"Blended Learning” Models and Their Effectiveness

by Hannah Black, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Health-North Mississippi

Many of us are familiar with the term, “blended learning.” While it is easy to assume that this teaching model simply involves a combination of in-class and online instruction, there are lots of different ways of accomplishing it. Although blended learning models are now commonplace (thank you COVID-19), there has been a lot of research published in medical education journals over the last 4 decades.¹ Many studies have documented the effectiveness of blended learning in health professions education but given that blended learning methods vary very substantially, what strategies are most effective?

The Journal of Medical Internet Research published a systematic review and meta-analysis examining the effectiveness of blended learning compared to traditional learning in health professions education.¹ Blended learning was stratified into different types of learning support, defined as follows:

• Offline Learning - the use of personal computers to assist in delivering stand-alone multimedia materials without the need for internet.
  • Videos and audio-visual learning materials (as long as the learning activities did not rely on internet connection)
• Online Support – all online materials used in learning courses.
  • Educational platforms (learning management system, LMS like Blackboard)
• Digital Education – a wide range of teaching and learning strategies exclusively based on the use of electronic media and devices
  • Facilitates remote learning for training purposes
• Computer-Assisted Instruction – the use of audio-visual material to augment instruction.
  • Multimedia presentations, live synchronous virtual sessions via a web-based learning platform, synchronous or asynchronous discussion forums
• Virtual Patients – interactive computers simulations of real-life clinical scenarios

The primary outcome of this study was to evaluate the effectiveness of blended learning to achieve knowledge outcomes compared with traditional teaching strategies.¹ Of the 3,389 articles identified in MEDLINE, 56 studies met the inclusion criteria with a total of 9,943 participants. Most of the participants were students in medical schools. Other participant subgroups included nursing, pharmacy, physiotherapy, dentistry, and interprofessional education.

Offline Blended Learning vs Traditional Learning

Some benefits of offline learning have been suggested, such as unrestricted knowledge transfer and enhanced accessibility. This type of learning gives students more flexibility to learn at a convenient pace, place, and time, which can improve retention of content. However, this study showed no significant difference in knowledge outcomes when compared to traditional teaching methods. It was noted that the majority of studies in this group were in nursing. These results were consistent with a previous meta-analysis on offline digital instruction.²

Online Blended Learning vs Traditional Learning

Online blended learning gives students more experience building competency in things that require repeated practice, such as EKG and imaging interpretation. The internet has provided students with an abundance of resources that can be used with the click of a button, so why not use it to the learner’s advantage? As expected, this study did show a significant advantage in knowledge outcomes of online blended learning versus traditional learning alone. Using the internet to deliver instruction does not come without challenges. Learning is highly dependent on the student’s ability to cope with technical difficulties and comfort using computers and navigating the internet.

Digital Learning vs Traditional Learning

Digital learning, or “eLearning,” is being used increasingly in health professional education for improvement of access to training and communication.³ However, the pooled effect for knowledge outcomes in this study suggests no significant difference.¹ This study was broken into subgroups, and the medicine subgroup showed digital learning had a positive effect when compared to the control group.¹ I feel this concept is not one to ignore because it facilitates remote learning, which could help in addressing the shortage of health professionals in settings with limited resources.¹

Computer-Assisted Instruction Blended Learning vs Traditional Learning

Computer-assisted instruction can provide students with innovative methods of instruction for things like physical examination techniques.⁸ The pooled effect for knowledge outcomes in this study suggested a significant improvement. Participants in one study reported difficulties accessing the course due to problems with the university’s internet, so the online discussion board was not used to its full potential.⁵ One could argue that similar problems could have emerged even in the traditional learning setting where students may choose not to or feel intimidated to engage in discussion. 

Virtual Patient Blended Learning vs Traditional Learning

Virtual patients are widely used in simulation-based instruction. These simulations can be used as a precursor to bedside learning, or to be used when direct patient contact is not possible. The groups with supplementary virtual patient learning support showed a significant improvement in knowledge outcomes compared to traditional learning.¹ These results reinforce the results found in a similar meta-analysis, showing that virtual patients have a positive impact in terms of skill development and problem solving.³

When combining all 56 studies, the pooled effect size reflected a significantly positive effect on knowledge acquisition in favor of blended learning versus traditional learning in health professions education.¹ A possible explanation could be that blended learning allows students to review materials at their own pace and as often as necessary. This reinforces the belief that the outcomes of blended learning is most dependent on student characteristics and motivation, rather than the instructional deliver method.

