Mindfully Teaching and Learning

by Alisha S. Nicks, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Before you clicked on the link to read this blog post, were you thinking about your to-do list? Or perhaps you were reflecting on a decision you made last week that you wish you could change? While our physical bodies are in the present moment, our minds often drift to thinking about mistakes of the past or planning for the future. Mindfulness, as defined by Jon Kabat-Zinn, Ph.D., is purposefully paying attention to the present moment in a non-judgmental manner.¹ Psychological and educational research shows that Dr. Kabat-Zinn’s mindfulness-based stress reduction (MBSR) program teaches individuals the power of paying attention to the present, models a conscious way of living, and provides healthy coping mechanisms for stress.²

MBSR is an eight-week training program centered around formal mindfulness practices, including mindful attention to breathing through sitting meditation and body awareness through Hatha yoga. MBSR also teaches participants to informally practice mindfulness through attentiveness in everyday activities, such as walking, talking, driving, and eating. In a systematic review assessing the efficacy of MBSR on stress management, MBSR interventions positively impacted both psychological and physiological measures of stress. Although an eight-week MBSR course may not be feasible for most schools to provide to their students, faculty, and staff, instructors can create “mindfulness moments” throughout the curriculum. Including mindfulness techniques in one’s instruction can motivate students to become more self-aware as well as build positive relationships.³ The results of one study in an early childhood education program showed that students who participated in an “awareness of the breath” activity at school also engaged in mindfulness-based conflict resolution strategies with friends and family.⁴

What if instead of telling students to focus on some end result, we encouraged them to focus on the actual pursuit itself?
– Amy Burke: Mindfulness in Education, Learning from the Inside Out

Health professional students often struggle with stress from challenging coursework, extracurricular activities, and personal responsibilities. Moreover, they often struggle with internal pressure to meet personal expectations of perfection and a fear of failure.⁵ After a case discussion I facilitated with students at the University of Mississippi School of Pharmacy, a few third-year students asked me for advice on how to prepare for pharmacy licensure exam. They seemed anxious about an exam that is more than 18 months away. After sharing a few recommendations, I encouraged them to focus on the materials they are learning now, taking action now to really understand what they are currently learning, rather than worrying about the exam or life post-graduation. Mindfulness is not turning a blind eye to present difficulties or future responsibilities. It involves conscious acceptance and intentional responses to current circumstances.

Mindfulness begins by observing one’s internal state (emotions and thoughts) as well as external environment (sensations) but without judgment or automatically reacting.  The five facets of mindfulness are described below (see Table 1).

Table 1: Five Facet Mindfulness Questionnaire⁷

Scales	Definition	Sample Item
Observe	Tendency to observe, notice, or attend to internal and external phenomena	I intentionally stay aware of my feelings.
Describe	Tendency to describe or label sensations, perceptions, thoughts, emotions, etc. with words	My natural tendency is to put my experiences into words.
Accept without judgment	Tendency to accept without making judgments or evaluations	I disapprove of myself when I have irrational ideas.
Nonreactive	Tendency not to react to one’s experience	I watch my feelings without getting lost in them.
Act with Awareness	Tendency to focus undivided attention on the current activity or avoiding automatic pilot; concentration	I easily get lost in my thoughts and feelings.

Instructors play a critical role in setting the tone of the learning environment and engaging students in the learning process. In a commentary exploring the lessons that teachers can learn from actors about living in the present moment, Daniel R. Malcom reflects on his lectures as a junior faculty member that focused on information delivery but neglected to fully engage learners.⁶ Dr. Malcom suggests being reliably in the present moment with learners as a key strategy for creating learner-centered environments and strengthening relationships between teacher and learner.

In a study conducted in Ireland regarding stress and stress management, student pharmacists were interviewed in a series of focus groups. Students who did not have strong and regular interactions with instructors felt a lack connectedness and this hindered their access to support systems and resources. Focus group participants recommended integrating mindfulness practices into the curriculum instead of didactic lectures on stress management to encourage active learning. In a clinical trial evaluating the impact of a four-week mindfulness course, student pharmacists experienced improvements in stress and became more skillful at the observing facet of mindfulness.⁷ Although additional evidence is needed to assess the impact of mindfulness on learning outcomes, techniques listed in Table 2 have shown to reduce stress and increase wellbeing. 

