Experiential Learning: On-Call!

by John Hammer Pharm.D, MBA, PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

Aristotle once said, "For the things we have to learn before we can do them, we learn by doing them."  I believe this quote encompasses what is meant by experiential learning.  I think of experiential learning simply as learning by doing.

Experiential learning is what residency training is all about.  Residency training is about learning new concepts and building on knowledge previously obtained in pharmacy school through hands on learning.  It is true that students learn through their experiences as well, but it is to a lesser degree – perhaps due to less responsibility.

I feel that the amount of knowledge gained during residency training, whether we are talking about a pharmacy residency or a medical residency, is second to no other learning experience.  A residency teaches one how to act as an individual practitioner and through this we gain practical application of the theoretical knowledge learned in pharmacy school.  As residents we are frequently faced with issues that we have never seen or even read about before.

I believe that an on call program is a great hands-on experience to add to residency training.  When on call, the resident achieves another level of responsibility; acting as the clinical pharmacist that handles code coverage, pharmacokinetics, drug information questions, and whatever issues may arise during after hours.  For new residents, this responsibility may cause some anxiety – particularly given that you don’t know what may come your way - like a code.  But this is a good thing.  Residency training has a lot to do with going outside of you comfort zone in order to learn new things.  After experiencing something once you will be less uneasy and able to handle the situation better the next time.

I know this was true for me and many other residents at Johns Hopkins Hospital.  During the first code everything seemed to happen so quickly. There were a number of people packed tightly into a room, while someone was giving orders and others were running around quickly to perform important tasks.  I remember standing by the dispensing cabinet, trying to stay out of the way, when the physician asked me to prepare three drugs STAT [immediately] – drugs that I had only vague familiarity.  My hands were shaking as I pulled out my resources to verify the appropriateness of the doses and confirm how to prepare them.  I fumbled around with vials and syringes; which never seemed to be an issue for me in the past.  I triple checked my math and had someone else check the doses.  Even though I was nervous and fearful that I might do something wrong, the situation went well and the patient was fine.

I feel that it is experiences like this, where you are by yourself and forced to learn something new, under pressure, that make for the best learning experiences.  Experiences that take you outside your comfort zone occur all the time during residency training, but I feel that these experiences are more abundant while acting as the resident on call.

Experiential learning is the primary method for learning during a residency.  The variety of those experiences help to make one well rounded, and a residency on call program is useful in that it exposes one to a variety of unique experiences and responsibilities that one otherwise might not obtain.

[Editor’s Commentary:  Pharmacy residency on-call programs have existed for many years.  Perhaps the best known and oldest pharmacy residency on-call program was described in the American Journal of Health-System Pharmacy by Dr. Karen Smith and her colleagues at the University of Kentucky (AJHP 2003; 60: 2236-41).  Most residency on-call programs require the resident to troubleshoot drug-related problems that emerge during off hours (e.g. between 5pm and 7am).  This includes participation in hospital emergency care (aka "medical codes").  On-call programs require residents to act autonomously - to make decisions on their own - and in so doing, its intended to build self-directed learning skills.  For the new practitioner who is not yet accustomed to making decisions on his/her own or directing his/her own learning, this can (and should) produce some degree of anxiety.  By placing residents in situations of responsibility, residents develop a greater (and sometimes urgent) awareness of their gaps in knowledge and skills ... and this is an important step in the experiential learning process.  John describes this gap in his essay (vague familiarity with the three drugs used during the code) ... and, similar to the experiential learning model described by Kolb, he identified resources to help him fill that gap.  In this case, it was a drug information source available at the bedside.  Like the experiential learning model, he implemented strategies (obtained information, calculated doses, and had someone else double check him) and reflected on the success of those strategies (in this case, "the patient was fine.").  It is the last step, the thoughtful reflection about the experience, which is perhaps the most critical.  Without reflection, one is unlikely to learn from the experience or to actively identify gaps, seek resources, and implement new strategies in the future.  Life is FULL of experiences - but many (perhaps most) are not learning experiences.  As teachers, we must be mindful of the experiential learning process - and help our trainees learn from their experiences.  Perhaps the most important thing we can do is to set aside time for reflection (by the student or resident) and discussion (with us) at regular intervals.  It is often through a dialog with a skilled preceptor and experienced practitioner that the trainee will have those "ah ha" moments of understanding.  Reflection and discussion should occur as soon as possible after the experience - preferably within hours for major new experiences and less frequently (a few days) for experiences that have slightly new features (relative to the trainee's past experiences).  In addition to setting aside time for reflection, we should strive to prepare our trainees for major new experiences by helping them to identify gaps and assemble resources ahead of time.  The EXPERIENCE is solely the student's or resident's to have.  As much as we might like to take away their anxiety or to be at their side to take the weight of the responsibility, attempting to do so (all the time) is a disservice.  Indeed, it is the EXPERIENCE that sets the learning process in motion. - S.H.]

