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.]

The Importance of Mentoring

by Joshua Raub, Pharm.D., Pharmacy Practice Resident, Johns Hopkins Hospital

Thinking back over the past five years when I first step foot in Wayne State University’s college of pharmacy to my current residency at The Johns Hopkins Hospital, I cannot help but think of all the influential people that have helped guide me along the way. Throughout this journey, there were many instances where I was faced with decisions ranging from trivial choices such as which elective to take, to life changing decisions such as moving away to pursue a pharmacy practice residency 500 miles from home. With all of the difficult decisions however, one individual in particular stands out as a teacher, a preceptor, and most importantly, my mentor.

The formal definition of a mentor is an individual who serves as a trusted counselor, guide, tutor, or coach¹. A mentor is someone with tenured experience within a certain field of practice or profession who lends their knowledge, experience and wisdom to a novice counterpart. The act of mentoring has a longstanding history dating back to the Ancient Greeks with Socrates serving as mentor and teacher to his student, Plato, and throughout the centuries, mentoring has been utilized in many specialized professions including academia, business, the arts, and pharmacy.

Upon graduation and licensure, the new pharmacist entering the workforce has an armamentarium of pharmaceutical knowledge, access to a plethora of primary literature databases, and specialized skills gained during their pharmacy education. Even with this impressive background however, the new pharmacist lacks one key characteristic, wisdom and experience in the profession. The involvement of a mentor not only ameliorates the angst in bridging the academic to the practice world, it allows the mentee to learn from years or decades of practical and personal experience. Mentorship is often described as a symbiotic relationship between two adults who assist each other to meet mutual career objectives in an organization or professional discipline². Anderson and Shannon further define mentoring as: a nurturing process in which a more skilled or more experience person, serving as a role model, teaches, sponsors, encourages, counsels, and befriends a less skilled or less experienced person for the purpose of promoting the latter’s professional and personal development. The definition of mentorship proposed by Anderson and Shannon highlight five main characteristics a successful mentor must provide:

• Teaching – assist in acquiring new knowledge, skills, and attitudes for success
• Sponsoring – use of the mentor’s power and professional status to help the mentee attain their career goals and objectives
• Encouraging – through affirming, challenging and inspiring the mentee
• Counseling – serving as advisor and mediator in times of conflict and distress
• Befriending – creating a longstanding professional and personal relationship

The importance of having a mentor can be seen at every level of ones pharmacy career. Starting pharmacy school can be a daunting task for the first year student. The bar is set high and the expectations are raised due to the graduate level of classes. A new vocabulary emerges, filled with Latin medical terminology, and sentences comprised entirely of acronyms. This transition from undergraduate to graduate level can be quite intimidating, however having a mentor to help adjust to the rigors of the program can prove to be very beneficial. As the student progresses through the pharmacy curriculum and enters into experiential education, a new mentor emerges: the preceptor. Providing a unique and clinical perspective, the preceptor serves as the bridge from pharmacy education to pharmacy practice. Finally, as the pharmacy graduate enters the workforce, they are welcomed with a new mentor, a pharmacist with tenured experience in the field who can help acclimate the new practitioner to the pharmacy practice setting.

I have always valued my mentoring relationships. This form of teaching however, I feel is largely underused. When I think back to my first two years of pharmacy school, I remember having so many questions that went unanswered. The new college, the self-directed learning process, the proliferating responsibilities; all sent me in a whirlwind of confusion and I found myself drowning in the chaos after my first year. I soon discovered I was not alone in this state of uncertainty as many of my classmates felt the same frustration and confusion with no one to turn to. The situation necessitated change and needed an answer. As a result, my colleague, Trevor Wood and I created a student driven mentoring program. The program consisted of matching a third year pharmacy student with an incoming first year student. The third year student serves as a mentor and guide to the new pharmacy student, providing helpful information in the transition to the college, coursework, and opportunities within the profession. The mentor role aided in the professional development of the third year student and also provided a “preceptor-like” role to the mentee; two crucial characteristics of a practicing pharmacist. We also discovered a method to bridge the student-faculty relationship by assigning the mentor and mentee with the same faculty advisor, thus incorporating another level of mentoring in the process. Our program, The Keys to Successful Mentorship was widely accepted, and I am proud to say was adopted by the college and added to the pharmacy curriculum.

