Teaching to Learn

by William Gust, PharmD, PGY-1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery V.A. Medical Center

Former French inspector general and poet Joseph Joubert once wrote that “To teach is to learn twice over.”¹ Joubert’s maxim is rooted in the idea that while the learner is only responsible for his or her own understanding, the teacher’s added responsibility to accurately communicate a concept to others incentivizes more active engagement of both the subject itself and one’s own deficiencies with it. Furthermore, teaching often necessitates the creation of educational materials, which requires the highest level of cognition.² Thus, promoting the sort of active engagement that teaching requires can be a powerful tool in expediting the learning process. By creating and presenting educational materials to teach others, students enhance their knowledge, comprehension, and confidence related to the subject far more than they would through traditional instructor-led methods.

Encouraging students to develop learning materials for themselves or fellow students bolsters their comprehension. Uskokovic demonstrated this during his employment of a co-creational classroom, in which students developed not only lectures and presentations but also the curriculum itself.³ In this model, the instructor assigns students a broad topic and encourages them to break it down into a series of questions that will be answered by their learning materials. Once questions are assessed for appropriateness of scope by the instructor, students are free to develop learning materials however they see fit. Following the creation of their learning materials, students present to the class for discussion who then ask questions and suggest revisions. In this study, the investigator compared exam performance using this co-creational model compared to the students' exam performance using a traditional didactic instructional model and a flipped classroom model, in which students read the material before class in preparation for elaborating on that material during class meetings. Although the sample size was small (n=8), students performed significantly better on exams when the co-creational model was used when compared to exams where the material was delivered via traditional didactic or flip methods.³

Student teaching also improves knowledge retention. In a crossover-study evaluating the benefit of peer-teaching on learning, Peets et al. randomly assigned medical students to serve as peer educators in small groups at different periods during a Gastroenterology/Hematology course.⁴ Peer educators were not given outside resources by the investigators but were responsible for coordinating and leading their assigned small group discussions. At the end of the course, the investigators administered a 94-item multiple-choice examination broken down by the various clinical cases covered during the course. After comparing student performance stratified by clinical case, students who served as peer educators for a given clinical case performed significantly better on questions than their group members who were only responsible for their own learning (Mean Score 80.7% vs 77.6%, Cohen’s d = 0.33; p < 0.01).

Taken together, these studies support the idea that student-teaching with student-created learning materials enhances student knowledge and comprehension. The results of Uskokovic make a particularly compelling case for the student involvement in the teaching process given the improvement in exam performance with the co-creational method when compared to the flipped classroom method. Had the results in both groups been similar, the better exam performance could have been explained by the presence of active learning, which is central to constructivist theory. The results of Uskokovic, however, suggest that student construction of the content to be covered as well as the learning materials promotes enhanced engagement that cannot be replicated by other active learning methods. Students who serve as peer teachers spend more time engaged with the material.  Peets et al. showed that student peer educators spent significantly more time engaging with the learning material (99 +/- 60 minutes vs 36 +/- 33 minutes, Cohen’s d = 1.3, p < 0.001) when compared to the other group members.

By encouraging (or perhaps requiring) students to create their own learning materials, teachers can improve student knowledge, confidence, and long-term retention. While the studies above focus on the creation of learning materials as a tool to teach other students in traditional classroom settings, this teaching strategy can be adapted to an array of settings, including patient education during practice-based experiences. It is important to note, however, that allowing students to teach with their own learning materials does not eliminate the need for a teacher. Critically, instructors that choose to employ student-generated materials as a teaching method must reduce cognitive load by choosing the right topics to cover and the right questions to ask. In this way, teachers can foster maximal learning in the students’ zone of proximal development while minimizing the chances the students will feel overwhelmed or bored. Overall, student-created learning materials offer a powerful way to enhance knowledge and retention by making the student an active participant.

References:

1. Joubert, J. Joubert: A Selection from His Thoughts [Internet]. New York: Dodd, Mead & Co.; 1899. Accessed 2020 Nov 23.
2. Armstrong, P. Bloom’s Taxonomy [Internet]. Nashville (TN): Vanderbilt University, Center for Teaching. Accessed 2020 Nov 1.
3. Uskoković V. Flipping the flipped: the co-creational classroom. Res Pract Technol Enhanc Learn 2018; 13(1):11.
4. Peets AD, Coderre S, Wright B, et al. Involvement in teaching improves learning in medical students: a randomized cross-over study. BMC Med Educ 2009; 9:55.

Simulation Activities Improve Students’ Perceptions and Confidence

by Erica Claire Loden, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Ledbetter E, Lau S, Enterline A, Sibbitt B, and Chen AMH. A simulation activity to assess student pharmacists’ knowledge and perceptions of oncology pharmacy. Am J Pharm Educ 2019; 84: Article 7474.

I am a student pharmacist and very interested in pursuing a career as an oncology pharmacy specialist. This study grabbed my attention because many of my classmates are unaware that knowledge regarding oncological diseases and treatments is essential in all practice settings. The study analyzed students’ perceptions of the importance of pharmacists in the treatment of cancer and measured their confidence in answering oncology-related questions. This study is necessary because improving confidence and perceptions of oncology therapeutics may help fill the gaps in patient care needs across practice settings.

The instructional activity was implemented by faculty at Cedarville University College of Pharmacy.  The intervention was a two-hour class session during week 4 of a required 5-week oncology module. There were two cohorts of students: third-year pharmacy students in 2016 and 2017. The same activity was implemented in both years. The instructional activity involved four interactive stations involving simulations in a managed care, community pharmacy, a hospital that does not have a clinical pharmacy oncology specialist, and a hospital that does have a clinical pharmacy oncology specialist. Students were placed in pre-assigned groups and given 75 minutes to complete all four stations and a 30 minute debrief followed. At the first station, students used information from a cost-minimization research abstract to examine the cost and efficacy of an oncology medication to be considered for the formulary. At the second station, students made non-pharmacological recommendations to help a patient presenting with chemotherapy-related adverse effects. At the third station, students determined when to discontinue medications and when to restart them for a patient enrolled in an oncology clinical drug trial who presented for cancer-related surgery. Students also developed a communication plan for the surgical team for this patient. At the fourth station, students utilized compounding and calculation skills to verify four prescriptions. The same faculty member facilitated the activity each year for both cohorts and led the debrief sessions. A pre-activity and post-activity survey assessed perceptions and knowledge of oncology-related topics. The same 17 item survey instrument was administered on day 1 of the oncology module (pre-activity survey) and again after students completed the activity in week 4 (post-activity survey). The survey rated items on a seven-point Likert-type scale. The survey measured two concepts: the first nine items assessed students’ confidence in answering oncology-related questions. The remaining eight items evaluated the student’s perceptions based on their level of agreement with pharmacists’ involvement in oncology patient care.

The results show that students in both cohorts had significantly greater confidence answering all nine oncology-related questions following the instructional activity than they did at baseline (p<0.001). Student pharmacists’ perceptions of pharmacists’ roles improved post-activity for all questions except one regarding hospital pharmacists’ ability to answer oncology-related questions at institutions with a clinical oncology pharmacist. Increases in knowledge between the pre-survey and post-survey were similar in both cohorts.