Rethinking the Art of Pimping

By Courtney Patterson, Pharm.D., PGY2 Oncology Pharmacy Resident, Johns Hopkins Hospital

The art of  medicine, the art of patient counseling, the art of using medications sound wonderful when discussed in the context of patient care, but there is another art that’s often used in the training of these fields - - it’s called pimping.

Palms sweating, beads forming on my forehead, and my mouth becoming dry as my preceptor hovers over me asking absurd questions that I am sure he / she knows I have no clue what the answers are. I knew there had to be a reason as a student, as a first year and now a second year resident, that there was a method behind making me so uncomfortable - - it’s called pimping.

Where there is established hierarchy, whether it be in the medical profession, pharmacy or nursing, there is a certain style of questioning that oftentimes prevails- - it’s called pimping.

Earlier this year an article by Detsky entitled, “The Art of Pimping” (JAMA 2009; 302: 1379-981) appeared in my social networking email.   Unfamiliar with the concept , I opened my email to find this art hit close to home - striking several personal nerves. Amazingly, a previous article written by Brancati also entitled “The Art of Pimping” appeared in JAMA some twenty years ago (JAMA 1989; 262: 89-90). This blog essay is my attempt to delve into this “art” and offer some advice on how to revamp this feared form of questioning.

Pimping occurs when an attending or preceptor (the Pimper) poses a series of difficult questions to a student or resident (the Pimpee).  The setting for this style of teaching typically occurs during rounds, topic discussions or in a circumstance where the Pimper has the expectation to retrieve direct answers from the Pimpee.  In this situation, the Pimper exudes power and fear as they are evaluating the Pimpee’s performance and are their superior.

Pimping is quite an old concept, as the earliest reference dates back to 1628 where Harvey, a physician, laments his students lack of enthusiasm, “O that I might see them pimped!” In 1889, Koch recorded a series of “Pimp Questions” that he later used on medical rounds. This concept has even fluttered through Johns Hopkins - in 1916 Abraham Flexer made the observation, “Rounded with Osler today. Riddles house officers with questions, like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”

In the 21^st century, pimping has survived because it’s based in the age-old style of question and answer. In this light, pimping can resemble the Socratic method but there are some distinct differences. The Socratic method is a kind of questioning that requires the student or resident to do more in depth thinking, it oftentimes presumes that the student knows the answer and the instructor is attempting to allow the student to answer their own question by bringing about questions that will better formulate the student’s answer. Pimping however, is asking questions with minimal expectation that the pimpee will know the answer. This form of questioning is used to either bring about a teaching point or show superiority of the pimper. Thus the difference between these methods is the intent behind the questioning.

I have alluded to the technique utilized in pimping, but there are only two components at its center: fear and power. A rapid fire session of questions combined with fear and power --you’ve got a pimping session.  Power is needed because it reinforces the relationship between the preceptor and the student or resident. Fear is present because the student or resident wants to know the answers to the questions and grimaces at not being able to respond in a manner that will quench the preceptor’s satisfaction.  And for those fellow residents, upcoming residents, and students I offer three tokens of advice in avoiding the dreaded feeling of being pimped.