Table 2: Mindfulness Strategies and Practices for Educational Settings³

 

Setting/ Audience	Learning Objective	Mindfulness Strategies	Example of Practice	Benefits
Educators	Understand how to treat students with respect, fairness, and non-judgment	Cultivate self-awareness to identify preconceived notions or judgments that may stand in the way of treating students equitably	Practice moment-by-moment awareness of your thoughts and feelings by focusing on bodily sensations or taking deep breaths	Educators become more reflective, thoughtful, and culturally responsive in their language and actions toward students
Educators	Proactively manage the stresses of teaching and leading	Educators recognize triggers of their own stress and emotional reactions	Pause and take several deep breaths whenever a strong emotional reaction is triggered, to cultivate self-awareness rather than reactivity	Educators can manage stress, personal hardship, and trauma
Elementary & Secondary Education Students	Cultivate focus and attention	Integrate a deliberate pause to help students settle their minds and bodies in preparation for learning	Begin class with a “mindful moment” where students are guided through either (1) sitting and noticing their bodily sensations or (2) slow and deliberate movement (e.g., deep breaths with movements such as raising their arms over their heads and down to their sides in repetition)	Students learn to slow down, quiet down their nervous systems, and check in with themselves and any feelings or thoughts that might need attention as they get ready to learn
Elementary & Secondary Education Student	Increase academic confidence, reduce stress, and manage anxiety	Use mindful breathing to help students self-regulate when under stress	Teach students to recognize the symptoms of anxiety in the body (e.g., elevated heart rate, fast-moving thoughts) and to practice taking several slow, deep, and full breaths to signal ease to the body when they feel these symptoms	Students are better able to manage stress and anxiety by practicing a healthy behavior

The highest function of education is to bring about an integrated individual who is capable of dealing with life as a whole.
– Krishnamurti: Education and the Significance of Life

Being more aware of the present moment is a healthy coping mechanism as students navigate virtual learning environments which have been required due to restrictions during the COVID-19 pandemic. Studies show that virtual learning settings create new challenges for students and many feel less confident in their ability to master the material.⁸ Mindfulness can serve as a constructive way to support student and faculty resilience during these unprecedented times. Incorporating techniques such as mindful breathing before exams and mindful appreciation of positive moments during instructional activities can inspire perseverance and reduce burnout. While mindfulness has proven to enhance emotional regulation, some people do not respond to these practices as there is no one-size-fits-all wellness model. Therefore, institutions should provide mindfulness activities and courses as an option to help teachers and learners become skilled in responding intentionally rather than reacting irrationally to life’s circumstances. Mindfulness can create meaningful connections between students and teachers both in and out of the classroom.

References

1. O’Driscoll M, Byrne S, Kelly M, et al. A Thematic Analysis of Pharmacy Students’ Experiences of the Undergraduate Pharmacy Degree in Ireland and the Role of Mindfulness. AJPE [Internet]. 2019;83:6457.
2. Sharma M, Rush SE. Mindfulness-Based Stress Reduction as a Stress Management Intervention for Healthy Individuals. J Evid Based Complementary Altern Med [Internet]. 2014;19:271–286.
3. Browning A. Mindfulness in Education: An Approach to Cultivating Self-Awareness That Can Bolster Kids' Learning. WestEd(2020). Accessed: February 6, 2021.
4. Ager k, Albrecht NJ, and Cohen M. Mindfulness in Schools Research Project: Exploring Students’ Perspectives of Mindfulness—What are students’ perspectives of learning mindfulness practices at school? Psychology 2015; 6 (7): 896-914.
5. Murry LT, Witry MJ. ‘Wasting Time Inside My Mind’: Exploring Student Pharmacists’ Perspectives on Engaging in Mindfulness Oriented Meditation Using Concepts From Education Research. Pharmacy Education [Internet]. 2020;204–214. Accessed: February 6, 2021.
6. Malcom DR. Being Present With Learners and the Deeper Lessons From Acting. Am J Pharm Educ [Internet]. 2020; 84: Article 8062.
7. O’Driscoll M, Sahm LJ, Byrne H, et al. Impact of a Mindfulness-Based Intervention on Undergraduate Pharmacy Students’ Stress and Distress: Quantitative Results of a Mixed-Methods Study. Curr Pharm Teach Learn [Internet]. 2019;11:876–887.
8. Schlesselman LS, Cain J, DiVall M. Improving and Restoring the Well-Being and Resilience of Pharmacy Students During a Pandemic. Am J Pharm Educ [Internet]. 2020; 84: Article 8144.

Preparing Health Professions Students for Telehealth

by Madeline Wolters, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Telehealth is a rapidly growing modality for delivering health care services.  It can improve access to care, enhance quality and frequency of visits, and reduce costs.¹ Telehealth can be administered in many ways but the most common are video conferencing, telephonic communication, and remote patient monitoring.² The World Health Organization defines telehealth as:

The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.¹

As a pharmacist who trained in Mississippi, I did receive some instruction regarding the delivery of teleservices since access to transportation and the geographic availability of providers are common barriers in rural areas. However, with the arrival of the COVID-19 pandemic, we have seen traditional healthcare delivery restructured, moving away from face-to-face visits to telehealth services.