Overall, this educational activity adheres to some of the best practices in instructional design. The pre- and post-activity assessments were created carefully by the module coordinator and by a faculty member with experience developing surveys. Additionally, the instructional activities were kept constant between both cohorts. The study found no difference in responses based on differences in ages, ethnicity, past oncology experience, or gender. However, there are several weaknesses and limitations to this study. The instructional design was incomplete. Learning objectives were unclear and difficult to measure. Students were all from the same school; therefore, the results are less likely to be generalizable to other institutions. There are also other variables that researchers failed to consider. The increase in confidence and perceptions could be due to students completing the other instructional activities during the course before taking the post-survey, rather than the two-hour activity. Future studies could give the survey immediately before and after the instructional activity to alleviate this attribution problem. This study only addressed perceptions and not knowledge or outcomes. Responder bias is a concern because students may have given favorable ratings based on a belief that favorable survey responses could have positively influenced grades. Future studies could include administering knowledge assessments before the activity and administering longitudinal assessments to determine the long-term impact on students’ knowledge and perceptions following the course.

In a similar study which surveyed students from five pharmacy schools in Florida, the investigators found that the majority of the pharmacy students surveyed (75%) were only moderately or not at all comfortable with the field of oncology¹. They concluded maximizing experiential opportunities for students could potentially close knowledge gaps and improve confidence levels. In both studies, researchers found a desire from students to increase experiential learning opportunities related to oncology pharmacy practice. A separate study conducted at the University of South Florida showed participation in an ovarian-cancer simulation improved students' oncology-related knowledge and their perceived understanding of the roles of oncology pharmacists.² This study used a similar study design in that it utilized pre-assessment and post-assessment surveys to assess students’ perceptions.

I believe further studies are needed to produce higher quality, generalizable results. I am unsure if this educational intervention would increase students’ desire to become an oncology pharmacist. The study did show that instruction about oncology pharmacotherapy increases students’ confidence in oncology but it’s not surprising that perceptions about pharmacists' roles in oncology practice would increase after these learning activities. Insights from the science of learning indicate that the brain is malleable and that learning is an experience-dependent process.³ In that way, the 4-stations were well-designed and offered students a range of simulated experiences that illustrate what pharmacists can do across several practice settings. Another study showed experiential learning is capable of improving students’ confidence and perceptions and that students desire more experiential learning opportunities.⁴  The implications are that the best instructional activities immerse students in rich, engaging tasks that can help them achieve a conceptual understanding. Therefore, it is my recommendation that educators balance lectures with a number of simulation and experiential activities to facilitate comprehension and skills development. These activities would be more successful if done multiple times during a module. Providing oncology pharmacy experiences across all pharmacy schools and developing awareness on the importance of knowledge and training in oncology practice will better prepare students to deliver high-quality patient care.

References

1. May P, Ladd J. Florida Pharmacy Students’ Perspectives on Careers in Oncology. J Hema Onc Pharm 2017; 7 (2): 69-75.
2. Serag-Bolos ES, Chudow M, Perkins J, Patel RV. Enhancing Student Knowledge Through a Comprehensive Oncology Simulation. Am J Pharm Educ. 2018; 82(3): Article 6245.
3. Cantor P, Osher D, Berg J, Steyer L, Rose T. Malleability, plasticity, and individuality: How children learn and develop in context. App Developmental Sci. 2018; 23 (4): 307-337
4. Darling-Hammond L, Flook L, Cook-Harvey C, Barron B, Osher D.Implications for educational practice of the science of learning and development. Appl Development Sci 2019; 24 (2): 97-140.

Group-based Education for Self-Management of Type 2 Diabetes Mellitus

by Olivia Husband, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Rygg LØ, Rise MB, Grønning K, Steinsbekk A. Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial. Patient Education and Counseling. 2012 Jan;86(1):98–105.

Type 2 Diabetes Mellitus (T2DM) is one of the most prevalent disease states worldwide, and it is projected that the number of people diagnosed with T2DM will continue to increase over the next decade.¹ As a student pharmacist, T2DM is something I am interested in, not only because of its high prevalence but the impact a pharmacist can have on the management of people with T2DM. An integral component of T2DM treatment is patient self-care and management, including self-monitoring blood glucose and self-administering insulin injections. Patient education is crucial in ensuring that patients are getting the greatest benefit out of their diabetes treatment regimen. The authors of this study state there was very little evidence regarding the efficacy of local, group-based T2DM education.¹

This randomized controlled trial was conducted from May 2006 to November 2008 in central Norway. Participants were patients age 18 or older with a physician confirmed diagnosis of type 2 diabetes mellitus who had at least one general practitioner consultation within the previous three years.¹ There was no specific A1C requirement to enter the trial; however, patients who previously attended a diabetes education program in the past 12 months were excluded from the study.¹ Twenty general practitioners in the local area were asked to evaluate their patients to identify those who met the inclusion criteria for T2DM group education and then to mail out an invitation to participate in the diabetes management course.  Patients who accepted the invitation were then interviewed and randomized into one of two groups: the intervention group, which consisted of two cohorts, hospital 1 and hospital 2, and a control group.¹ The intervention group cohorts attended 15 hours of T2DM education delivered over three class sessions. The members of the control group were told they would be placed on a waiting list and would be offered the education program after one year.  Control group patients were instructed to continue their self-management practices.¹ The intervention received education about T2DM as well as nutrition taught by a diabetes nurse educator who had several years of experience. The education methods used included lectures, interactive skills training with activities, including blood glucose monitoring and problem-solving activities, and group discussion.¹ The primary outcomes of the study were changes in A1C (a measure of long-term blood glucose control) as well as patient response to a questionnaire that assessed their knowledge.  The outcomes were measured at baseline, at 6 months after the education program, and again at 1-year post-program.¹ The results were analyzed using both per protocol and intention to treat analysis.¹

There were no statistically significant differences between the intervention and control groups in regards to primary outcomes at 6 months.¹ But, after 1 year, the control group had a worsening of their A1C level from baseline of 0.3% while the intervention group maintained their baseline A1C (p=0.032).¹ All groups improved their diabetes knowledge after 12 months, but the patients in the intervention group significantly greater improvements in diabetes knowledge when compared to the control group.¹ The intervention group also had a higher level of treatment satisfaction at 6 months, but not at 12 months.¹ There was also a significant increase in the number of participants who avoided fatty foods and regularly self-monitored their blood glucose (p=0.027) among members of the intervention group.¹ Although the intervention group improved their knowledge of self-management of T2DM, their quality of life decreased from baseline over the course of 12 months (p=0.005).¹ This was not the case for the control group, as their quality of life scores remained unchanged when compared to baseline.¹ I think the decline in quality of life in the intervention group might be due to the more intensive monitoring and, ironically, with greater knowledge, more anxiety about the negative effects of diabetes.

Many of the participants in the study had a baseline A1C that was below the recommended treatment goal, and this is a major limitation of this study. To offset this limitation, a sub-group was performed for the subset of patients with an A1C greater than 7.7% at baseline.¹ These participants had poorer glycemic control at baseline, so they reaped the most benefit from the T2DM education program. One way the investigators could have prevented this limitation is to have a baseline A1C requirement for participants to enter the study. I think it is important to note the general decline in patient quality of life within the year following the education program perhaps due to more stress and anxiety related to the management of their T2DM. The program consisted of 15 hours of education across 3 sessions which are very long sessions and it’s hard to absorb that much information. This could have been avoided if the 15 hours was separated into more sessions. The sessions themselves seemed to use an effective combination of lectures, activities, and discussions, with breaks provided for participants.¹ I think overall, the methods of this study were appropriate because the investigators measured both glycemic control as well as patient knowledge after attending the classes.  However, I think they should have scheduled shorter sessions and perhaps included sessions about stress reduction strategies.