In my opinion, one of the most interesting findings from this study comes from the subgroup analysis. For the top 3 subgroups, the pooled effect difference in the medicine subgroup was 0.91, nursing studies was 0.75, and dentistry studies was 0.35.¹ This reiterates that the effectiveness of blended learning is complex and dependent on the learner characteristics and needs of the student population. One tool that can be used to develop and implement a personalized blended learning curriculum is the six step Kern cycle⁶, described below:

1. Problem identification – The first step begins with the identification and analysis of a specific healthcare need or group of needs. It could relate to the needs of the provider, or the needs of society in general.
2. Targeted needs assessment – The second step involves assessing the needs of your group of health professional students, which may differ from the needs of providers or society in general.
3. Formulating goals and learning objectives – Once the needs have been clearly identified, goals and objectives should be written starting with broad goals, then moving to specific, measurable objectives.
4. Selecting educational strategies – After objectives have been finalized, the content and methods can be selected that will help to achieve the educational objectives.
5. Implementation – In this step the finalized curriculum is implemented.
6. Evaluation and feedback – This final step is important to help continuously improve the curriculum and gain support to drive the ongoing learning of participants.

 Overall, this meta-analysis reinforces the notion that blended learning has a positive effect on knowledge outcomes in healthcare education. However, it also indicates that different methods of conducting blended courses could demonstrate differing effectiveness based on the student population, their needs, and the learning objectives.¹ When strategically developed and implemented, I believe blended learning enhances outcomes.

References

1. Vallée A, Blacher J, Cariou A, Sorbets E. Blended learning compared to traditional learning in medical education: Systematic Review and meta-analysis. Journal of Medical Internet Research. 2020;22(8): e16504.
2. Posadzki P, Bala MM, Kyaw BM, et al. Offline Digital Education for Postregistration Health Professions: Systematic review and meta-analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(4): e20316.
3. Kononowicz AA, Woodham LA, Edelbring S, et al. Virtual patient simulations in Health Professions Education: Systematic Review and meta-analysis by the Digital Health Education Collaboration. Journal of Medical Internet Research. 2019;21(7): e14676.
4. Song L, Singleton ES, Hill JR, Koh MH. Improving online learning: Student perceptions of useful and challenging characteristics. The Internet and Higher Education. 2004;7(1):59–70.
5. Al-Riyami S, Moles DR, Leeson R, Cunningham SJ. Comparison of the instructional efficacy of an internet-based temporomandibular joint (TMJ) tutorial with a traditional seminar. British Dental Journal. 2010;209(11):571–6.
6. Kern D. Curriculum Development for Medical Education: A Six-step Approach. Baltimore, MD: Johns Hopkins University Press, 2022.
7. George PP, Papachristou N, Belisario JM, et al. Online elearning for undergraduates in Health Professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction. Journal of Global Health. 2014;4(1).
8. Tomesko J, Touger-Decker R, Dreker M, Zelig R, Parrott JS. The effectiveness of computer-assisted instruction to teach physical examination to students and trainees in the Health Sciences Professions: A systematic review and meta-analysis. Journal of Medical Education and Curricular Development. 2017 Jul 14;4:2382120517720428

Portraying Social Constructs that Influence Health in Patient Cases

by Jewlyus Grigsby PharmD, PGY1 Community Pharmacy Practice Resident, University of Mississippi School of Pharmacy

One of the most common ways health profession programs assess students’ knowledge is through patient cases intended to mirror real-life practice scenarios. These cases are meant to place students in a “what would you do?” simulation and facilitate the development of their critical thinking and clinical skills. These cases are used during in-class discussions, on exams, in clinical skills competitions, in interviews, and for professional development. When designing these cases, faculty consider a variety of factors such as the severity of the patient’s symptoms, lab values, comorbidities, allergies and intolerances, and even family history. One set of factors that must be carefully considered when creating a case is the patient’s race, ethnicity, nationality, and socioeconomic status. These factors are social constructs, and therefore influence perception, decision making, and (all too often) health outcomes. In August 2021, the American Medical Association published updated guidelines about how to report race and ethnicity in the medical literature. These guidelines state that the words and terms used must be, “accurate, clear, and precise and must reflect fairness, equity, and consistency.”¹ Furthermore it also provides guidance on how to address sex and gender, sexual orientation, age, and socioeconomic status in research reports, review articles, and case reports. The goal of these guidelines is to reduce unintentional bias within the medical and scientific literature. However, despite now having a guideline instructing health care researchers and educators on how best to include these social constructs, how should this be done in the classroom setting and during experiential courses?