First, attitude is everything.  During rounds, topic discussions, and presentations, the goal should be to learn. Even with sweaty palms as questions are being fired away at you, take it in stride, right the questions down and look them up later. There is no need to feel downtrodden; if you are being pimped then you should understand that the expectations are low for you to answer spot on. Second, be okay with not knowing the answer.  I know this is hard, maybe because of embarrassment or ego or a type A personality, but you aren’t going to know everything. Third, just because it was done to you doesn’t mean that you have to perpetuate it. Pimping is different from the Socratic method. Pimping utilizes fear and relies on the system of hierarchy. I know as a future preceptor, I hope to ask my residents what they should know and not emphasize what I know. I plan to give them the tools, assist in the search of articles and journals to assist them in order to make them better equipped when questions are posed.

Pimping is an old concept that needs to be re-examined. Going forward, I hope to use the term (it’s still a great word!), but rewire the concept by tossing out the thought that my residents should fear me or that I should be asking questions I know they don’t know. After reading these articles, I walked away with the view that I will rewire pimping by crafting questions to increase retention and hone in on key points … and diminish the embarrassment and diffuse sweating.

[Editor's Commentary:  There is a subtle difference between asking questions with the intent to teach ... and asking questions with the intent to ridicule, embarrass, or establish hierarchy.  However, on the surface it can be difficult, based solely on the phrasing of the question being asked, to determine the intent.  Questions that have very specific answers and require only factual recall of information are more likely to be "pimping" questions intended to demonstrate the superior knowledge of the questioner.  But even open-ended, analytical questions which have several potential solutions can be "pimping" questions if the intent is to exert power and fear.  Thus, context and non-verbal communication are important.  Context is the circumstances under which the question is being asked and its sets the stage (for success or failure).  Does the student have prior knowledge or experience ...  or an opportunity to prepare for the question(s) being asked?  Is the question being asked in a group setting ... and if so, is everyone encouraged to answer the question or contribute to the discussion?  Non-verbal communication also informs the student or resident about the questioner's intent.  An encouraging smile and a nod of the head can set the student at ease.  Moreover, patiently waiting and allowing the student sufficient time to think through the question and its potential solutions is important.  A preceptor or instructor who quickly answers his or her own questions really isn't interested in hearing what the student has to say - rather they just want to tell students about what HE / SHE knows.  Finally, creating an atmosphere of open dialog requires the questioner to be open to being asked questions, to expanding on important points, and redirecting statements that might not be articulated very well.  Effective questioning requires practice, practice, practice ... but its important to understand your own motivations and intent.  Pimping is about power and fear ... effective questions is about facilitating learning.  -S.H.]

Beyond Evidence-Based Medicine: Information Management

By Zachariah Deyo, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Maryland

The amount of medical information is increasing exponentially in a variety of forms.  Information is available faster than we are capable of mentally digesting.   For these reasons, it is important to develop a personal system to triage new information.   Additionally, the number of new drug therapies is continually increasing, the scope of pharmacy practice is broadening and the expectations of our profession are growing.