Several studies have analyzed the benefits of providing group-based type 2 diabetes management education and most have produced positive results. Participants saw an improvement in their glycemic control.  In one analysis patients were more likely to see improvement when the program was taught by a pharmacist rather than a different healthcare professional.² In most other studies, participants also saw an improvement in their overall quality of life, which was not seen in this study.^1-3 

This study shows that patient education about type 2 diabetes mellitus and self-care is an essential element of its management. This study reinforces the importance of patient education while providing insight on how to structure it. Learning how to manage a disease can be overwhelming, so it is important to address the stress and anxiety that can occur.

References

1. Rygg LØ, Rise MB, Grønning K, Steinsbekk A. Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial. Patient Education and Counseling. 2012;86:98–105.
2. Mikhael EM, Hassali MA, Hussain SA. Effectiveness of diabetes self-management education programs for type 2 diabetes mellitus patients In middle east countries: A systematic review. Diabetes Metab Syndr Obes. 2020;13:117-138.
3. Kumah E, Sciolli G, Toraldo ML, Murante AM. The diabetes self-management education programs and their integration in the usual care: A systematic literature review. Health Policy 2018;122:866–77.

Pharmacist-Led Educational Interventions Decrease Prescribing Errors

by Michaela Shoup, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Winder MB, Johnson JL, Planas LG, Crosby KM, Gildon BL, Oberst-Walsh LA. Pharmacist-led educational and error notification interventions on prescribing errors in family medicine clinic. J Am Pharm Assoc 2015; 55(3): 238-45. doi: 10.1331/JAPhA.2015.14130

Medication errors are a serious problem in the United States’ healthcare system. Studies have shown that medical errors account for over 250,000 deaths every year, making medical errors the third leading cause of death in the United States. Reducing prescribing errors is a vital step in decreasing the number of patients harmed and improving outcomes.  Another issue plaguing healthcare in the United States today is the lack of available positions for pharmacists and the failure of many healthcare professionals to fully realize the value and knowledge pharmacists can bring to the healthcare team. In this study to evaluate the impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic, the researchers created a program that addresses both of these issues at once. This study showed that physicians made fewer errors when writing prescriptions for pediatric patients after participating in a pharmacist-led educational program.¹

This 14-month study took place in an outpatient academic family medical clinic affiliated with the University of Oklahoma. Of the twenty-four resident physicians at the clinic, fourteen residents participated in the educational program and their prescribing habits were longitudinally assessed. The study was composed of four phases: preintervention error assessment, educational intervention, error notification intervention, and postintervention error assessment. First, prescriptions written by the resident physicians were assessed for the number and types of errors they contained, including missing information such as date, unclear directions, or incorrect dose. The researchers used multiple instructional methods to educate the residents. First, they employed a pharmacist-led lecture with active learning activities in which residents learned about the most common types of prescription errors, how to effectively use an electronic medical record (EMR), and the necessary elements of a prescription. In the error notification intervention, pharmacists used a feedback system for a period of three months to help the residents see what strengths they had and what areas they should improve. As a part of this feedback system, residents received notification of errors in prescriptions they had written and were offered assistance from clinical pharmacists. Residents also received a weekly newsletter summarizing the most common errors made and providing recommendations for improvement. The feedback and audit system likely played a vital role in training these physicians— feedback enables learners to gain perspective from others on how they can change and improve. A year after the initial data collection began, the postintervention assessment was conducted. A new set of prescriptions written after the conclusion of the program was assessed for errors to see if and how the residents’ prescribing practices had improved.

The results showed that the rate of prescribing errors was 23% lower during the postintervention period when compared to the preintervention period.  However, this difference was not statistically significant when controlling for time. The lack of statistical significance could be due to each resident having different baseline knowledge and experience. For example, the more experienced residents may not have benefitted from the program as much as the less experienced physicians, and this may have diminished the impact of the educational intervention. In addition to the primary analysis, the researchers analyzed the error rates of residents who participated in the educational program compared to those who did not. Controlling for time, pediatric prescription error rates were 36% lower among physicians who participated in the educational intervention versus those who did not participate. This difference was statistically significant, and the authors concluded that the prescribing of pediatric medications was positively impacted by the program.

This study aimed to show the value of pharmacists’ knowledge and expertise.  While the results are promising, the Hawthorne effect could have played a role in the results — physicians could have changed their prescribing habits simply because they knew they were being evaluated, possibly leading to a lower error rate than might have been seen had the physicians been unaware their performance was being evaluated. The study group was diverse—it was comprised of PGY1 through PGY4 residents.  So each physician had a different level of experience. The residents received uniform education and feedback, which is a strength of the study. However, we do not know which of the individual components of the program – the lecture, audit and feedback, or the newsletter – had the most impact.  Indeed, we don’t know if the residents actually read the newsletter.

Other studies have been conducted to show that pharmacist-led education positively impacts prescribing practices and, ultimately, the quality-of-care patients receive. The DEPRESCRIBE study evaluated the effect of a pharmacist-led educational invention on discontinuation of medications that were inappropriate for patients aged 65 and older (based on Beers criteria).² Pharmacists in this study provided education to patients (supplemented by educational brochures) and made pharmacological recommendations to their providers regarding medications that may be more harmful than beneficial in older adults. Over 40% of the potentially harmful medications were discontinued by the physicians that were educated by the pharmacist.  This substantially greater than the discontinuation rates (12%) observed when the patients and physicians were not educated.

In a time when an alarming number of patients are being by less-than-optimal medication regimens and when job positions for pharmacists are not as plentiful as they once were, pharmacists must use their training to improve patient outcomes and make their value evident. Pharmacists are capable of educating both their coworkers and patients to decrease error rates, provide high-quality patient care, and improve health outcomes. Pharmacists are in the ideal position to share their knowledge and expertise to benefit patients, colleagues, and the profession of pharmacy. 

References:

1. Winder MB, Johnson JL, Planas LG, Crosby KM, Gildon BL, and Oberst-Walsh LA. Impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic. J Am Pharm Assoc 2015; 55(3): 238-245. doi:10.1331/japha.2015.14130
2. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018; 320(18): 1889-1898. doi: 10.1001/jama.2018.16131.

Prescribing Education for Medical Students

by Danielle McGrew, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Newby DA, Stokes B, Smith AJ. A pilot study of a pharmacist-led prescribing program for final-year medical students. BMC Med Educ. 2019 Feb 12;19(1):54. doi: 10.1186/s12909-019-1486-1 

I love to find articles in the literature focused on ways pharmacists have implemented a program, educated others, or proven their worth while working on an interprofessional team. So, when I came across an article about a pharmacist-led educational program that benefited patients and prescribers alike, I was immediately intrigued.  The purpose of this study was to improve prescribing confidence and skills and to improve medical students’ understanding of the role pharmacists can play in the management of patients. It is known that prescribing medications is one of the intimidating tasks for medical students as they transition to becoming licensed physicians. One study found that recent medical school graduates did not feel prepared for prescribing in clinical practice, which they attributed to a lack of opportunities to develop the skill-based, applied aspects of prescribing.¹  Other studies have shown that medical interns often prescribe inappropriately for many common conditions.² Thus, there is a need for more training and practice opportunities for medical students to prepare them for clinical practice.