Ensuring the appropriate portrayal of diversity in patient cases should start with a careful reflection on the objectives of the lecture or topic being taught. This is especially important because test questions are often developed from the learning objectives. When writing learning objectives, one must ask what participants should be able to do as a result of the lecture, what the audience needs to know, and communicate the take-home message. By including objectives that relate to the social determinants of health, diversity can be introduced into the patient cases, and assist students in practicing disease state management with patients from diverse backgrounds. Here are three examples of how to structure objectives that include some of these social factors:

1. Create a treatment plan for patients within the confines of the state’s Medicaid medication formulary.
2. Design a medication regimen that accounts for and is consistent with a patient’s religious beliefs and practices.
3. Compare and contrast the prevalence of medication allergies and intolerances present in specific racial and ethnic groups.

These objectives challenge students to analyze a patient’s financial status, religious beliefs, and race/ethnicity in the context of the treatment regimen and medication characteristics.

After establishing the objectives for a presentation and determining whether specific social factors should be incorporated, the next step is to design the cases that will be used during the in-class activities and on exams. The cases should highlight the medical conditions under consideration but also highlight how political, economic, and social factors contribute to the patient’s o vernal health outcomes. It is also important to ensure the case does not reinforce biases and avoids stereotypes. This can be challenging because there is a fine line between something that might be more common in a particular population and a stereotypical patient presentation. For example, psoriasis is more common in Caucasian patients and diabetes is more common in African Americans. However, not all diabetes-related cases should be about an African American patient, and not all psoriasis cases should feature a Northern European! These diseases occur in people of all racial and ethnic backgrounds, but there may be some differences in presentation, clinical features, and severity that can be explored by featuring patients from various backgrounds.

One group, a non-profit organization, produces cases for courses in medical schools in the United States. They design their cases using an approach called “structural competency” defined as: 

the trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health.²

Based on this definition, the group produced a guide to assist educators in the implementation of the cases and how to discuss race and culture in the classroom.²

Using our learning objectives above, we could construct a patient case to explore a range of issues.  Here is an example of a patient case that a teacher might create:

RS is a 30 YO bisexual African American male with type 2 diabetes, hypertension, and dyslipidemia. He is coming to clinic for the first time since being hospitalized due to diabetic ketoacidosis. His diabetes is uncontrolled and he probably doesn’t have health insurance. His family history includes type 2 diabetes, stroke, and heart failure. He states that he drinks very little water and because he works all the time in a factory, he eats a typical Southern diet: high calorie and high carbohydrates with little to no vegetables. What medication regimen would you recommend in this case? What are some non-pharmacological interventions would you suggest?

This is a suitable case to evaluate a patient newly diagnosed with diabetes however, it does perpetuate stereotypes and can reinforce some implicit biases that many practitioners have. First, in the introductory sentence, it states the patient’s sexual orientation. This information really isn’t necessary to answer the key questions. Nonetheless, patients sometimes disclose personal information during a clinic visit or hospital stay. Although it does not contribute information that is useful when addressing the key questions in the case, it might be an opportunity to introduce students to a patient whose sexual orientation may be different than their own. However, the manner in which the patient’s sexual orientation is included doesn’t flow with the narrative of the case. Also, the case alludes to the possibility that this patient is uninsured, but based on the objectives, we should indicate that the patient is on Medicaid. Lastly, the patient’s diet is described in a stereotypical manner. Instead of labeling this a "southern diet" that all African Americans in the south consume, it would be better to describe the patient’s diet without ascribing it to the patient’s race or ethnicity. So here’s a way to change the case without perpetuating these biases and stereotypes:

RS is a 30 YO African American male with type 2 diabetes, hypertension, and dyslipidemia. He is coming to the clinic for the first time after being hospitalized for diabetic ketoacidosis. He has trouble getting his medications because his Medicaid plan’s limited formulary and normally his boyfriend helps him pay for his medications. His family history includes type 2 diabetes, stroke, and heart failure. When ask about what he has eaten over the past 24-hours, he indicates he did not eat breakfast, he ate a chicken sandwich meal from Chick fil A for lunch, and had fried chicken with bread for dinner. What medication regimen would you recommend in this case? What are some non-pharmacological interventions you would suggest?

