January 26, 2012

Teaching Pharmacy Students to be Excellent Communicators

By Allison Lardieri, PharmD, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

After completing four years of undergraduate education, four years of pharmacy school and now six months of PGY1 pharmacy residency training, I’ve come to the realization that communication skills are perhaps the most important skill I need – and I continue to work on them!  Being a skillful communicator does not require one to know the mechanism of action of a specific drug, disease pathophysiology, or the most recent CHEST guidelines – not that these concepts aren’t extremely important.  But, I have found that the importance of effective, clear, and assertive communication by pharmacists surpasses drug knowledge.
Communication skills are vital to pharmacists every day, regardless of whether they work in a community or hospital setting.  As pharmacists move from a medication-dispensing role to a patient-centered role, they must communicate regularly with other health care practitioners and patients.  In the hospital setting, a clinical pharmacist participating on interdisciplinary rounds needs to feel confident speaking up at the appropriate time and needs to know how to make recommendations in a manner that is well-received by the team.  I believe this is a skill that does not come naturally, but rather can be practiced and refined.  Whether in the hospital setting or community pharmacy, pharmacists have opportunities to counsel patients and need to master the best way to illicit pertinent medical information from patients.  Pharmacists in the community are often pressed for time, and it is important to convey the critical counseling points to patients in a caring and knowledgeable way.  Lastly, communication between pharmacists is another area where being open and assertive allows workflow to go smoothly.  Pharmacists and technicians working together should be constantly communicating about tasks that need to be completed and patient care issues that require resolution.

There are countless times where communication is critical, and as future pharmacy educators we need ensure we train students to become excellent communicator.   In the article, “A Tool to Teach Communication Skills to Pharmacy Students” by Susan Hasan, students developed scripts to illustrate interactions between physicians and pharmacists.1  Three different scripts were developed based on three communication styles:  assertive, aggressive, and passive.  One of the scripts was turned into a multimedia CD and used for future students.  This activity allowed pharmacy students to explore different communication techniques and improve their communication skills. 

For a majority of pharmacy students, clinical rotations are where they refine their professsional communication skills.  Optimally students should model the behaviors and communication style of their preceptors.  McDonough and Bennett describe several effective strategies for preceptors to improve pharmacy students communication skills.  This includes a thorough orientation to the practice site, establishing pharmacist-patient relationships, and using a counseling model.2  They emphasize that students cannot improve communication skills by just observing, but rather must participate in communication encounters.  The authors point out that feedback immediately after the student-patient encounter is critical as this will help students to improve.  The authors recommend that preceptors think of students as an extension of themselves and train them to be an active participant in the workflow of the practice.

During my advanced practice experiences as a student and now as a resident, I have noticed that medical students are taught about communication skills and case presentations very early in their education.  Beginning in their third year, medical students are required to do a patient presentation daily to the interdisciplinary team and to work throughout the day on patient care issues.  I think pharmacy students would benefit from earlier exposure to inter-professional interactions.  Even as first or second year students, I think activities requiring students to discuss patients with each other and present their pharmaceutical plans to preceptors would help them to improve their communication skills.  This could also be accomplished by having students practice counseling patients in front of other students, where feedback is provided at the end of the session.  By incorporating these informal activities earlier in pharmacy students’ education, it will help students gain confidence. 

One interesting and creative communication activity involves the use of simulated patients and video review.  In a study conducted at the South Dakota State University College of Pharmacy, video review increased first year pharmacy students’ counseling skill achievement scores and helped to develop their self-assessment skills.3  Video review really helps when giving feedback to students.  I think it is important to have informal opportunities for students to learn from video review prior to using video recording for assessment purposes. 

Communication skills must be taught and students can only improve their communication skills through practice.  I recommend a mix of formal assessment activities and informal opportunities to practice communication beginning early in pharmacy students’ education.  Informal activities can include having students present a patient to a faculty member or counseling a simulated patient as part of a group activity.  The formal and informal use of video review is also helpful.  Feedback by the faculty member and peers can be provided to each student following the activity. I think we teach pharmacy student to be excellent communicators, but only if we start early!
1. Hasan S. A tool toteach communication skills to pharmacy students. Am J Pharm Educ. 2008;72(3): Article 67.
2. McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effectiveprecepting. Am J Pharm Educ. 2006;70(3): Article 58.