In this study conducted in Australia, all final-year medical students at three tertiary hospitals were invited to take part in an eight-week prescribing training program. The program consisted of three instructional strategies: prescribing and calculation tutorials, weekly feedback from a pharmacist regarding prescribing, and one afternoon spent in the pharmacy to learn about and observe the dispensing process. The tutorials involved allowing the students to practice either selecting and prescribing medications or calculating and prescribing a dose of a medication based on a case scenario representing the most common conditions faced by junior doctors. The common conditions included stroke prevention (anticoagulation therapy), diabetes, pain management, constipation, nausea and vomiting, asthma, and hypertension. Confidence and appropriateness of prescribing were measured upon completion of the tutorials on week one and week eight. Confidence in a variety of prescribing areas was assessed using a confidence scale adapted from a questionnaire developed by the TOPDOC study team to rate junior doctor confidence.³ The tutorials covered such topics as selecting a medication for a condition, writing a prescription order for both inpatients and outpatients, taking a medication history, identifying potential drug interactions and adverse events, monitoring effectiveness, and planning discharge medications.  To assess the appropriateness of prescribing, the students completed a prescribing exercise based on a clinical scenario. Blinded to what student was completing the exercise and to whether it was a pre- or post-assessment, a clinical pharmacist and clinical pharmacologist assessed the appropriateness of each prescription using a previously validated scale. Additionally, students provided feedback about the impact of the program at the completion of the program by participating in focus groups and completing a questionnaire. Pre- and post-program assessments were examined using permutation tests, which assesses whether two distributions are significantly different from each other without making any assumptions about the shape of the distributions.

Twenty-three students completing their rotations at three hospital sites agreed to participate, with only 16 participating in most or all of the required activities and taking the pre- and post-course questionnaires and assessments. Results showed a significant increase in confidence across all areas of prescribing skills assessed. At baseline, a majority of students rated themselves as ‘not confident’ or ‘satisfactory but lacking confidence’ in each area, but upon completion of the program none of the students rated themselves as ‘not confident’ in any area, with the exception of one student that rated him/herself as ‘not confident’ in writing an outpatient prescription. The most noteworthy improvement was found in writing inpatient prescriptions – after the program, all students rated themselves as ‘confident in most cases but would like more experience’ or ‘fully confident in most cases.’  None of the students rated themselves ‘fully confident’ at baseline. Students were most confident in writing prescriptions for medications related to the disease states discussed in the tutorials.

There was a small and non-significant improvement in the appropriateness of the students’ prescribing from baseline to week eight. However, it is important to note is that none of the students’ prescriptions were rated ‘inappropriate and potentially harmful’ after finishing the prescribing program. Student feedback was uniformly positive, with students agreeing or strongly agreeing to statements about the practical aspects of prescription writing, therapeutic appropriateness, and calculations aspects of the program.  Also, students indicated that the program helped to prepare them for their intern year. The focus group sessions revealed that students most valued the practice and immediate feedback they received.  Moreover, they learned about the support pharmacists can provide to them as prescribers. Negative comments centered on the difficulty of fitting the program into their schedule during demanding clinical rotations.

I thought that this was a good study to evaluate how influential a prescribing program may be on medical student’s knowledge and confidence in writing prescriptions. One major weakness was the small sample size. Larger studies would be needed to quantify the impact of such a program on prescribing appropriateness. Given the small sample size, assessing changes in student confidence was the most appropriate thing to measure. A major strength of the program was the immediate feedback that was provided to the medical students. I also think that the use of focus groups to gather feedback was really important, especially since this was a pilot program.

Other studies focusing on prescribing education for medical students have shown positive results as well. Medical students participating in a ‘near-peer’ prescribing education program reported increased confidence in their prescribing knowledge and skills after attending the tutorials.⁴ Similarly, results from medical students participating in a teaching program on practical prescribing showed that their knowledge of pharmacotherapy, drug information, and prescribing skills was significantly improved.⁵

Educators should pay attention to this pilot study it appears to be a well-designed educational program intended to improve the confidence and skills of future physicians. In particular, I would recommend educators replicate the content of the tutorials and providing immediate feedback. In this instance, medical students are getting to practice real-life scenarios using clinical cases. I believe the best practices of instructional design are being upheld. The material is presented in the form of tutorials, the instructor tests the student’s knowledge on what has been taught through the clinical cases, and students can reflect on their performance based on immediate feedback. Educators should take into account the challenges of offering this program due to time constraints during demanding clinical rotations. My recommendation would be to initiate the prescribing program earlier in the medical school curriculum (perhaps during an early practice experience) and to reduce the weekly workload required. One medical school has already implemented “Safe Prescribing Teaching” earlier in their curriculum, resulting in students feeling remarkably more confident in prescribing situations.⁶ This strategy allows students to revisit and build on the knowledge they learn each week and would likely yield even better results.

 References

1. Rothwell C, Burford B, Morrison J, et al. Junior doctors prescribing: enhancing their learning in practice. Br J Clin Pharmacol. 2012 Feb;73(2):194-202. doi: 10.1111/j.1365-2125.2011.04061.x. PMID: 21752067; PMCID: PMC3269578.
2. Pearson S, Smith AJ, Rolfe IE, Moulds RF, Shenfield GM. Intern Prescribing for Common Clinical Conditions. Adv Health Sci Educ Theory Pract. 2000;5(2):141-150. doi: 10.1023/A
3. George JT, McGrane DJ, Warriner D, et al; TOPDOC Study Team. Protocol for a national audit on self-reported confidence levels, training requirements and current practice among trainee doctors in the UK: the Trainees Own Perception of Delivery of Care in Diabetes (TOPDOC) Study. BMC Med Educ. 2010 Jul 27;10:54. doi: 10.1186/1472-6920-10-54.
4. Gibson KR, Qureshi ZU, Ross MT, Maxwell SR. Junior doctor-led 'near-peer' prescribing education for medical students. Br J Clin Pharmacol. 2014 Jan;77(1):122-9. doi: 10.1111/bcp.12147. PMID: 23617320; PMCID: PMC3895353.
5. Javadi MR, Khezrian M, Sadeghi A, Hajimiri SH, Eslami K. An Interprofessional Collaboration between Medicine and Pharmacy Schools: Designing and Evaluating a Teaching Program on Practical Prescribing. J Res Pharm Pract. 2017 Jul-Sep;6(3):178-181. doi: 10.4103/jrpp.JRPP_17_16. PMID: 29026844; PMCID: PMC5632939.
6. Lloyd N. Pharmacist-led teaching as a longitudinal theme for medical school curriculums - a solution for reducing prescribing errors in junior doctors? BMC Med Educ. 2019 May 29;19(1):173. doi: 10.1186/s12909-019-1632-9.

An Apple a Day: A Parental Education Program to Reduce Childhood Obesity

by Trenton Goff, M.S., Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Review and Summary of:  Gomes AI, Barros L, Pereira AI, Roberto MS. Effectiveness of a parental school-based intervention to improve young children's eating patterns: a pilot study. Public Health Nutr. 2018 Sep;21(13):2485-2496.