In an ideal world of medical information management, clinicians can obtain valid and relevant information that is available with the least amount of work.   Slawson and Shaughnessy explore information mastery in an article entitled Teaching Evidence-Based Medicine: Should We Be Teaching Information Management Instead? (Academic Medicine. 2005;80:685-9).  Technology is a useful tool to organize information and alleviate the amount of work involved in its management.  It can be used as part of a system to decrease the time, money and effort required to obtain information, answer questions and build knowledge.  Current resources include free or paid subscription services that summarize medical research and drug information.  Examples of these resources that may be useful to pharmacist’s include: Pharmacist’s Letter, JournalWatch, Pharmacist’s FirstWatch, MedScape, MedWatch and Wallstreet Journal-Health.  Electronic tables of contents (eTOC) are available from a variety of peer reviewed journals across multiple specialties.  Professional organizations offer list-serves to network with colleagues and experts to ask and answer clinical questions.   This list is by no means complete and myriad resources exist.  Their utility may vary based on ones practice, skill level or interest.  Additionally, to manage them in a central location most can be linked to an email account.  As an alternative, really simple syndications or RSS feeds can be used with a variety of “readers” to manage resources.  Some readers offer the ability to track reading and subscription trends and offer recommendations based on browsing in an effort to pick and choose what is most relevant to ones practice.  Readers can also be used to link to blogs and professional websites.  Also, social networking sites such as facebook and Twitter can be linked to some of the resources previously mentioned.

I was introduced to feed readers as a pharmacy practice resident.  My reader is a useful tool to manage the constant influx of medical information.  As I became more familiar with information management resources, I also began to think of the importance of exposing pharmacy students as well as practicing clinicians to these new tools.  After taking several courses in biostatistics and literature evaluation (as a student), during my residency I was required to take analysis of information to another level.  Should we be incorporating knowledge management strategies into the Doctor of Pharmacy curriculum?

I found several interesting publications on this subject.  The first was an article by Phillips and Glasziou (Postgraduate Medical Journal. 2008;84:450-3) which highlights the importance of keeping up with clinical evidence while in training.  These authors give several reasons :  the need to learn evidence-based medicine(EBM) skills, developing a system that helps manage the volume of new information and helping patients ”get better sooner.”  The importance of quality patient-oriented evidence is also discussed.  The article includes an explanation of the difference between “just in case” and “just in time” learning.  Although the authors write that both are beneficial the former is much more inefficient and information overload can be attenuated by using filtered resources.  Key resources are discussed to help clinicians stay up to date.  A four step approach to EBM including asking questions, acquiring information, appraising evidence, and applying results is explained.  The authors conclude with the goal of developing lifelong learning habits.

Slawson and Shaughnessy (Academic Medicine. 2005;80:685-9) discuss helping students, residents, and clinicians develop skills beyond EBM.  The authors point out that although critically evaluating medical literature is an essential skill, clinicians (in training and practice) must be able to find, evaluate and use information at the point of care.  The authors describe a curriculum that contains three levels of education based on experience and practice.  The three core skills they describe are: selecting tools for “keeping up”, selecting the appropriate hunting tool, and developing patient-centered, not evidence centered, decision making.  In helping students incorporate these skills and tools into their daily lives we foster lifelong learning.

In a subsequent article, Shaughnessy (American Family Physician. 2009;79:25-6) describes how to set up a system for keeping up.  The system  filters information and leads to answers that are valid, efficient, evidence-based, and patient oriented.  This is “system” is often referred to by the acronym POEM (patient-oriented evidence that matters).   Phillips and Glasziou write that focusing learning on information that is directly relevant to patients produces “better” clinicians.  Even the best tools offer little benefit unless you access them on a regular basis.  It can be challenging to find enough time in the day to check email, let alone a feed reader.  By exposing students to these resources early in their professional development we instill habits that will carry into their professional lives.

My recent trip to the American Society of Health-System Pharmacist Midyear Clinical Meeting re-enforced my thoughts on this subject.  I attended an excellent continuing education (CE) session titled: In Case You Missed It: Top Papers in Medicine 2009 (http://www.softconference.com/ASHP/sessionDetail.asp?SID=155655).  This was a great session.  After the conference I thought how true it is that we cannot rely solely on annual meetings and CE to meet the cognitive demands placed on our profession.  Our goal should be aware of and read important papers soon after their publication.  Technology in the form of feed readers and other resources is just one of many tools that can be incorporated into our practices.  Moreover, we must introduce these tool during the education of current and future pharmacists.