Finally, I feel mentoring holds two very important characteristics. First, having one mentor does not preclude someone from having additional mentors. More often than not, an individual will encounter many mentors in their lifetime, each offering a unique vantage point for the mentee. Second, mentoring is a continual process. The lessons, skills, and wisdom obtained by the mentee from their mentor not only aides in personal growth and development, but also prepares the individual to assume the role of a mentor for the next generation. The value of mentorship is great and every individual should be encouraged to utilize the act of mentoring to its fullest potential.

Reference:

1. Ladd EM. The value of mentorship. J Am Pharm Assc 2008;48:335.

2. Haines ST. The mentor-protégé relationship. Am J Pham Educ 2003;67(3):1-7.

[Editor's Commentary: Having written a review article on this subject some years ago, I too believe that mentoring has a special place in education. Some mentoring relationships exist for a single purpose (e.g. related to specific project or job or organization) - while other mentoring relationships transcend traditional professional boundaries, maturing into deep friendships, and continuing for a lifetime. Similar to a parenting relationship, good mentoring relationships are INTENTIONAL - where the mentor and mentee (or protege) purposefully engage in mutually beneficial activities. In most mentoring relationships, the mentor is responsible for sending the welcoming messages (verbal and non-verbal) that initiates the relationship. Some people seem more able and/or perhaps more willing to enter into mentoring relationships. Some are more capable of nurturing and maintaining many mentoring relationships simultaneously. Mentoring, like teaching, requires the mentor to be mindful of the mentee's capabilities and needs ... and to "let go" when the appropriate time comes. But unlike a typical teacher-student relationship, the mentee enhances the mentor's career by contributing to their mutual work in substantive ways. Everyone should be fortunate enough during their professional lives to have a (at least one) mentor .. .and should be willing to serve as a mentor to others. It is through mentoring that our professional life becomes more satisfying ... and our profession advances. -S.H.]

Inspiring Dreams

by Patricia Ross, Pharm.D., Clinical Pharmacy Specialist, Johns Hopkins Hospital

I am a dreamer. I have been since age 13 when my father passed away. As you can imagine, my father’s death had a profound impact on me. It inspired me to set goals for myself and dream big. These goals and dreams have helped me get to where I am today.

I first heard about the book “The Last Lecture” by Dr. Randy Pausch, a professor at Carnegie Mellon University, two years ago. Reading Dr. Pausch’s book has been on my to-do list ever since. When I discovered there was a video of the lecture, “Really Achieving Your Childhood Dreams,” I finally made time to sit and watch it.

I have watched Dr. Pausch’s last lecture twice now. Prior to pressing the play button, I was not certain what to expect. Within the first five minutes of the video, I realized it was nothing like I expected. Dr. Pausch first takes the opportunity to remove the “giant elephant in the room” by discussing his cancer diagnosis, displaying his CT scans and stating his prognosis (three to six months at the time of the lecture). The next 75 minutes are filled with personal stories, photos, live props, a lot of laughter and a few tears.

Dr. Pausch’s lecture is personal to me because shortly after he delivered it, his children suffered a loss that will change them forever, just as I had 22 years ago. At the end of his lecture, Dr. Pausch points out two “head fakes.” First, it is not about achieving your dreams; it is about how to lead your life. The second “head fake” is that he wrote and delivered his last lecture for his children, not for the audience in front of him that day. When the time is right for his children to watch their father’s lecture, I am hopeful they will understand the first “head fake,” just as Randy had envisioned.

