Expanding APPEs – Meeting Future Needs

by Jennifer Thompson, Pharm.D., BCOP - Oncology Clinical Specialist, University of Maryland Medical Center

Due to the current pharmacist shortage and predictions of increased demand for pharmacy services, there has been rising pressure to create and expand PharmD programs. Subsequently, this creates more demand for personnel (preceptors) and resources (rotation sites) for advanced pharmacy practice experiences (APPEs) within the PharmD curriculum which is critical for the successful training of future pharmacists. This topic is of personal interest to me as an APPE preceptor at an acute care institution with several pharmacy residency programs. I will attempt to explore the topic stepwise by discussing a recent needs analysis, the standards, and my evaluation.

Brackett and colleagues performed an APPE organizational needs analysis for pharmacy schools based in the states of Georgia and Alabama (See: Am J Pharm Educ 2009; 73 (5) Article 82). The analysis was performed through the collaboration of the Southeastern Pharmacy Experiential Education Consortium (SPEEC) which includes: Auburn University Harrison School of Pharmacy, Mercer University College of Pharmacy and Health Sciences, South University School of Pharmacy, and The University of Georgia College of Pharmacy. The authors performed a gap analysis by comparing past APPE needs to forecasted future needs. Data regarding APPE class size for the 2006-2007 academic year, number of non-community APPEs needed per class, and total non-community APPE availability was gathered from the Experiential Education Management Systems database. Each SPEEC institution’s experiential learning director estimated needs for the 2010-2011 APPE year based upon their knowledge of anticipated changes in class size or curriculum. The 2006-2007 non-community APPE needs and availabilities were 3,590 and 4,427 sites, respectively, with a surplus availability of 837. Combined projected 2010-2011 non-community APPEs were estimated at 4,309. Assuming 2006-2007 non-community availability remained unchanged, the surplus declined to 118. The authors discussed many limitations to their analysis and acknowledge that they may have overestimated the APPE surplus. Indeed, they anticipate if they had separated required and elective rotations, accounted for rescheduling variables, and worked within a less complex system this surplus might evaporate.

Part of the motivation for Brackett and colleagues to conduct their research was the Accreditation Council for Pharmacy Education (ACPE) revised accreditation standards and guidelines for the PharmD degree adopted in 2006. These standards require that APPEs comprise a minimum of 25% of the curriculum and be at least 1440 hours in length. Standards set for preceptors include: they should be oriented to goals and objectives of the APPE PharmD curriculum and should be well versed in teaching methodologies that enhance learning. Preceptors need to be aware of students' prior knowledge and experience relative to the rotation's objectives so that they may tailor the rotation to maximize the educational experience. (See: ACPE. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree.)

Based on the analysis and standards described, one can summarize that expanding APPE availability is complex. I applaud the efforts of Brackett and his peers. The methods and the results can perhaps be extrapolated to other geographic regions. The top two factors on my mind are balancing the increasing numbers of PharmD students with limited availabilities in acute care settings combined with the economic crisis faced by many health systems. Hospital practitioners with the required skills and training may not have adequate time to precept students during APPE, especially if they also have institutional obligations to pharmacy residency training. Practitioners’ workloads need to reflect their educational commitments. As schools and colleges of pharmacy adapt to the new ACPE standards, scheduling students for APPE rotations should be synchronized and balanced with residency schedules. We can also empower residents to co-precept students.

As described in the ACPE Standards, schools and colleges of pharmacy need to review objectives and instructional activities and assess learning environments. The college or school must ensure that preceptors receive orientation, especially for first-time preceptors. Effective communication regarding student performance and expectations is critical. The defined procedures should be unambiguous and adhere to the task standards. Another method of standardization is through collaboration by consortiums of schools and colleges of pharmacy. Pooling resources between academia and practice sites could assist with preceptor development. Schools or colleges should provide structured feedback to preceptors based on their student evaluations and identify areas the require further development. I believe a combination of these strategies can assist us in meeting the projected APPE needs. By sharing resources and skills through partnerships between educators and practitioners and educational consortiums, future pharmacists and patients will ultimately benefit.

[Editor's Commentary: Preceptors, particularly those like Dr. Thompson in academic health science centers and teaching hospitals, are feeling the pressure to do more with less. Teach more students, train more residents, and see more patients with fewer resources. I'm afraid there is no immediate solution to this problem. On the one hand, pharmacists, particularly those with advanced training and skills, are needed more than ever. On the other hand, the free flow of money into healthcare systems is being increasingly scrutinized. Budgets are trimmed, cut, and slashed to meet immediate financial woes. And yet, inefficiency abounds, not only in patient care but also in the traditional methods we've used for decades to train pharmacists. Pooling limited resources and creating more efficient training models will certainly help. These problems aren't unique to pharmacy - clinical training in medicine and nursing have faced these same problems. Perhaps there are lessons we can learn from our clinical brethren? S.H.]