The new case removes the patient’s sexual orientation from the introductory statement but its still alluded to it later in the case.  The case introduces access to medications as a potential problem. Also, there is specific information about the patient’s eating habits, rather than sweeping generalizations. These changes do not alter the case entirely, but they do remove some of the stereotypical elements and biases. In order to introduce students to the social determinants of health, social constructs need to be included in patient cases but must be constructed in such a way to reduce biases while reflecting the diversity in the patients we serve.

References

1. Flanagin, A., Frey, T. and Christiansen, S., 2021. Updated Guidance on the Reporting of Race and Ethnicity in Medical and Science Journals. JAMA 2021; 326(7): 621. Available at: <https://jamanetwork.com/journals/jama/article-abstract/2783090> [Accessed 28 April 2022].
2. Krishnan A, Rabinowitz M, Ziminsky A, Scott S, and Chretien K. Addressing Race, Culture, and Structural Inequality in Medical Education. Academic Medicine 2019; 94(4): 550-555.

Cased-based Learning From Two Perspectives: Learner and Teacher

by Madison Parker, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Who enjoys being proved wrong or having to learn the hard way? The rhetorical answer is no one! However, in the last couple of months, it has happened to me time and time again. I recently graduated from pharmacy school. I matched for a PGY-1 pharmacy residency at the medical center associated with my alma mater. Wanting to be a well-rounded pharmacist and a successful preceptor, I decided to participate in an elective academia rotation. I quickly learned how different things are on the “other side.” As a student, I never understood the time commitment and detail that went into teaching a class and developing cases.

As a student, I did not enjoy the “case-based approach.” I did not understand why we were going to school if we were essentially just teaching ourselves. What I didn’t realize at the time was how much I was learning and growing as a health professional by grappling with cases. Hindsight always seems to be 20/20! Case-based learning made me dig far deeper than typical lectures ever did during pharmacy school. I was no longer just memorizing a drug side effect to regurgitate it back on a multiple-choice test. It was challenging, and it made me think well beyond “the right answer.” I had to learn how to pivot when a treatment was contraindicated or what to do next if a patient suffered a side effect.  Essentially, I learned how to contingency plans to better take care of my future patients.

I have also learned about Bloom’s Taxonomy during my teaching experience and the “cognitive skills” that case-based learning requires. Lectures rely on regurgitating information and the goal is to have students “remember” and “understand” whereas case-based learning requires the student to “analyze,” “evaluate,” and “create.”¹

During case-based learning, the student is provided a detailed clinical case or scenario that they need to work through and discuss. This typically involves a small group rather than a large lecture hall. Case-based learning, like typical lectures, should still include learning objectives, but the teacher won’t always disclose all of the objectives before the case discussion occurs.¹ This non-disclosure allows the learner to think for themselves. Case-based teaching dates back to the early 1900s. Dr. James Lorrain, a professor at the University of Edinburgh, was thought to be the first teacher to use case-based teaching during his pathology course. 

One study surveyed health professional students about their opinions toward case-based learning. There were 520 students invited to participate. These students were from various professional schools including medicine, pharmacy, nursing, and social work.  Students were required to work through the cases as teams during the course. Students were given a nine-item survey that asked about their satisfaction with small-group, case-based learning format using a 7-point semantic differential scale. The students were asked to rank each point from 1-to 5 where 1 indicated ‘strongly disagree’ and 5 indicated ‘strongly agree.’ Ratings were reported as a mean: e-learning discussions (3.54 ± 0.99), small group learning experiences (3.94 ± 0.88), and panel discussions (3.76 ± 0.91). Based on student satisfaction scores, one can infer that case-based learning can be challenging but also rewarding for the learner.³

Another study examined medical students in their pre-clinical years from 2015-2018 at Stanford who chose to enroll in an optional case-based learning course. This course was led by a facilitator and involved a small group of students who would discuss a prospective patient case. At the end of the course, the medical students were asked to participate in a pre-and post-intervention study reflecting on their clinical skills. The control sample included medical students who did not participate in the course. Non-participants were encouraged to participate in pre-and post-intervention surveys as well. A 14 item survey was given to assess participants’ self-reported skills including the ability to report, interpret, manage, educate, and course-specific skills and objectives. A 5-point Likert scale was utilized with 1 indicating ‘strongly disagree’ whereas 5 indicated ‘strongly agree.’ Two surveys were administered; the first survey was completed within two weeks before the first session of the optional course, and the second survey was completed within 2 weeks after the final session. The difference between the post-intervention score and pre-intervention score was calculated. The intervention group resulted in a more positive change in the following categories: understanding how clinicians arrive at a diagnosis, using a step-by-step approach in a longitudinal primary care setting, and how to ultimately share information with their patients.⁴