The percentage of children and adults who are obese continue to climb in the United States and worldwide.  The World Health Organization (WHO) estimates that obesity has nearly tripled since 1975, with more than 650 million adults considered obese and 1.9 billion adults overweight in 2016.  Moreover, 38 million children under the age of 5 were considered obese in 2019.¹ As a student pharmacist, I am interested in weight management because so many chronic illnesses are the result of obesity.  There are diet pills and weight loss drugs aplenty, but medications are generally NOT the healthiest options.² While obesity may be a physical sign of disease, the real problems lie in the harmful metabolic changes that develop after weight gain, and children are not immune.  Young children depend on their parents, or guardians, to provide them with daily meals and nutrition.  A recent study conducted in Portugal caught my eye because the researchers created a school-based parental education program to improve children’s eating patterns and behaviors.³ Targeting and educating individuals, adults and children, before the onset of chronic complications, is the best chance we have at combating the obesity epidemic.  Giving parents the tools necessary to make healthy dietary choices for their children would be a step in the right direction.  Developing healthy eating habits early in life can have an impact on the rest of a child’s life.

In this longitudinal cohort study, parents of children 3-to 6-year-old who attended a public kindergarten were assigned to one of three groups: Complete Intervention Group (CIG), Minimal Intervention Group (MIG), and a Control Group (CG).  In the CIG, the primary instructional intervention was the “Red Apple” curriculum, which consisted of 90-minute educational sessions every other week for a total of four sessions.  These sessions focused on the young child’s growth and development, nutrition guidelines, and strategies for parents to promote healthy eating behaviors in their children.  In addition to the in-person instruction, the CIG was also given “homework assignments” to practice what was learned and a weekly newsletter was distributed to parents.  The MIG was provided with only one nutritional counseling session, one “homework assignment”, and one follow-up newsletter.  The CG was given no nutritional or behavioral instruction. All parents completed a series of evaluations and surveys at baseline.  Parents were evaluated on their self-efficacy in promoting healthy food intake, their ability to rate their child’s current weight against CDC standards, their nutritional knowledge, and recognize the healthy and unhealthy eating habits of their children.  The initial evaluations were meant to provide a baseline for follow-up analysis upon completion of the intervention.

Immediately following, 6-months, and 1-year after the educational program, parents in the three groups completed the same surveys they were given at baseline.  Nutritional knowledge and parent self-efficacy improved in both the CIG and MIG at the conclusion of the intervention and these improvements persisted 1 year later.  Conversely, nutritional knowledge and parental self-efficacy actually decreased in the CG during the same assessment periods.  Healthy food intake also increased in the CIG at the completion of the intervention, but the improvement did not persist at the six-month and one-year follow-up assessments.

This study, and the “Red Apple” curriculum, was very comprehensive.  The authors provide a detailed account of their intervention and results and clearly discuss the limitations and barriers that were observed in their study.  Participant recruitment and attrition, for instance, were key issues that resulted in a smaller than expected sample size in the intervention group.  The curriculum was well developed and could be used in other settings.  The curriculum included group discussions after each session and at-home assignments both of which support long-term knowledge retention.

From an instructional design perspective, I noticed a few key issues with the “Red Apple” program.  An outline of the curriculum was provided in the article.  Each session had a theme and particular objectives to cover, which is important, but the objectives reflect the intent of the instructor.  Objectives should state what the learner is expected to do and this allows the creation of assessment to measure their learning.  For example, “encourage parents to implement dietary and behavior changes according to age-appropriate strategies,” could be changed to “Parents will be able to verbalize two strategies to implement healthy dietary changes in their child.”  This example provides a clearer expectation of what the learner is expected to do.

The “Red Apple” program is a well-designed curriculum for universal application, but it does not assess the learner’s prior knowledge to tailor the curriculum.  The authors discuss this issue of individualization by stating, “…the general objectives of the sessions may not fully match the needs of all participants.” Perhaps a better approach for this program would be to use the pre-intervention surveys to modify the content and learning activities.  In this way, the program can be customized to meet the individual learner’s needs.

In any educational program, it’s important to gain the learner’s attention.  In one study conducted in England, nearly 80% of parents of obese/overweight children did not perceive their child’s weight to be a health risk.⁴ The “Red Apple” curriculum taught parents how to calculate their child’s BMI and how to interpret the results, but there may not have been enough attention given to the long-term health risks associated with elevated BMI.  Gaining attention by discussing the health concerns associated with obesity in children may increase the learner’s motivation to adopt behavior change.

While the “Red Apple” program was an intensive and comprehensive course in nutrition, healthy eating, and behavior modification for parents of young children, unfortunately, improvements in dietary habits did not persist long-term.  Thus, to have a sustained impact, we’ll need to consider additional ways of reinforcing learning and the development of healthy habits over time.  Educating parents on how to improve their children’s health is a noble endeavor.  Adequate instruction on diet and health in children could improve the health of an entire generation.  Children have the most to gain from developing healthy lifestyles – and the most to lose from unhealthy ones. 

References

1. World Health Organization. Obesity and Overweight. Key Facts [Internet]. Geneva, Switzerland.: World Health Organization. 2020 April [cited 2020 Nov 2].
2. Grundlingh J, Dargan PI, El-Zanfaly M, Wood DM. 2,4-dinitrophenol (DNP): a weight loss agent with significant acute toxicity and risk of death. J Med Toxicol. 2011 Sep;7(3):205-12.
3. Gomes AI, Barros L, Pereira AI, Roberto MS. Effectiveness of a parental school-based intervention to improve young children's eating patterns: a pilot study. Public Health Nutr. 2018 Sep;21(13):2485-2496.
4. Park MH, Falconer CL, Saxena S, et al. Perceptions of health risk among parents of overweight children: a cross-sectional study within a cohort. Prev Med. 2013 Jul;57(1):55-9.

Integrating LGBTQIA+ Health Education into the Curricula of Professional Healthcare Students

by K. R. Fairley, Doctor of Pharmacy student, University of Mississippi School of Pharmacy

Summary and Analysis of: Kelley L, Chou CL, Dibble SL, and Robertson PA. A Critical Intervention in Lesbian, Gay, Bisexual, and Transgender Health: Knowledge and Attitude Outcomes Among Second-Year Medical Students, Teaching and Learning in Medicine 2008; 20:3: 248-253.

It is estimated that up to 4.5% of the U.S. population actively identifies themselves as a member of the LGBTQIA+ community.¹  When broken down, this equates to nearly 15 million Americans, being found across all major racial, ethnic, religious, and age-based groups.² Despite these staggering figures, however, the LGBTQIA+ community remains one of the most underserved populations in the United States when it comes to healthcare.³  The reasons for this disparity are multi-factorial, ranging from a lack of trust in providers due to previous discriminatory experiences in the healthcare system to issues with accessing insurance coverage based on name changes or sex and gender differences.  While not the only cause of these disparities, the lack of provider knowledge and competence to furnish the appropriate care to this diverse group of individuals is a contributing factor. 