I challenge educators in all fields to explore new technology in keeping up with information.  These concepts can be applied to any professional practice.  If you are already familiar with or use these resources, that’s great.  Share them with your students and residents.   But don’t be afraid to let students teach YOU something about these new technologies.   These new technologies are not a replacement for biostatistics or literature evaluation but rather a supplemental tool.

Interprofessional Teams - Personal Reflections

By Min Kwon, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

I remember the day I found out that I got internal medicine as my first rotation as part of my advanced pharmacy practice experiences.  I was so excited!  I remember spending a month before the rotation reviewing all of my notes from the previous 3 years in pharmacy school.  I looked over all the disease states.  I memorized which medications were 1st line and what side effects to look for.  I felt so prepared and ready to apply what I’ve been learning to actual patients.  But I was not prepared for what happened next.

On the first day, my preceptor brought me up to the medical resident’s office and told me this would be the team I would be rounding with and introduced me to the team.  The team consisted of 2 medical students, two interns and one post-graduate year 3 (PGY3) medical resident.  They all said “hi” and immediately returned to what they were doing.  It wasn’t exactly the warm open arm welcome I was expecting, but I tried to stay positive.  As we started rounds, the students or interns started to present patients and they would discuss different aspects of each patient’s disease course and medications.  I noticed that one medication needed renal adjustment and therefore, after rounds I discussed it with my preceptor.  With my preceptor’s approval,  I felt confident about the recommendation - so I went  to find the intern taking care of the patient.  I approached the intern and asked if she would change the dosing on the medication based on the patient’s poor kidney function (as evidenced by her estimated creatinine clearance).  The intern looked at me with dismay and said “I am not going to change anything and don’t tell me how to manage my patient’s medications.”  I was in a state of shock … disbelief.  I couldn’t believe she wasn’t even going to consider my recommendation.  Why didn’t the medical intern understand my role as a pharmacist on the team?

As a background, I went to school in New York and had most of my rotations in city hospitals.  In New York, many feel that clinical pharmacy practice still lags behind many other places in the US.   Even after 10 years of pharmacists going to the state legislature in Albany to advocate for collaborative drug therapy management, laws permitting this practice still had not passed.  Pharmacists just received the right to vaccinate in the past year.  Many physicians in New York are not aware of what clinical pharmacists can bring to the team.  After 3 years of pharmacy school, no one ever told me that I might get push back from physicians or how I should handle these types of situations.   I went into my clinical rotations assuming that the medical team would be embrace me.  I assumed they knew my role on the team.  Well that was definitely not the case.  Instead, I found myself routinely demystifying all their beliefs about pharmacists.  Some of the medical students assumed pharmacists went to school the same length of time as nurses and that pharmacists only worked in retail settings or in the basements of hospitals.

When looking back at my pharmacy curriculum, I realize that all the pharmacology and therapeutics courses did not prepare me one very important tool needed as a clinician.  I needed to learn how to build collaborative relationships on a multidisciplinary team.  As I neared the end of my Doctor of Pharmacy curriculum, I realized that the dynamics of developing collaborative working relationships between pharmacists and physicians is not straightforward.  It requires a lot of thought and dedication.

Pharmacists are aware of the expertise we can provide the medical team to improve a patient’s drug therapy.  However, physicians and other health professionals often are not.  As a student, resident, or a new practitioner, it is less important to understand what pharmacists can bring to the team but rather knowing where to start in building a relationship with the team.