Like the millions that have watched the last lecture and have been inspired, I too learned many things. Most importantly, the brick wall theory. Dr. Pausch weaves this concept throughout his lecture. He teaches that brick walls are there for a few reasons. They are not there to keep us out, but simply to let us prove how badly we want something. The brick walls are there to stop the people who do not want it bad enough, the “other people.”

Realizing that this one lecture is a snapshot of Dr. Pausch’s teaching style, I believe there is a lot for present and future teachers to learn from it. It is easy to see that Dr. Pausch is an effective teacher. In this one lecture, he used humor, real life stories, photos, and props all to deliver his message. His teaching style was very comfortable and engaging, he took command of the stage and never looked rigid. Dr. Pausch also demonstrated an effective way of pausing, timed just perfectly, to allow the audience to process the message he was trying to deliver. He was also not afraid of showing emotion, excitement mostly, which made him more real to the audience.

Dr. Pausch’s central message is that achieving dreams and goals are possible if you get tough enough with yourself and do not give up. That is one of the main reasons Randy Pausch loved to teach. He created courses to help students achieve their dreams. After all, isn’t that one of the main reasons teachers become teachers?

Lastly, Dr. Pausch provided advice that I will carry with me forever. “You just have to decide if you’re a Tiger or an Eeyore? Never lose the childlike wonder. It’s just too important. It’s what drives us.” In the end, Randy Pausch was not only trying to teach his students, he was trying to make them happier people. He has inspired me to try and do the same.

[Editor's Commentary: If you haven't seen "The Last Lecture" yet ... well, you should. The message is inspirational and Dr. Pausch's book expounds on his central messages in greater detail. So, if for no other reason than your own personal growth, you should watch the presentation and read the book. But as teachers, I think there are important lessons that we can derive from "The Last Lecture." For me these include: your enthusiasm and passion are critical ingredients to success; delivering simple messages and illustrating them with stories is a powerful teaching tool; and teaching is less about the content ... and more about inspiring people to do more related to the content and helping them to organize the journey to see the big picture. In Dr. Pausch's case, the content was an examination of the "important values in life." Lecturing is but one instructional methodology teachers have in their tool chest and Dr. Pausch is truly a gifted lecturer. But during his presentation he explores other teaching methodologies that are equally important including discovery learning, mentoring, and performance feedback. So check out "The Last Lecture" - and view it from two perspectives: as a student listening to Dr. Pausch's lesson and as a teacher observing Dr. Pausch's techniques and methods. -S.H.]

Professional Attire And Professional Attitude

by Noella Mbah, Pharm.D., PGY1 Pharmacy Resident, Shady Grove Adventist Hospital

Being well groomed and wearing the appropriate clothing is evidence that a person takes his or her professional responsibilities seriously. This is especially true for practitioners in the health care professions. A majority of studies evaluating a patient’s perception of a health care professional’s appearance have found that patients care about their provider’s appearance.(Goodsman-Snikoff G. International Journal of Pharmacy Education 2003 (Spring); 1(1). Available at: http://www4.samford.edu/schools/pharmacy/ijpe/103.htm#ethics). These studies have found that patients use appearance to judge the provider’s competency and credibility. It is for this reason that the majority of colleges or schools of pharmacy implement a dress code for all experiential rotations. Patients trust pharmacists as a source of accurate medical information and depend upon them to act in their best interest while providing pharmaceutical services. Each student and graduate pharmacist inherits this time-honored legacy to dress and act professional at all times.

After acceptance into a doctor of pharmacy program, the students begin a process of developing the knowledge, skills and attitudes that are the fundamental core of the profession. Implementing a professional dress code amongst pharmacy students, even during the classroom-based portion of the pharmacy curriculum may help prepare students for the practice of pharmacy. The impact of formal dress codes in pharmacy school have a demonstrable effect on student attitudes regarding professional behaviors.(Gorham, J et al; Communication Quarterly 1999; 47(3): 281-299)

Many colleges and schools of pharmacy have attempted to emphasize the importance of student professional development by establishing ceremonies and policies that place value on professional appearance and behavior such as white coat ceremonies, pinning ceremonies, and codes of professional conduct. During the classroom-based portion of the curriculum, some schools require their students to dress professionally with white coat on campus at all times while other schools haven’t implemented such a requirement yet. However, all schools require students to dress professionally during their experiential practice rotations. Is there a difference between the performance of students who were required to dress professionally on campus when compared to those who were not required to do so? Do preceptors see a difference in their professional attitudes and their desire to uphold the oath they took during their white coat ceremony?