As a third-year pharmacy student, the topic of LGBTQIA+ health has long been of importance to me.  I think that, over the course of this past year, that importance has only grown, especially after witnessing some of the disparities play out first-hand during my clinical rotations. The discrimination faced by members of the LGBTQIA+ community in the healthcare system, including pharmacies, is just as prevalent now as ever. I knew immediately when the topic of this essay was announced that I wanted to use this time and space to talk about a learning intervention for professional healthcare students to educate them about the needs of LGBTQIA+ patients, as well as to discuss why learning interventions such as this one are so important.

Image credit: Discoversociety. “Focus: Looking Critically at Gender and Sexuality.” Discover Society, 5 Dec. 2016, discoversociety.org/2016/12/06/focus-critical-perspectives-in-gender-and-sexuality/.

Originally published in 2008, the study by Leah Kelley and colleagues describes one of the very first interventions of its kind to incorporate LGBT health education into the curriculum.  This educational event was part of the second year Doctor of Medicine program at the University of California San Francisco.  The goals of the intervention were three-fold: (1) To increase the students’ awareness and address existing assumptions about LGBT people, (2) To highlight disparities in health care delivery to which LGBT patients, and (3) To underscore the important role that physicians can play in dispelling these disparities to optimize LGBT health care.³  In order to achieve these goals, the directors of the course developed a three-pronged intervention, consisting of a syllabus, a 1-hour patient panel, and a 1-hour small group session. The syllabus was distributed to the students prior to class and served as a brief introduction to the educational event, while also emphasizing basic definitions and health hazards associated with homophobia.  The 1-hour patient panel was organized based on prior studies that indicated direct contact between students and patients helped medical students form more positive impressions of marginalized populations. The panel consisted of three voluntary participants: an older gay man, a middle-aged lesbian, and a young transgender man.  Each participant gave a short presentation, which was then followed by an interactive Q+A session with the students.  The 1-hour small group sessions focused on working through three case studies designed to highlight several LGBT health issues.  Additionally, a pre-and post-class survey was created to assess if student attitudes had changed as a result of the intervention.

At the conclusion of the two-hour course, more than 90% of students agreed that the combination of the syllabus, patient panel, and small-group cases helped to educate them about relevant LGBT issues. The majority of student comments left on the surveys were overwhelmingly positive, with most of the students indicating that hearing about personal experiences of the LGBTQIA+ panel members was most helpful in terms of identifying and addressing unconscious biases toward the LGBT community.  The results of the pre- and post-class surveys indicated that the students experienced a significant increase in their general knowledge of the challenges that LGBT individuals face in the healthcare system. They also showed an increased level of awareness about sexual orientation, gender identity, and other related attributes relevant to clinical practice.¹

A couple of the strengths of this study included (1) the integration of three different but cohesive teaching interventions to achieve the stated goal and (2) the inclusion of face-to-face contact between the medical students and members of the LGBTQIA+ community.  A few limitations were: (1) the short-term follow-up period, (2) the ability to measure a change of attitude as an outcome, and (3) the limited definitions of sexual orientation, attraction, and identity when describing the LGBTQIA+ population.  The authors in this paper continually made references to the LGBT community as “homosexual”, which is not true for every self-identified LGBTQIA+ individual.  I think the study could have been more comprehensive/ inclusive had the researchers also addressed the problems of transphobia and biphobia, as well as some of the more common issues faced by non-binary and asexual individuals in the healthcare system.  In terms of the outcome measures for this study, I believe that the investigators measured them in the best way available, given that a change in attitude is difficult to measure and prone to social desirability bias. I would have liked to have seen a longer follow-up period to this study to evaluate just how much the intervention affected the students during clinical rotations and, ultimately, their practice habits as healthcare providers.

Regardless of its limitations, this study truly has made waves in the medical education community since it was first published. I found over 200 articles citing this paper as well as two books. I believe that educators should take this study as an outline when developing courses to educate healthcare students about the challenges faced by minority groups, including but not limited to the LGBTQIA+ community.  Integrating a working knowledge about the causes and consequences of health disparities, discrimination, and unconscious bias into the professional curriculum can help increase access to healthcare and trust in providers.⁴ 

The authors state:  “It is essential for students to understand that a common causative factor in these health risks is not necessarily in merely being lesbian, gay, bisexual, or transgender: it is living as a LGBT person in a homophobic society.”³ Or, more generally, in a LGBTQ-phobic society.  This remark, I think, is the central message that educators should take away from this paper and it states clearly why educational interventions are so crucial.  More schools (including schools of medicine, pharmacy, and nursing) should consider adding similar interventions to their curriculums.

References

1. Newport F. In U.S., Estimate of LGBT Population Rises to 4.5%. com, Gallup, 29 Oct. 2020,  Accessed November 5, 2020.
2. Macapagel K, Bhatia R, Greene GJ. Differences in Healthcare Access, Use and Experiences Within a Community Sample of Racially Diverse Lesbian, Gay, Bisexual, Transgender and Questioning Emerging Adults, LGBT Health 2016; 3 (6): 434-442.
3. Kelley l , Chou CL, Dibble SL, and Robertson PA. A Critical Intervention in Lesbian, Gay, Bisexual, and Transgender Health: Knowledge and Attitude Outcomes Among Second-Year Medical Students, Teaching and Learning in Medicine 2008; 20 (3): 248-253.
4. Rowe d, Ng YC, O’Keefe L, Crawford D. Providers’ Attitudes and Knowledge of Lesbian, Gay, Bisexual and Transgender Health, Federal Practitioner 2007; 34(11): 28–34.

Mental Health First Aid Training for Student Pharmacists

by Taylor Williams, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy 

Summary and Analysis of:  El-Den S, Chen TF, Moles RJ, O’Reilly C. Assessing Mental Health First Aid Skills Using Simulated Patients. Am J Pharm Educ 2018; 82 (2): Article 622.

One in six people in the United States uses psychotropic medications and psychotropic medications representing 13% of the top 300 most frequently prescribed medications in the United States.¹  In a 2012 survey designed to characterize the relationship between individuals with mental health conditions and community pharmacists, approximately 80% of individuals and family caregivers indicated they received their medications for mental health conditions from a community pharmacy.²  Given that community pharmacists see patients with psychiatric illnesses every day, it is imperative that student pharmacists know how to skillfully interact with these patients. Many prescriptions have refills for up to three months, so these patients may see their pharmacist more than any other healthcare provider. This is why it is essential that student pharmacists have adequate training on how to interact with people who suffer from mental illness.

However, a survey of pharmacy schools reported that only 9.5% of the didactic course content was dedicated to psychiatric topics.³  Furthermore, a survey of North Carolina pharmacists, concluded that despite the volume of prescriptions with mental health-related medications every day, a significant portion of licensed pharmacists indicated that the emphasis on mental health in their training was inadequate.⁴  These results suggest that pharmacy programs are not providing student pharmacists with enough training to become mental health first aid responders. So how are we preparing our future pharmacists to serve patients with mental illness? While being knowledgeable about psychiatric medications is essential, many student pharmacists have not been trained to manage a mental health crisis.  The methods and criteria used to ensure students have mastered these skills before graduating do not appear to be adequate.