Patient Education and Health Literacy

by Jessie R. Lish, Pharm.D. - PGY2 Ambulatory Care Resident, Baltimore VA Medical Center

Educators are those who serve as learning facilitators, coaches, and guides to learners of all abilities and learning styles. No two learners are created equal, and no two educators teach in the exact same way. The unique teaching characteristics that educators possess are the reasons why they are able to teach courses and topics of all varieties. As an example, my father is a high school biology teacher, and my mother is a retired K-3 art teacher. My father teaches best through lecture in class with a little bit of laboratory work woven into his classes. My mother, on the other hand, taught mostly through hands-on art-making. For my father, using lecture and laboratory means to teach his classes was effective. In my mom’s art classes, younger children responded better to hands-on activities and would not have been well suited for a lecture-type of activity. The common theme in both examples is that educators portray information in ways best suited to their particular audience. As educators and pharmacists, we have to remember that even though we’re not in a formal classroom setting, our patients are learners and our “audience.” The same teaching principles hold true when we are educating and counseling our patients.

I recently read an article in Pharmacy Today (Ngoh LN. Health literacy: a barrier to pharmacist-patient communication and medication adherence. Pharmacy Today 2009;15(8):45-57.) – a publication of the American Pharmacists Association. The article is a review of existing literature regarding medication adherence, health literacy, and the use of written patient information in health care and pharmacy in particular. This article caught my attention because my PGY2 residency project is examining barriers to patient follow-up and monitoring in a psychiatric patient population taking second generation antipsychotic medications. After reading through the review article, I began to think that the patients we serve and educate everyday are kind of similar to our students that we teach in a more formal setting. Students come from a variety of backgrounds, learning styles, and interests. The same holds true for patients! Anyway, this article/review indicated that the health literacy skills of American adults have not changed considerably over the past decade. The author goes on to say that health literacy is a characteristic of a patient that may place him/her at higher likelihood of poor adherence to a medication regimen. I think about this everyday…how can we combat this and help educate our patients so that they truly learn about their health and the medications needed to control disease states?

I think it all comes back to a learner’s style of absorbing information presented to him/her. I relate this to Kolb’s learning styles. Kolb says that how we learn, or our “theory of learning,” is grounded in our experiences. He goes on to say that there are four styles through which learners glean information: 1) feeler; 2) doer; 3) watcher, and 4) thinker. Feelers learn best from specific examples in which they can be involved. Doers like to see everything and then determine their own criteria. Watchers learn best from demonstrations/lectures. Thinkers like to take new information and incorporate it into their own experiences. To relate this to our patients, a doer might be a patient who wants to see all medication options and then determine which one he/she would want to take depending upon the information presented. A watcher may be a patient who would benefit from listening to a short lecture on diabetes and how he/she can decrease his/her risk factors. A thinker may be a patient who would try a medication, think about how it made him/her feel, and then approach the health educator to discuss different options. A feeler may be a patient who takes the medication information home to read it on his/her own time and formulate his/her own opinion. No matter which learning style a patient possesses, he/she is going to benefit from a variety of teaching styles.

I believe that if we approach each patient with a fresh mindset, we can take into account our audience (i.e. the patient), the learning content (i.e. medication information/disease state information), the learning style of the patient (i.e. if the patient is a more hands-on learner and requires pictures; if the patient cannot read/understand English and requires a translator; if the patient prefers to read the information him/her self, etc.) and adapt our teaching style to fit that patient. From personal experience, I know that the patients I see in geriatrics clinic differ from my younger patients in the diabetes clinic, who differ from the patients I serve in the mental health clinic. I am constantly adapting my teaching and educating styles to fit whichever patient population I’m working with that day. I truly believe that all teachers and learners/patients are not created equal, and to truly benefit our patients, we must adapt to each situation.

[Editor's Commentary: Health literacy can significantly impact health outcomes and its an issue that every clinician should have a working knowledge about. Health literacy is NOT synonymous with literacy. While they are related concepts, patients can be literate - indeed, well educated - and have relatively poor HEALTH literacy. Clinicians often make assumptions about patients who are articulate and well educate. Some fully understand health terminology and complex health concepts. But many don't. That's why its so critically important to know your learners - to figure out what they already know, what they need to know, and how they learn best. S.H.]

Student Absenteeism

by Lauren Hynicka - Assistant Professor, University of Maryland School of Pharmacy

The branch campus is becoming ever more popular in higher education. As a result, lectures are recorded for students at the distance campus to view asynchronously and often students on the "main" campus also have access. The University of Maryland School of Pharmacy recently started its own branch campus at Shady Grove. I have heard during my short time here that there has been a decline in student attendance since the adoption of the recorded lecture. [Editor's Note: Dr. Hynicka joined our faculty in August 2009]

Over the past several weeks, we have been discussing teaching and learning styles. I was curious to see if I could find any information that might give me a clue as to the types of students who would be more apt to be absent from lectures and what if anything could be done to encourage attendance. In my search I found an article by Westrick and colleagues entitled, “Factors influencing pharmacy students’ attendance decisions in large lectures.” (Citation: Westrick SC, Helms KL, McDonough SK, Breland ML. Am J Pharm Educ 2009; 73: 1-9).