Professional socialization within pharmacy has been described by Duke et al as ‘‘the general process whereby students learn about the professional role of pharmacists and the expectations of performance in that role”.(American Journal of Pharmaceutical Education 2005; 69(5); 104) The article goes on to list the factors affecting the professional attitude of students such as, individual student values, reason for selecting pharmacy as a profession, role models (including faculty members and practicing pharmacists), ideology and culture of the College of Pharmacy, curricular content and design, past and current practice-based experiences, and peers. Many colleges or schools of pharmacy teach professionalism to their students by emphasizing the “Oath of the Pharmacist”, encouraging students to observe and learn from role models, and assigning faculty or staff to students to serve as mentors.

Although professional behaviors may be addressed in professional schools through dress code requirements and other practices, it is ultimately the student’s responsibility to develop an appropriate professional attitude and to demonstrate this in his/her professional life after graduation. Personally, as a new practitioner, I strive to implement the virtues of professionalism which I learned from my years in the Doctor of Pharmacy curriculum.

[Editor's Commentary: Whether pharmacy students are more likely to develop professional behaviors by wearing professional attire in the classroom is an unanswered question. It seems doubtful that the mere act of wearing a neatly pressed shirt/blouse with dress pants is going to lead to other behaviors we often associate with professionals - such as initiative, self-confidence, timeliness, persuasiveness, and possession of advanced knowledge and skill. However, by bringing conscious attention to these professional behaviors - including attire - we heighten awareness about what it "means" to be a professional. Humans quickly ascribe "meaning" to objects. Uniforms are a clear example. The police uniform represent authority. For some, the mere sight of someone wearing a police uniform evokes respect and trust. For others, it evokes distrust and anger. Thus, the object (in this case, a police uniform) is imbued with meaning that leads to cognitive responses ... which leads to behaviors. These responses occur not only in the person seeing the police uniform, but also in the person WEARING the uniform. We invest deeper meaning in these objects through ceremony and rituals (e.g. graduation from the police academy or burial ceremonies for slain officers). Similarly, medicine, nursing, and pharmacy have uniforms, symbols, and ceremonies - to instill meaning (for us and our patients) and to formally acknowledge our societal obligations. And these symbols and ceremonies are an important part of adopting an attitude ... which often leads to professional behaviors. -S.H.]

Duty Hours and Their Effect on Learning

by Elizabeth A. Sinclair, Pharm.D., PGY1 Resident, Johns Hopkins Hospital

The beginning of my PGY-1 Pharmacy Practice Residency at the Johns Hopkins Hospital was filled with days and days of orientation. We covered everything from fire safety to service excellence. One day, as we reviewed the Pharmacy Residency Handbook and residency-specific policies, the topic of duty hours came up. In order to be eligible for accreditation, the American Society of Health Systems Pharmacists requires that pharmacy residency programs follow the duty hour requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). These requirements, which became effective July 1, 2003, were issued in an effort to prevent excessive fatigue, which could potentially lead to medical errors. Residency duty hours are limited as follows:

• Duty hours must not exceed 80 hours per week, averaged over a 4-week period.
• Every 7 days had to contain at least one 24-hour period free of clinical responsibilities.
• In-house call could not be more than every 3^rd night, averaged over a 4-week period.
• In-house call could not last more than 24 hours (plus 6 hours for continuity of care) per shift.
• A minimum of 10 hours between daily duty periods and after in-house call must be allowed.
• No new patients may be accepted after 24 hours of continuous duty.
• Vacation days may not count as “days off”.
• Home call must count toward the 80 hours if the resident comes to the hospital.