The American College of Clinical Pharmacy (ACCP) recognizes that the delivery of interprofessional education (IPE) in the classroom and clinic can be difficult.  A white paper by ACCP on IPE on addresses the terminology, levels of evidence, environment-specific models, assessment methods, funding sources, and other important implications and barriers as they apply to interprofessional education (IPE) and clinical pharmacy.   In discussing IPE implementation, ACCP describes that deployment of a multidisciplinary team in which professionals from different disciplines work independently of one another, is not considered an interprofessional approach.  This was the type of multidisciplinary practice I saw most commonly during my Doctor of Pharmacy curriculum.  On my first day of internal medicine, my preceptor brought me up to the floor, introduced me to the team and left.  Being the only pharmacy member on the team, I was not sure what my role was on the team, nor did the team.   Later I found out that the preceptor never rounded with any of the teams.  Therefore, there wasn’t an established relationship between the clinical pharmacist and the medical team.  Even though I would present the patients to my preceptor after rounds and we would review and discuss patient’s profiles from a pharmacy perspective, it was independent from the medical team.  In order to teach IPE, it is important to begin in a setting where there is a solid foundation and established relationships between the pharmacy preceptor and other members of the team.  This allows for students to role model what they observe and for them to understand what is expected.  Discussions between pharmacy preceptors and students should include not only the patient’s medication therapy but also how the student should approach, interact, and communicate with the medical team.

In an article by McDonough and Doucette (J Am Pharm Assoc 2003; 43(5 Suppl 1): S44-5), the authors comment on several methods for fostering the pharmacist-physician relationship.  They recommend that the first initial steps should be taken to introduce and to establish yourself as a valuable resource.    You should always be prepared to defend your response and recommendation toward drug therapy with reliable literature.  Next they recommend reaching out to physicians, by inviting them to pharmacy-related meetings.  Third, they recommend getting involved, by joining committees, groups, or other organizations.  This creates a great forum for your presence to be seen and voice to be heard.  Sometimes, your input may not be sought but rather initiative is required to build awareness and to demonstrate your desire to collaborate.

As a resident, I came in knowing that not everyone on the medical team will appreciate my role and accept my recommendations.  But I have implemented many of the recommendations described in the ACCP White Paper and the article by McDonough and Doucette.  By developing collaborative relationships with physicians and other health professionals, I know I can make a difference in patient care.

[Editor's Commentary:  Developing relationships based on mutual respect and trust, not only with physicians and other health professionals but also with patients and peers, is the cornerstone of our professional lives.  These relationships are built one-on-one and require the tincture of time. Through personal initiative and commitment, many pharmacists have forged strong collaborative relationships with physicians, nurses, patients, and caregivers.  Trust and confidence is not automatically bestowed on every member of the medical team.  Collaborative professional relationships, like friendships in our personal lives, are nurtured through a series of events.  Like friendships, these relationships can be enhanced or destroyed by our actions.  Zillich, McDonough, Carter, and Doucette examined factors that influenced the development collaborative relationship between physicians and pharmacists (Ann Pharmacother 2004; 38: 764-70).  Not surprisingly, relationship initiation, trustworthiness, and role specification were strong predictors.  Moreover, regular interaction/communication between the physician and pharmacist pair was critical.  None of this should be surprising.  Collaborative professional relationships are like any other human relationship.  Indeed, we need to spend more time teaching people how to initiate and sustain productive professional (and personal) relationships as a core element of our curricula.  While some didactic instruction may be helpful, role modeling of successful collaborative relationships is ultimately the key.  -S.H.]

Interprofessional Education - Benefits and Barriers

by Victoria T. Brown, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

The American Journal of Pharmaceutical Education (AJPE) recently published a theme issue on interprofessional education (IPE) (AJPE. 2009;Vol 73, Issue 4). The article that caught my attention utilized focus groups to identify perceived benefits and barriers to providing IPE (Smith KM, et al. AJPE 2009;73(4): Article 61). Representatives from six colleges of pharmacy separately attended a one-hour focus group session where open-ended questions were asked to assess the environment related to IPE at their respective institutions. The representatives were all considered to be leaders in education delivery at their institution. Most of the participants were affiliated with medicine (n=11, 27%) or pharmacy (n=9, 23%). However, there were also representatives from nursing, dentistry, and allied health.