The authors introduce the topic by identifying the reasons why educators should be concerned about absenteeism in the classroom. Negative impacts on both academic performance as well as professional development were identified as two major consequences of student absenteeism. In order to better delineate strategies to improve student attendance at classes, a study was conducted at the Auburn University School of Pharmacy. The study consisted of a two step process - the first step was to develop a survey instrument. All students were invited to participate in a discussion on student absenteeism. They were asked to identify reasons to attend and not to attend classes. Following the generation of this list, the students ranked the reasons based on how much they agreed or disagreed. In addition to student generated ideas about absenteeism, a literature search revealed two research studies evaluating similar research questions. A compilation of these sources lead to the generation of the survey instrument.

A cross-sectional survey was disseminated to 131 second-year pharmacy students via email. Students were asked to identify the number of times they were absent from 3 courses: integrated pharmaceutical sciences, management, and pharmaceutics. Demographic information was also collected. Finally, students were asked rate 14 reasons to attend class and 22 reasons not to attend class. Students were asked to use the following scale: main reason, moderately important reason, minor reason, or not a reason.

A total of 98 (75%) students responded. Three-quarters of the students were female and unmarried. Prior education was split down the middle, with half of the students earning prior college degrees. The majority of the students was not working during school and lived less than 10 minutes from campus. The average age was 23 with a cumulative GPA of 3.0. Student reports of absenteeism were highest in the pharmaceutics course with 38% of students reporting 11 or more absences and lowest in the management course with 100% of student reporting ≤ 2 absences. When analyzing the effect of student characteristics on absenteeism there were no statistically significant differences in the pharmaceutics or management courses. In the integrated pharmaceutical sciences course students were more likely to miss more classes if they lived more than 10 minutes from campus (p=0.04) and paid for their own education (p=0.04).

The main reasons to attend or not to attend class varied based on the course. A resounding reason to attend class (common to all courses) was the desire to take notes and to hear what the instructor considered important to know. In the management course a strong motivator for student attendance was the implementation of pop quizzes and activities that would impact student grades, with 97.7% of students reporting this as a reason to attend class. In terms of reasons not to attend class, students stated they would skip class if they were sick, they were studying or working on an assignment for another course, and the material was available from another source. These reasons were common to all three courses.

One thing I have gleaned from this article is that awarding credit (or points toward the student’s grade) for attending class is a strong incentive. I also think one of the students' justification for not attending class - the need to study or work for other courses - is an interesting one. In pharmacy education we have the unique advantage in that our students are taking essentially the same classes and we (the teachers and administrators) have access to their schedules. While I recognize that developing time management skills is important, perhaps we (the faculty and administration) are doing a disservice to ourselves and our students by not exploring better ways to schedule course-related activities that would enable more students to complete assignments, study for tests, and attend class.

Relative to the student reasons to attend class it is interesting to note that one is an intrinsic characteristic of the learner (a desire to take notes) and the other is a quality related to how the teacher presents the material (emphasizing what’s important). While the authors were not able to delineate which students were more likely to miss class based on demographic characteristics, I would argue that the authors failed to collect some important information. I believe information about the students’ learning style, perhaps by using an inventory such as Kolb’s learning style indicator, would have been helpful . This might have provided additional insight into student responses to the survey and may be helpful for instructors to design learning activities for large groups that would entice more students to attend. Instructors are the other piece to the equation of classroom attendance and yet this crucial stakeholder was not surveyed in this study.

I think that this study could be used as a tool for faculty development. Having faculty members participate in a similar survey to see what biases / beliefs they have as it relates to student absenteeism would add an interesting dimension. Taking this a step further I would like to see faculty members complete an inventory to identify their teaching style. A better understanding of their own teaching tendencies will allow faculty members to see what areas they should strive to develop to better meet the needs of their students.

[Editor’s Commentary: Should we force, coerce, or bribe students to attend lectures (e.g. take attendance, administer pop quizzes, give attendance points)? Is there any evidence that attendance (per se) improves outcomes? If students perform equally well (or perhaps better) on assessments and exams when they skip class, what is the incentive to attend? From the student’s perspective, if the benefits of not attending outweigh the potential consequences, being absent is a simple benefit-risk decision. Does absenteeism bother us (the faculty) because it reflects badly on us (the faculty)? Does it annoy us because its boring talking to a bunch of empty seats? Are we failing to measure and assess important aspects of learning that best occur during face-to-face encounters with and between students? Or are students simply making rational decisions about how best to use their time? Food for thought. S.H.]