Duty hours were defined as: all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site.

After my initial review of these requirements, I found them reasonable, and I did not feel that I would be affected greatly by them. I was expecting that 80 hours per week would be the maximum I would ever need or want to work (oh, new resident, so young and naïve!). However, as I have progressed through my residency, I have discovered that I was quite mistaken. It is incredibly easy to come dangerously close to that 80-hour mark. When non-duty hours are included, I guarantee that I, along with all my fellow residents, exceed 80 hours on a weekly basis. However, as much of our work is not related to patient care, e.g. educational presentations, committee responsibilities, research activities, course work for classes not required for completion of the residency, etc., we remain within the ACGME requirements. Although I appreciate the ACGME requirements, especially when they allow me to sleep until 7:30 or 8 AM on a post-call day, there are times when they seem to make life a bit more difficult. For example, on post-call days, although it is nice to have the built in rest time, one often ends up joining rounds somewhere in the middle, not having had the opportunity to pre-round. This makes it very difficult to contribute to the team and also results in the resident spending a good portion of the day playing catch-up. Overall, I feel the effects of ACGME duty hour requirements are beneficial for my educational experience, but there are times when learning might be enhanced if they were not followed.

My mixed feelings toward the ACGME requirements are consistent with what’s been documented in the literature. In a survey of chief residents and neurosurgical program directors examining the impact of ACGME duty hour requirements on neurosurgical residents, 96% of the respondents believed that the requirements had compromised resident training, and 98% thought that it had decreased resident surgical experience. Most thought that the requirements negatively affected patient safety and access to care, and that the residents’ cognitive development and education had been compromised (Jagannathan, et al. J Neurosurg. 2009;100:820-7). Similar sentiments were seen in another study which compared the operative experience of chief residents before and after duty-hour restrictions were in effect (Damadi, et al. J Surg Ed. 2007;64:256-9). This study, which included general surgery residents, found that residents experienced an approximately 25% decrease in the number of cases during their chief-year and an approximately 15% decrease in number of cases during their non-chief years. A survey of internal medicine residents found that about 25% of residents reported spending less time teaching patients. However, these residents did report being less emotionally exhausted, and, in contrast to the previously cited studies, were more satisfied with the patient care they provided (J Hosp Med. 2009;4:476-80).

Overall, the ACGME requirements seem to have both positive and negative impact on residency training. Further study is needed to discern if training under these restrictions leads to inferior or superior job performance as residents move into independent practice.

[Editor's Commentary: Whether the ACGME duty hour restrictions has had the intended effect - reduce the risk of patient harm due to medical errors cause by fatigue - has not, to my knowledge, been clearly shown. However, there is a significant body of literature that demonstrates that excessive fatigue adversely impacts learning. The relationship between stress and learning is an interesting one. Similar to the Frank-Starling Curve of the heart, low to moderate levels of stress can improve performance and accelerate learning.

But, similar to the heart muscle, there is a point of diminishing returns. As the graph illustrates, initially, stress (end diastolic pressure) has a positive influence on learning (peak systolic pressure) .... but excessive stress results in (brain and muscle) fatigue and eventually learning (peak systolic pressure) begins to decline. But where is the point of diminishing returns (you may be asking)? Similar to the heart muscle, the point of diminishing returns depends on a number of factors and varies from person to person. A young heart (or brain) is generally more resilient than an older heart (or brain) ... and can withstand greater pressure over longer periods of time. But do we really want to push people to their limits? Duty hour limits are a good idea - even if they (occasionally) result in missed opportunities for learning. -S.H.]