The benefits of IPE are well-recognized. The Institute of Medicine includes IPE in its ten tenets for reforming healthcare education to improve the quality of patient care by teaching students to work in an interprofessional practice. A book published by the National Academies Press entitled Health Professions Education: A Bridge to Quality is largely dedicated to interprofessional education and the Institute of Medicine's call to action. The benefits of IPE identified by the focus groups included: (1) enhancing student education and training, (2) capitalizing upon economies of scale, (3) expanding opportunities for research and scholarship, (4) improving communication among healthcare professions, (5) promoting teamwork, and (6) improving quality of care and patient outcomes.

The barriers to IPE are not abstract, but tangible issues related to the current structure of healthcare education. The barriers identified revolve around the themes of curricular concerns, limited resources, lack of conceptual support, and cultural challenges connected to each profession. Currently, each discipline lives in a silo with different curricular requirements, accreditation standards, and budgets. Pharmacy has perhaps taken the boldest steps to reform accreditation standards. The Accreditation Council for Pharmacy Education (ACPE) Standards 2007 holds schools accountable for training students to provide patient care as a member of the interprofessional health care team. I would agree with the authors that until accreditation standards explicitly require interprofessional education there will be little external motivation for changing the current structure.

My initial reaction to the move towards more IPE was one of excitement and opportunity. As a new practitioner, I often wish I understood more about the training of other healthcare professionals. More so, I often wish they understood more about my training. Nevertheless, the barriers presented in this paper are very real, especially those related to financial constraints. With the economy being what it is, completely redesigned curriculums for multiple disciplines is a low priority for most institutions. Therefore, my prediction is that the changes towards IPE will be made in small incremental steps and will focus initially on service-learning activities and elective courses. As a student, I took two elective interprofessional courses. One of the courses focused on creating services for an urban middle school. The other course was an ethics course in which interprofessional groups discussed various ethical dilemmas related to patient scenarios. In neither of these courses was I learning pathophysiology or drug therapy alongside my colleagues in medicine or nursing. However, at the end of the course, I left with an appreciation for their thought process and experiences. When providing patient care together, these insights may be more valuable than knowing we learned similar scientific information. The article indicates that a couple of the programs have their students participate in interprofessional cases or OSCEs (objective, structured clinical examinations). This would seem to be the next logical step following service-learning or elective courses. In practice, the expectation will be to care for the patient in this manner. This takes team-based learning to an entirely new level.

Finally, the authors conclude that new faculty will be called on to deliver IPE as never before. For me, this is a strong call to learn all I can during my residency from physicians, nurses and other allied health professionals. By taking this opportunity now, I hope to have the skills and evidence to breakdown some of the barriers. In the end, patients will reap the benefits from a healthcare team which is working together.

[Editor's Commentary: Implementing interprofessional education in a meaningful way throughout the curriculum is a major challenge. Beyond the logistical issues, such as physical space and scheduling, there is a lack of expertise (e.g. faculty who have the knowledge, skills, and attitudes needed to teach interprofessional skills) and a pervasive fear that professional identity will be lost. If all healthcare professionals are trained in a similar way, what special knowledge or skills will each professional bring to the team? Pharmacy faces unique challenges because many (indeed most) work in places (such as community pharmacies) where the physical proximity to other members of the team is a structural barrier. While clinically trained pharmacist often work along side physicians, nurses, dietitians, and social workers in teaching hospitals, this model of care has not yet been widely adopted. And even in teaching hospitals, team-based interprofessional collaboration is less than optimal. Just because a group of people walk around together from room-to-room doesn't mean they are functioning as an effective team. We have a lot to learn! The American College of Clinical Pharmacy recently published a comprehensive White Paper on Interprofessional Education and an official Position Statement. I believe the key to changes in interprofessional care are linked to the payment model. It is only through a payment system that emphasizes quality and provides incentives for interprofessional collaboration will we see major changes in the structure of health care delivery ... which in turn will necessitate major changes in the structure of health professional education. In the mean time, health professional educators will need to continue to experiment with various of models of care AND interprofessional education to prove that these new models are indeed worth adopting! -S.H.]