An educational program implemented at The University of Sydney explored different teaching strategies to train student pharmacists to become mental health first aid (MHFA) responders.⁵ One hundred and sixty-three fourth-year bachelors of pharmacy students in their final semester before earning their degree completed MFHA training, with 88% of the students completing the post-training confidence level evaluations following the simulations.⁵ Postnatal depression (PND) and suicide vignettes were randomly assigned to 36 students and their simulation performances and MHFA training were compared to their self-evaluations.⁵ The study compared the teacher feedback with post-training self-evaluations. The trainers developed an assessment rubric based on the Mental Health First Aid Action Plan. This rubric was completed by the simulated patients to assess students’ MHFA skills during the roleplays.  The encounters were audio recorded in order to facilitate performance feedback and to give students an opportunity to self-assess their own performance.⁵ The study authors concluded that after receiving MHFA training most students overestimated or underestimated their ability to appropriately respond in a mental health first aid crisis. While these results show there is much work to be done, it also gives insight into how we can better educate students.

 

Learning is an active process. We learn by doing. 

Only knowledge that is used sticks in your mind. 

– Duke Corregie

 

The key to this educational program and others is the realization that “knowing” is different than “knowing how”.⁵  In other words, while students may know what to do in a mental health crisis, they may not know how to respond when confronted with a patient in crisis. Indeed, over 95% of pharmacy students who participated in this study agreed or strongly agreed that they were confident after participating in the suicide vignette. Moreover, only 50% of students took the appropriate actions, which involved both referring the patient to an appropriate health care professional and not leaving the simulated patient alone.⁵  This suggests the best way to assess pharmacy students is to not depend solely on written or verbal evaluations of their knowledge, but we must evaluate their actions when placed in real-life scenarios. This study had notable limitations, one being that the sample was only from one university.  Further, there were only two types of mental health crisis scenarios evaluated. Thus, the results might not be generalizable to students attending other schools or when addressing other mental health problems. However, despite these limitations, the study hypothesized the reason the student’s scores did not align with their self-assessment may be due students felt uncomfortable providing help to suicidal persons. None-the-less, MHFA training with the addition of simulation proved to be an effective teaching method.

There are many benefits to role-playing/simulation training. The Northern Illinois University Center of Teaching and Learning explained some advantages of using role-play.⁶ Some of the benefits include motivating and engaging students, enhancing current teaching strategies, providing real-world scenarios to help students learn, and providing opportunities for critical observations of peers.⁶  Simulation training gives students the opportunity to receive positive and constructive feedback from their teachers.

In a recent study that surveyed mentally ill patients, they found that 75% of respondents reported they seldom or never receive assistance from their pharmacist regarding their medication when they pick up their prescription at a community pharmacy, and 40% of participants felt that they did not have a strong relationship with their pharmacist.¹  As future pharmacists, we should work to eliminate barriers to care. I feel the best way to do so is to actively engage students through role-playing/ simulation scenarios paired with training while in school similar to the MHFA developed by the University of Sydney.

This study reinforces the effectiveness of using simulation training as a teaching tool. Simulation training allows pharmacy students to practice in a setting similar to where they will be practicing. During simulation training, students are given feedback on their performance and have an opportunity to correct problems. Becoming a mental health first responder takes both knowledge and experience. By implementing simulation training into the core curriculum in pharmacy school, students will be better prepared for their future roles.

References

 

1. Moore CH, Powell BD , and Kyle JA. The Role of the Community Pharmacist in Mental Healt U.S. Pharmacist 2018; 43 (11): 13-20. Accessed October 14,2020 
2. Carley CF and Stimmel GL. Characterizing the Relationships Between Individuals with Mental Health Conditions and Community Pharmacy . CPNP Foundation, December 2012. Accessed October 14, 2020
3. Cates ME, Monk-Tutor MR, and Drummond SO. Mental Health and Psychiatric Pharmacy Instructions in US Colleges and Schools of Pharmacy Am J Pharm Educ 2007; 71 (1): Article 04 Accessed November 1,2020
4. Goodman CS, Smith TJ. and LaMotte JM. A Survey of Pharmacists’ Perceptions of The Adequacy of Their Training For Addressing Mental Health-Related Medication Issues. The Mental Health Clinician 2017; 7(2): 69-73. Accessed November 1,2020
5. El-Den S, Chen TF, Moles RJ, and O’Reilly C. Assessing Mental Health First Aid Skills Using Simulated Patients Am J Pharm Educ 2018; 82 (2): Article 6222. Accessed October 14,2020
6. Role Playing. Northern Illinois University Center for Innovative Teaching and earning. 2012. Accessed October 14,2020

Improving Scientific Reasoning Levels through Active Learning Strategies

by Hannah Schmoock, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Marušić M and Dragojević A. Assessing Pharmacy Students' Scientific Reasoning After Completing a Physics Course Taught Using Active-Learning Methods. [Internet] American journal of pharmaceutical education, 2020: 84(8): Article 7610

This article piqued my interest because it aimed to show how implementing active learning methods into physics courses could improve scientific reasoning.¹ Active learning is a widely used instructional method in our pharmacy curriculum at the University of Mississippi and I find active learning techniques useful in helping to deepen my understanding of the topics we discuss. As future pharmacists, we are expected to be able to think critically when it comes to devising solutions to complex patient cases and medication regimens. Using active learning in pharmacy curricula, students build their scientific reasoning skills which will be very important throughout their careers. This study aimed to compare two groups, an active-learning group, and a traditional-learning group. The active-learning group received a traditional 60-minute lecture followed by 30 minutes of active learning activities during each class meeting. The traditional-learning group received a traditional 90-minute lecture-style class.

This study took place from 2013 to 2018 in a Physics for Pharmacists course taught by the Faculty of Chemistry and Technology at the University of Split in the Republic of Croatia. A total of 150 first-year pharmacy students participated in the course over the five years. In the first 3 years of the study, the active learning method was used. During the active learning activity, the instructors described an experiment to the students and had them predict all of the possible outcomes that might result from performing the experiment. The experiment was then be performed by the instructor. After the experiment, the students were allowed to repeat the experiment themselves and ask questions. During the 2017 and 2018 academic years, the traditional lecture style was used. This meant that no time was allotted to the active learning activity. Over the 5 years during which this study was conducted, the same professor was responsible for all instruction, and the same course syllabus was used. Each year the students were assessed before and after completing the physics course using Lawson's Classroom Test of Scientific Reasoning. This assessment consists of 12 two-tiered multiple-choice questions where students are awarded points for correctly answering the question and also correctly identifying the reason for that answer.¹ This test helped differentiate how the different teaching methods affected the students' scientific reasoning skills. Based on the results of the test, students were classified as either a concrete, transitional, or formal learner, with formal being the highest level of learning.² A formal thinker is defined as being able to understand different variables within a problem as well as explain how these variables relate to each other.

The results of this study revealed that the active learning group had a significant improvement in a students’ level of scientific reasoning and also the ability of students to transition to a higher level of scientific thinking.² The percentage of formal thinkers in the active learning group increased from a baseline of 14.4% to 33.3%. In the traditional instructional group, the percentage of formal thinkers remained stagnant at 13.3%. When comparing the active learning group to the traditional group, performance in the physics course was significantly improved, with the mean grade point average of 4.0 on a 5.0 scale in the active learning group versus 2.8 in the traditional learning group.

The strengths of this study include the use of a control to compare the results of the two teaching approaches as well as the use of a pre- and post-assessment to assess each students’ scientific reasoning level. The LCTSR is a validated and widely used tool to assess scientific reasoning. Some of the weaknesses of the study include the fact that the control and intervention cohorts were concurrently conducted during the same academic year. It’s possible that the two groups had very different experiences in other course work that might explain the different outcomes.  By having both comparison groups happen simultaneously, students would have experienced the same course curriculum and instructors. 