The Clinical Pharmacy Movement

By Dachelle Johnson, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

The profession of pharmacy has undergone many changes. The pharmacist is no longer confined to a strict dispensing role but now has multiple responsibilities including consultative services to health care professionals regarding general and patient-specific issues related to drug therapy. In preparing for these new roles, pharmacy education has changed as well. An article by John A Biles published in 1983 (JAMA. 1983; 259(9): 1157-1160) addressed the evolution of pharmacy in the context of the clinical pharmacy movement. This commentary and accompanying editorial (Lundberg GD. The Clinical Pharmacist. JAMA. 1983; 249(9): 1193) were interesting to me because it provided some insights regarding the history of my profession. As a clinician in training I found it fascinating to evaluate where the profession of pharmacy has come from, where it is going, and what education methods have been applied at different time points.

Clinical pharmacy services were developed in the 1960’s after extensive reports in the medical literature regarding drug interactions and medication errors. A group of “forward thinking educators” at the University of California, San Francisco, the University of the Pacific at Stockton, California, and the University of Southern California are credited with coming up with the concept of "the clinical pharmacist." In order to successfully prepare pharmacists for this new role, the pharmacy curriculum had to change. The degree program transitioned from a baccalaureate to a doctor of pharmacy. This transition is reminiscent of andragogy in that a subset of educators during that time did not feel as though the pedagogy methods were sufficient. The implementation of clinical rotations as a requirement for the Doctor of Pharmacy degree utilizes many adult learning principles. Learners are involved in planning there course of study by choosing which electives and rotations they would prefer, rather than a strict assignment. Also, self directed learning is important during clinical rotations. Learners must ask questions, identify their own knowledge and skill gaps, and utilize the resources available to make interventions and get the most out of their experience.

In addition to the new degree program and the additional clinical rotations, residencies and fellowships were implemented (residencies date back to the 1930’s but standards and an accreditation process was implemented in the 1960’s). These post graduate training programs act as a bridge from student to practitioner. In the setting of post graduate training, the learner (resident) also uses self directed learning skills.

Constructivism is another educational theory that has been applied in pharmacy education. The teacher (preceptor) facilitates learning, rather than transmitting knowledge. In accordance with the principles of constructivism, the preceptor explores inconsistencies between students’ current understanding and their experiences.

The profession of pharmacy has seen many changes and will continue to evolve in the future. As stated by Robert H. Ebert, MD, professor of medicine at Harvard University, “the future of the pharmacist lies in the direction of clinical medicine and the education of the pharmacist must reflect this need.” The newest change in pharmacy education is the increasing use of technology in the classroom. The number of pharmacy schools is increasing much quicker than the number of pharmacists pursuing academia as a career; this shortage makes web-based learning and distance education a potential solution.

One conclusion that Biles made in his commentary more than 20 years ago (and I agree with) - the future of the clinical pharmacist will be determined by an ability and desire to participate in patient care and relate effectively to physicians, nurses, and patients. Desire is not something that can be taught, but post graduate training gives the pharmacist the necessary tools. As the profession continues to change, the way we educate future pharmacists will need to change as well. The result is pharmacists who are better prepared to improve patient outcomes. As stated in our oath, “I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.”

[Editor's Commentary: Its taken nearly four decades to transform pharmacy from a product-centered to a patient-centered profession. This transformation has required pharmacists and pharmacy educators to acquire new knowledge, skills, and - most importantly - attitudes. However, the clinical pharmacist isn't merely a fountain of knowledge (although, he or she should, of course, be knowledgeable) about drug products but rather a trusted advisor who evaluates data and synthesizes solutions that are most likely to succeed. This requires considerable judgment and wisdom. Wisdom requires more than knowledge, skills, and attitudes but also experience and maturity. Thus, the training of clinical pharmacists, similar to the training of physicians, requires an extensive period of time to acquire the "real life" experiences needed to become a fully developed clinician. Long ago pharmacists trained for many years as apprentices under the guidance of a more experienced practitioner. Perhaps pharmacy education is coming full circle? An excellent review of the history of the clinical pharmacy movement was just published: Clinical Pharmacy in the United States: Transformation of a Profession by Robert Elenbaas and Dennis Worthen. Check it out! - S.H.]