There are many benefits associated with case-based teaching. It challenges health professional students to use their problem-solving skills before encountering real patients in their clinical years. This in turn allows students to practice and sharpen their skills so that they know how to grapple with real problems and challenges using the same resources that practitioners use when faced with the unknown.⁴ As a future preceptor, I am a big fan of case-based teaching!

In my opinion, cases should be created by experts in the field of practice. Cases should be constructed in a way that they spark students’ interest when hearing about “the real world.” Case-based learning should be facilitated, but by whom? In my experience, it doesn’t have be an expert in the field, just someone with a general knowledge of the subject matter. However, it is helpful for facilitators to have a guide created by the case author.  The case guide should clearly state the objectives the students should acheive and give “tips for success” in the written matters.

In summary, case-based teaching is effective and encourages higher order thinking. It is particularly effectives in health professions education, giving students a chance to practice in a safe environment where “no harm” will arise from a poorly conceived or ill-informed decision. Case-based learning should be extensively used in every health-related curriculum as the benefits and positive results are well established.

References:

1. Armstrong, P. Bloom’s Taxonomy. Vanderbilt University Center for Teaching. 2010.
2. McLean SF. Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature. Journal of Medical Education and Curricular Development. 2016;3:JMECD.S20377.
3. Curran VR, Sharpe D, Forristall J, Flynn K. Student satisfaction and perceptions of small group process in case-based interprofessional learning. Medical Teacher. 2008;30(4):431-433.
4. Waliany S, Caceres W, Merrell SB, Thadaney S, Johnstone N, Osterberg L. Preclinical curriculum of prospective case-based teaching with faculty- and student-blinded approach. BMC Med Educ. 2019;19(1):31.

Assisting Students with Disabilities During Experiential Education

by George Lamare Haines, PharmD, PGY1 Community Pharmacy Resident, The University of Mississippi School of Pharmacy

There is only one way to look at things until someone shows us how to look at them with different eyes.

—Pablo Picasso

At times it is hard to see problems that face others. Often, when a problem doesn’t affect a person, they don’t perceive it as a problem or that it exists because they don’t have to deal with it. This is certainly true when it comes to people with disabilities. There are many things that an able-bodied person takes for granted and never even considers. When it comes to students in college, title II of the Americans with Disabilities Act (ADA) protects people with disabilities from discrimination by universities, community colleges, and vocational schools.¹ Most of us are at least somewhat familiar with accommodations for students with disabilities in the classroom setting, but it is far less common to see these considerations in experiential learning environments.

Every educator tries their best to determine the most appropriate teaching methods for the largest number of students. For most programs, there are special accommodations made for students with learning disabilities in the classroom, like providing extra time during testing or having someone read the exam questions aloud. When students with disabilities enter professional programs, they will be required to participate in experiential education that places them in environments similar to those that they will work in after completion of their program. These “non-academic” settings, which are not under the control of the university or college/school, can be challenging for students with disabilities.

When the University of Colorado School of Medicine was faced with this, they took steps to ensure that their students were set up for success. To illustrate, the school made special accommodations for a third-year medical (M3) student who uses a wheelchair. The student was scheduled to start an Operative/Perioperative clerkship. Before the start of the student’s M3 year, the student met with the medical school dean to discuss requirements, barriers, and reasonable accommodations for the clerkship. The dean then met with preceptors for the clerkship to inform them of the student’s disabilities and to develop a plan for an optimal experience, which included selecting clerkships that would allow for maximal physical access and participation. By putting in this extra effort, the student was able to fully participate in all required clerkships and went on to complete the degree with honors.²

Due to the student’s proactive behavior, there was effective communication and reasonable accommodations made so that they could complete their clerkship. Early communication is the key here. As with most issues, if they are addressed as early as possible, the issue can be addressed before it causes real problems. Often administrators have to do the groundwork to ensure that learners with disabilities are able to complete the requirements of an experience. These steps are important for both physical and learning disabilities. Students with learning disabilities are often hesitant to report these since there is often stigma and shame. Or they may not understand the impact of their disability and the potential benefits of sharing the information with their preceptors.³