A similar study by Styers was conducted in 2018; however, the investigators used Critical Thinking Assessment Test (CAT) to assess critical thinking rather than the LCTSR.³  While the findings were similar, the Styers study did not use a control group.³ A third study by Latif and Mumtaz looked at implementing active learning using a debate type approach.⁴ This study also showed positive outcomes, but this was only on the basis of how the student’s perceived the growth in their critical thinking skills. No test to objectively measure critical thinking was administered. 

I believe this study provides strong evidence that implementing active learning activities can help improve scientific reasoning. From my own experiences, I personally found active learning activities in my physics courses and other science-based courses helped me to be more successful because it made me think more about the topic. The goal of initiating active learning is to stimulate thinking and allow students to make mistakes. Every educator should strive to include active learning activities in their instruction to help mold future scientific thinkers. 

References

1. Khoirina M, Cari C, Sukarmin. Identify Students’ Scientific Reasoning Ability at Senior High School [Internet]. Journal of Physics: Conference Series 2018; 1097: 012024.
2. Marušić M and Dragojević A. Assessing Pharmacy Students' Scientific Reasoning After Completing a Physics Course Taught Using Active-Learning Methods. [Internet] Am J Pharm Educ 2020: 84(8): Article 7610.
3. Styers ML. Active Learning in Flipped Life Science Courses Promotes Development of Critical Thinking Skills [Internet]. CBE-Life Sciences Education. 2018; 17 (3): [cited 2020Oct16]. https://doi.org/10.1187/cbe.16-11-0332
4. Latif R and Mumtaz S. Learning through debate during problem-based learning: an active learning strategy [Internet]. Adv Physiol Educ 2017; 41: 390-394.

Student Pharmacists as Pediatric Asthma Educators

by Caroline Adrian, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Review and Summary of: Elliott JP, Marcotullio N, Skoner DP, et al. Impact of student pharmacist-delivered asthma education on child and caregiver knowledge. Am J Pharm Educ. 2014 Dec 15;78(10):188.

 As a student pharmacist, I recognize the importance of medication adherence in the management of chronic conditions. However, when I was diagnosed with asthma as a child, I did not understand the concept of maintenance therapy. I didn't understand that I needed to use my inhaled corticosteroid every day to prevent exacerbations. Frankly, I didn't even know what that inhaler was for, so I frequently missed doses. Looking back, I wish someone had taken the time to educate me about asthma and the medications I needed to use so I might have had better symptom control. I recently discovered a study¹ that looked at the impact of student pharmacists as asthma educators to both children and their caregivers. I was eager to learn more.

This cross-sectional study enrolled children and caregivers who attended at least 1 of 6 For Your Good Health, LLC asthma camps at Duquesne University over a two year period. The asthma camp series was developed to teach children, ages 5-17 years, and their caregivers asthma self-management skills. The camps were directed by an interdisciplinary team of physicians and pharmacists and staffed by student pharmacists and university athletes. Camps were held on Saturdays from 9:00 am to 2:00 pm, with asthma screenings and education being conducted during the morning session. The primary objective was to evaluate the impact of student pharmacist-delivered asthma education on child and caregiver knowledge about asthma. The secondary objective was to assess child and caregiver baseline asthma knowledge and its correlation with asthma control.

The hands-on educational activities implemented at each asthma camp were developed by sixth-year Doctor of Pharmacy students under the guidance of two faculty members. The activities focused on the 4 key components of effective asthma management: avoidance of triggers, medication compliance, proper inhaler technique, and the importance of an asthma action plan. Some of the activities included interactive skits to teach proper inhaler technique, game shows highlighting the differences between controller and reliever medication, and a memory game of asthma triggers. One group of students built a large cardboard house that contained common asthma triggers for their activity. They worked with the children to make the house more "asthma-friendly," discussing how to limit exposure to each of the triggers. Caregivers were not required but strongly encouraged to attend with their children.  The participants rotated through 4 stations of activities that lasted up to 15 minutes each. 

An asthma knowledge questionnaire was administered separately to the children and to the caregivers at the beginning and end of each asthma camp to assess the effectiveness of the educational program. Of the 87 children enrolled in the study, 76 completed both the pre- and post-intervention questionnaires. Only 45 caregivers participated in the educational intervention with 42 completing the pre- and post-intervention questionnaires. Statistical analyses compared the pre and post-intervention scores. 

The study found that the asthma education program was effective in increasing asthma knowledge among children. However, the student pharmacist-delivered education was not effective in increasing asthma knowledge among caregivers. Many of the caregivers who participated did not have children with asthma and the investigators also noted that many caregivers opted to socialize amongst themselves rather than participate in the educational components of the For Your Good Life camp. It was unclear to me whether the investigators designed the educational intervention with the caregivers in mind, or if they designed the intervention to focus on the children alone with hopes that the caregivers would be willing to participate. It seems the educational intervention was engaging for the children but perhaps not of great interest to adults. However, the investigators found a strong association between caregiver pre-intervention scores and asthma control in their children, suggesting that caregiver knowledge of asthma plays a role in asthma control.

This study found that the educational program was beneficial to the children who participated as well as the student pharmacists. The student pharmacists were able to practice their role as future educators by developing and implementing novel educational activities. A weakness of this study was that the investigators used different student pharmacists at the camps and this may have led to differences in how the educational activities were conducted. A limitation of this type of educational intervention is that the development and implementation of such a camp requires a significant amount of time and resources.

This was the first study to assess the effectiveness of student pharmacists as asthma educators in a pediatric population. Other studies have shown student pharmacists can effectively educate adults with chronic illness.^2,3 Other studies have found that asthma education of children and caregivers can lead to better symptom management and fewer acute exacerbations,⁴ and educational programs for asthma self-management in children alone can also lead to improved lung function and fewer trips to the emergency department.⁵

This is a great way for educators to engage student pharmacists to conduct hands-on learning experiences teaching children about asthma. Similarly, structured learning activities may be beneficial in teaching children about other disease states as well. Diabetes and epilepsy are also common chronic conditions in children where student pharmacists can assist in delivering fun educational programs to kids. 

References:

1. Elliott JP, Marcotullio N, Skoner DP, et al. Impact of student pharmacist-delivered asthma education on child and caregiver knowledge. Am J Pharm Educ. 2014 Dec 15;78(10):188.
2. Letassy N, Dennis V, Lyons TJ, et al. Know your diabetes risk project: Student pharmacists educating adults about diabetes risk in a community pharmacy setting. J Am Pharm Assoc (2003). 2010 Mar-Apr 1;50(2):188-94.
3. Shrader S, Kavanagh K, Thompson A. A diabetes self-management education class taught by pharmacy students. Am J Pharm Educ. 2012 Feb 10;76(1):13.
4. Agusala V, Vij P, Agusala V, et al. Can interactive parental education impact health care utilization in pediatric asthma: A study in rural Texas. J Int Med Res. 2018 Aug;46(8):3172-3182.
5. Guevara JP, Wolf FM, Grum CM, et al. Effects of educational interventions for self-management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003 Jun 14;326(7402):1308-9.