January 16, 2012

The Socratic Method - Asking the Right Questions

by Whitney Chaney, Pharm.D., PGY2 Critical Care Pharmacy Resident, University of Maryland Medical Center

If you are like most pharmacy students or residents completing clinical rotations, you have probably come into contact with a preceptor whose main teaching strategy is to fire questions, one after another.  This can be a good learning experience or a very bad one.  Imagine going on patient care rounds with a preceptor.  As you discuss various diagnoses and treatments, you are asked a series of very pointed questions to which the preceptor is looking for very specific answers.  You may know a few answers.   Some questions you are unsure what the preceptor is asking.  And sometimes you have no idea what the correct answers are.  As this goes on you get more and more nervous, blurting out a few too many "I don’t knows," and the scenario ends with the preceptor giving you a long lecture about the disease state … very little of which you remember because you have become so flustered, frazzled, and distracted by your thoughts.  The strategy of teaching through questions is often called the “Socratic teaching” method.  The Socratic method can be very useful and effective, but all too often it is misused and abused. 

Defining the Socratic teaching method is challenging – there is a lack of consensus on the exact definition.  Much of the information describing Socrates' teaching comes from the writings of his students.  They describe conversations with deep inquiry and intense debates on philosophical topics.  Generally speaking, the Socratic method involves asking a series of questions in a logical manner until a common “truth” is reached.  The goal of this type of inquiry is to stimulate critical thinking and lead to discussion in which the learner must use their baseline knowledge and analytical skills to reach a well supported conclusion.  This method is also meant to point out unsubstantiated, preconceived notions and gaps in knowledge.  In this process of inquiry, less emphasis was placed on the final answer, and more was placed on the thought process.  While Socrates generally used his method to explore and answer moral concepts, this strategy of questioning can be and often is applied to clinical teaching.

As pharmacy students and residents complete their pharmacy practice experiences, this method of questioning and discussion can be a very effective learning tool.  One key way in which it applies to healthcare is that good clinical practice (so called "truths") must be
critically evaluated and supported by good evidence.  Teaching with Socratic questioning forces the learner to not only know the "answers," but also to understand the background and reasoning to support them.  Thus, the learner must be able to defend her/his recommendations and conclusions.  Furthermore, as the Socratic method helps build critical thinking skills, it prepares the learner to become an independent practitioner in an environment where the standard of care continues to change as new information becomes available.  Lastly, this method is very useful in experiential clinical settings because questioning and discussion can occur as situations arise in practice.

In order to effectively use the Socratic method, it is important to make sure that teachers and preceptors are asking the right questions – ones that stimulate discussion.  Questions should be asked in a thoughtful and logical manner in order to guide the learner to appropriate conclusions.  Using a variety of question types is more likely to achieve the learning objective.  Questions can be exploratory ... these types of questions probe for basic knowledge.  Challenge questions are intended to scrutinize conclusions and assumptions.  Diagnostic questions probe for causes, connections, or cause-and-effect relationships.   Extension questions are meant to expand on the discussion.  It is often useful for the instructor to use priority questions to help identify the most important points and, at the conclusion of the discussion, ask summary questions.  Questioning can also be categorized by the type of cognitive level following Bloom’s hierarchy of cognitive skills: knowledge, comprehension, application, analysis, synthesis, and evaluation.  In addition to the type of question, another strategy is to think about the order of the questions.  Specifically, are the questions going from general to specific, simple to complex, or convergent to divergent?  Finally, as the teacher probes the learner, the teacher’s response to the answers also impacts the learning process.  It is important for the teacher to listen to the entire answer and use non-verbal cues that signals that he/she is interested in the learner’s thoughts.  Correct or well-reasoned answers should be appropriately praised, while partially correct answers should be accepted and the learner should guided down the correct path with additional inquiry.  Incorrect answers should be tactfully corrected in a non-judgmental manner. 

The Socratic method of questioning and discussion can be a valuable teaching tool, especially in the setting of clinical pharmacy training.  The secret to using this teaching tool is the appropriate use of questioning strategies and responding to the learner’s answers.  The Socratic method should be used to facilitate an open dialog and the instructor must take care to create a non-threatening learning environment, where learners are free from fear and anxiety.  Its important to keep an open mind, accept feedback, and be prepared to adjust the questioning strategy to ensure that every student and resident gets the best learning experience.   

1.  Oh RO.  The Socratic Method in Medicine—The Labor of Delivering Medical Truths.  Fam Med. 2005; 37:537-9.
2.  Lewis DP.  Using the Socratic Method in Office-based Teaching.  Fam Med 2004; 36:162-3.
3.  Edwards S, Bowman MA.  Promoting Student Learning Through Questioning: A Study of Classroom Questions. Journal on Excellence in College Teaching.1996; 7: 3-24.