Preceptors and faculty in experiential education administration can determine reasonable accommodations for students if they are given adequate time, resources, and knowledge of the disability.⁴ There are five basic principles that should guide institutions to ensure that reasonable accommodations are provided. The accommodations should be based on a reliable diagnosis; they must mitigate factors of the disability that affect student competencies; it should be tailored to each experiential site; they must ensure collaboration and communication occurs between the students, staff, preceptors, and administration; and most importantly, it must uphold privacy. If the accommodation takes away from any of these, it can not be considered reasonable.⁴ Often, accommodations for a student with a learning disability can be made by minor adjustments to the environments, policies, and procedures. Students with physical disabilities may require significant adjustments in the environment.  By having proactive policies and procedures in place, preparing preceptors for what to expect, and monitoring student learning outcomes, students with disabilities have the best chance for success during experiential education.⁴

A recent commentary published in the American Journal of Pharmaceutical Education provides a stepwise approach to addressing these needs.⁵ The first step is to create a system for students to submit a request when entering the experiential program. Once the student has submitted the request, the program is then responsible for exploring accommodation options and sites that either already meet the requirments of the accommodation or that can reasonably accommodate the request. The next step would be applying and fully implementing these accommodations. This will look different for different locations and will depend on the needs of the student. For example, a student who does not have sufficient strength may be accommodated by shortening the length of the rotation day but extending the total number of days in order to meet the required number of experiential hours. Another example would be to avoid rapid-fire questioning for a student that struggles with processing information.⁴ A practice walkthrough by both the student and preceptor may also be useful before the start of the rotation to allow the student to familiarize themselves with the environment and what to expect when they start the experience. The final, and possibly most important, step is to monitor the effectiveness of the accommodation. Continued communication between the preceptor, student, and experiential program director is essential to quickly address oversights and ensuring the accommodation is effective.⁵

When we start looking at these required experiences from the student with a disability perspective, we see problems that we didn’t know were there. It takes students with courage to tell you what their needs are. Open, honest communication seems to be the key to addressing the needs of students with disabilities, especially in experiential education.

References:

1. Americans with Disabilities Act of 1990; 42, USC §§ 12101 et seq.
2. Malloy-Post R, Jones TS, Montero P, et al. Perioperative Clerkship Design for Students With Physical Disabilities: A Model for Implementation. Journal of Surgical Education. 2022; 79(2): 290-94.
3. Vos S, Kooyman C, Feudo D, et al. When Experiential Education Intersects with Learning Disabilities. Am J Pharm Educ 2019; 83(8): Article 7468.
4. Vos S, Sandler L, Chavez R, et al. Help! Accommodating learners with disabilities during practice-based activities. J Am Coll Clin Pharm; 2021; 4(6): 730-37.
5. Kieser M, Feudo D, Legg J, et al. Accommodating Pharmacy Students with Physical Disabilities During the Experiential Learning Curricula. Am J Pharm Educ 2022; 86(1): Article 8426.

Should We Adopt a Two-tier Grading System in Health Professions Education? Benefits and Practical Considerations

by Mary Kathryn Vance, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Grades have long been a cornerstone of educational systems, giving students and educators a way to measure the achievement of learning objectives within courses. Grades were first instituted in the 1700s in Europe to assign a rank order among students. By the late 1800s, several American universities had adopted a grading system with “passing” rates ranging from 26-75%. Eventually, this transitioned to the tiered grading system we recognize today, where an A generally means the student has scored at least 90% on the assessment (or received >90% of available points in the course), a B means 80-90%, a C means someone scored in the 70s, and so forth. Grades typically are attached to a descriptor.  For instance, an A might signify an exceptional level of achievement, a B good but not outstanding level of performance, a C a fair level, and a D signifies significant performance deficiencies but still passing.¹ While this is still the system widely employed by the majority of Doctor of Pharmacy programs in the United States, some programs have adopted a pass/fail or two-level grading system.

