a common concern is that it may not lead to the same level of performance on standardized exams, which often focus on knowledge recall and memorization.⁶

Various disciplines and institutions have been experimenting with how best to implement PBL and to what degree this teaching strategy should be used throughout the curriculum. Should it be implemented in a single year as preparation for advanced practice experiences? Or used exclusively throughout the entire curriculum? Or sporadically as a substitute for case-based learning? Several investigators have now published about their experiences with PBL. In pharmacy education, feedback from students and educational performance data provide some insight into the methodology’s successes.

In a comparative study conducted at the University of Southern California, student rotation performance was compared after students participated in either PBL (Class of 1995) or received traditional didactic lectures (Class of 1994) during their third year of the pharmacy curriculum.¹⁰  Both groups received the same instruction in the first year of the curriculum and had similar mean GPAs (2.88 vs. 2.9, p=0.1). However, when comparing the graduating classes of 1994 and 1995’s mean GPA during experiential rotations, the PBL group was had significantly higher GPAs for both elective and required rotations (3.29 and 3.38 vs. 3.09 and 3.11, respectively). The authors concluded that PBL produced positive outcomes during fourth-year advanced practice experiences because it increased students’ ability to engage in self-directed learning, increased their independence, and enhanced their decision-making skills. The authors felt these results were important given that the functions, responsibility, and skillsets required during the fourth year of the curriculum are similar to that of pharmacists providing pharmaceutical care.

A relatively recent meta-analysis analyzed 5 studies conducted in Canada, the US, and UK comparing the outcomes of PBL to conventional didactic instruction in pharmacy courses.¹¹ The primary endpoints were midterm and final grades, as well as subjective evaluations. While both the midterm (OR = 1.46; 1.16–1.89) and final (OR = 1.60; 1.06–2.43) grades were significantly higher in the PBL groups, subjective evaluations between the two did not differ. The authors concluded that PBL yielded superior student performance on assessments, while also promoting clinical reasoning and self-directed learning. However, the authors did note that the relatively small sample size may not be large enough to ensure the generalizability to other pharmacy programs.

Student assessment of PBL seems largely positive as well. In one survey, graduates from the University of Mississippi School of Pharmacy were surveyed regarding PBL and the adequacy of their preparation for Advanced Pharmacy Practice Experiences (APPEs).¹²  In disease state/drug therapy discussions, efficient retrieval of current medical literature, and patient-specific evaluation of drug regimens, 50% or more of graduates believed PBL had provided them with above average preparation in these areas. The authors point out that the success of PBL shouldn’t be solely measured by student success on licensing exams, but also students’ perceptions and self-confidence to enter practice.

Though the impetus for many colleges and schools of pharmacy to move toward PBL may have been, in part, to satisfy accreditation standards, it would seem that the results, at least in pharmacy education, suggest this instructional technique is effective. There are multiple sources of data that suggest the PBL is as good as, or possibly superior to, more passive learning strategies such as didactic instruction. However, while assessments and correlations with academic performance are helpful in gauging its efficacy and benefits, it can difficult to truly assess the student experience.

I recently had my first experiences as a PBL facilitator. When I begin a PBL session, I always ask the students what their expectations of the facilitator are. They frequently asked for clinical pearls. While I believe that PBL provides more robust, “real world” examples and deeper learning as a whole, I do think it is valuable for teachers to share “clinical pearls” with students. Traditional PBL offers little opportunity for teachers to share “pro tips,” instead emphasizing how to learn, apply, and approach a complex problem. Though assessments and surveys may indicate that students are more prepared for practice and are generally satisfied with PBL as a learning method, it does leave me wondering if learners are missing out on “fact-based learning” that more traditional methods of instruction afford.


References

1. Barrows H. A taxonomy of problem-based learning methods. Med Educ. 1986;20(6):481-486.
2. Creating Lifelong Learners. London: English National Board; 1994.
3. Ross L, Crabtree B, Theilman G, Ross B, Cleary J, Byrd H. Implementation and Refinement of a Problem-based Learning Model: A Ten-Year Experience. Am J Pharm Educ. 2007;71: Article 17.
4. American Council on Pharmaceutical Education. Chicago; 2000:52-53.
5. Accreditation Council for Pharmacy Education. 2016. Accreditation standards and key elements for the professional program in pharmacy leading to the Doctor of Pharmacy degree. Available at https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf.
6. Wood D. Problem based learning. BMJ. 2003;326(7384):328–30.
7. Romero R, Eriksen S, Haworth I. Quantitative Assessment of Assisted Problem-based Learning in a Pharmaceutics Course. Am J Pharm Educ. 2010;74(4):Article 66.
8. Savery J. Overview of Problem-based Learning: Definitions and Distinctions. Interdisciplinary Journal of Problem-Based Learning. 2006;1(1):9-20.
9. Barrows H. Problem-based learning in medicine and beyond: A brief overview. New Directions for Teaching and Learning. 1996;Winter 1996(68):3-12
10. Nii L, Chin A. Notes Comparative Trial of Problem-Based Learning Versus Didactic Lectures on Clerkship Performance. Am J Pharm Educ. 1996;60: 162-164.
11. Galvao T, Silva M, Neiva C, Ribeiro L, Pereira M. Problem-Based Learning in Pharmaceutical Education: A Systematic Review and Meta-Analysis. The Scientific World Journal. 2014; Feb:1-7.
12. Hogan S, Lundquist L. The Impact of Problem-based Learning on Students' Perceptions of Preparedness for Advanced Pharmacy Practice Experiences. Am J Pharm Educ. 2006;70:Article 82.