Several studies have shown that students in health professions programs, including pharmacy students, experience anxiety, depression, and stress at higher rates than their peers. This places students at a higher risk of developing burnout, which is characterized by exhaustion and a diminished sense of accomplishment.^2,3 Moreover, multitiered grading systems can foster unhealthy competitive environments among students. Two-level grading systems have been proposed as a potential way to mitigate stress, reduce competition, and increase students’ well-being. A survey with nearly 1200 first- and second-year medical student respondents found that students in schools using grading scales with three or more categories had higher levels of stress, emotional exhaustion, and depersonalization when compared to students in schools using two-level grading systems. Students in schools with multi-tier grades were also more likely to have seriously considered dropping out of school.⁴ Another study conducted at Mayo Medical School compared students from classes before and after implementation of a two-level grading system. Students graded with the two-level system had less perceived stress and greater group cohesion than their multilevel peers.⁵

One concern that educators express about two-level grading systems is that they can negatively impact academic performance. Students’ motivation to learn the material might be decreased because they may not have to understand the concepts as deeply to get a passing grade. Some evidence suggests this concern is more theoretical than true. At the University of Virginia School of Medicine, the first two years of the curriculum were changed from graded to pass/fail. When student performance was compared before and after the change, no differences were observed in subsequent course grads, grades during clerkships, or scores on the United States Medical Licensing Examination (USMLE) Steps 1 and 2 Clinical Knowledge boards.⁶ Similar results were seen at the Mayo Medical School — there was no difference in USMLE Step 1 board scores before and after changing from a multilevel to a two-tier grading system.⁵

While they do not appear to reduce students’ achievement during school, two-level systems may better position students to become self-regulated learners. Health professionals are expected to engage in a process of continuous learning throughout their careers. This may be difficult for some students after transitioning from a system with strong extrinsic motivators (i.e. grades) to professional life where the individual must muster the internal motivation to figure out what, how, and when to learn. Helping students develop into self-regulated learners while still in school lays the foundation for this to continue throughout their careers and ultimately increases their knowledge and skills to provide better patient care.⁷

Another potential disadvantage of two-level systems is a decreased probability for students to match with residency programs. The American Society of Health-System Pharmacists (ASHP), the organization that is responsible for pharmacy residency program accreditation, will soon be requiring that all accredited pharmacy residency programs develop procedures on how to evaluate the academic performance of applicants from pass/fail (two-tier grading) institutions.⁸ There is still the potential that students from institutions that have two-tier grading systems could be seen as less desirable or competitive. However, this effect was not seen in a study that examined the effect pass/fail grading on advanced pharmacy practice experiences (APPEs) had on residency match rates at 100 pharmacy schools in the United States over the course of 3 years.⁹ Unadjusted analyses showed that there was no difference in match rates between students from schools with multilevel and two-level grading systems. After adjusting for potential confounders, two-level grading was actually associated with higher match rates during one of the three years.⁹ Similar rates of success in residency placement were also seen in the study conducted at the University of Virginia School of Medicine before and after their transition to a two-tier grading system.⁶

Despite the potential benefits, two-tier grading systems have not been widely implemented in pharmacy education and when it has been implemented, they are some inconsistencies. A study examining the implementation of two-tier grading systems within Doctor of Pharmacy programs found that the programs varied in the terminology used to describe student achievement levels, minimum pass levels, and whether a class rank or GPA was calculated, among other factors.¹⁰ This lack of uniformity leads to questions as to how best to implement two-tier grading systems.

Experiential courses such as introductory and advanced pharmacy practice experiences would seem to lend themselves well to a two-tier grading system. These types of courses tend to vary in their rigor and requirements based on the practice site. This can make interpreting and interpreting letter grades assigned to a student’s performance is already difficult. There are a variety of labels that could be used in a two-tier system, such as pass/fail, pass/no pass, or satisfactory/unsatisfactory. These labels haven’t been evaluated, but the connotations with “fail” and “unsatisfactory” would seem to be more negative than “no pass.”

Converting non-experiential courses to a two-level system is controversial. In schools where this has been done, numerical grades given to assignments and assessments are used to calculate a student’s class rank. This could allow high achievers to be rewarded and give residency programs a way to compare applicants. We clearly need additional studies about two-tier grading systems to determine their benefits and risks and how to best execute them.

References

1. Cain J, Medina M, Romanelli F, Persky A. Deficiencies of Traditional Grading Systems and Recommendations for the Future. Am J Pharm Educ 2022; 86 (2): Article 8850.
2. Brazeau CMLR, Shanafelt T, Durning SJ, et al. Distress Among Matriculating Medical Students Relative to the General Population. Academic Medicine. 2014;89(11):1520-1525.
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