Technology and virtual services are here to stay, so we must provide instruction to students of all health professions about telehealth.  Here are the key elements that should be addressed in the core curriculum:³

1. Professionalism in a virtual age
2. Appropriate use of mobile health information and technology
3. Communication skills in online environments

In my own experience as a pharmacy student, I was taught these skills through a series of lectures, training courses, professional assemblies, and practice-based experiences. There are countless ways to present and teach about telehealth to fit the needs of learners. Because health professionals must earn and maintain the trust of the people we serve, as practitioners and educators, it is our responsibility to uphold professionalism and teach those principles to the next generation. It is also important to remember that what may seem obvious to an “old pro” might not be intuitive for a novice learner.

Most health profession programs begin with instruction that is primarily classroom-based.  Early in the curriculum is the ideal time to introduce the concepts of professionalism, appropriate use of technology and patient information, and the foundations of successful communication. As learners progress and enter into the experiential or clinical portion of their education, these concepts can be expanded and reinforced through hands-on experiences and practice. In an interview on how telehealth is transforming healthcare during the COVID-19 pandemic, Dr. Richard Van Eck of the University of North Dakota School of Medicine and Health Sciences stressed the importance of putting learners in simulated and realistic environments to truly understand telehealth.⁴ He stated,” you can do all the didactics you want, but until you're in the midst of doing it [telehealth], you don't really understand what's involved”.⁴

The American Medical Association released a “Telehealth Visit Etiquette Checklist” which provides valuable tips that can be applied to all patient care interactions.⁵ A telehealth visit should mimic an in-person appointment as close as possible. If the patient will be using video-capable technology during an encounter, the student should be aware to dress in the same level of professional attire, including a white coat, if applicable.⁵ Just as a practitioner would prepare an exam room, the student should prepare their virtual environment.⁵ The necessary technology should be accessible, the electronic health record (EHR) should be open, and the background scenery and lighting should be appropriate for the encounter. For telephone calls, make sure the student is either using a telephone owned by the healthcare facility or an application that scrambles or protects the student’s personal phone number. The teaching institution should be able to provide any space and equipment that the learner should need.

Learners should also be taught how to appropriately use and share health information and technology. The patient’s confidentiality should be ensured by managing the appointment in a private space and following HIPAA (Health Insurance Portability and Accountability Act) requirements. It is also important to teach what health information may or may not be sent through non-secure platforms like email or text messages. If written patient information is to be shared with other providers, students need to be taught how to encrypt emails or navigate messaging through the EHR. The student should know who to contact if he or she feels the patient’s privacy may have been breached. Additionally, students need to know how and when they are permitted to use personal and institutional issued technology. Specific policies may vary from site to site, but ultimately a student should be taught a general guide to appropriate technology use.

Lastly, communication is at the center of all patient interactions. From the very beginning, students should be taught how to engage in motivational interviewing, deliver patient education, and manage patient exams. However, adjustments may be needed when using a virtual platform. Dr. Van Eck noted that many students inexperienced with telehealth report that they have difficulty understanding what the patient is saying and they are not able to read body language.  Also, patients are more likely to say things like “Who are you?”⁴ It may be helpful to run through example scenarios to boost a student’s confidence with operating the technology and practicing how to interact with a patient. Since you are not in control of the patient’s environment, students should be taught strategies to redirect the patient’s attention. For example, if the TV is loud in the background, the student should have the practice and self-assurance to say, “I would like us to have the best visit possible. Would you be able to turn the TV off for now?²” The importance of speaking clearly and deliberately is heightened during a telehealth encounter. Students may need to make frequent pauses to allow for transmission delays.⁵ During video-capable visits, students must be taught how to maintain eye contact and use non-verbal cues as much as possible.⁵ For telephone calls, students need to learn how to introduce the encounter and explain why they are calling the patient. Since hearing will be the only sensory mechanism, students will need to learn how to use inflection with their voice and implement continuous confirmation with empathetic language.⁵ As with all patient encounters, students must know to verbalize and clarify the next steps and patient care plan. The "teach-back method" is still helpful to confirm a patient's understanding.

A recently published systematic review examined the integration of telehealth topics in health professions curricula.¹ The review noted that telehealth concepts are multifaceted and can be overwhelming for students without foundational knowledge and guided experiences.¹ However, instruction provided to students using different modalities (online delivery, clinical experiences, simulations, and face-to-face instruction) all improved student satisfaction and self-confidence with telehealth encounters.¹ Ultimately, multiple exposures to these concepts throughout the curriculum are essential for the next generation of health care works to become competent and confident using telehealth technologies.¹ As telehealth becomes commonplace, telehealth experiences must become a required component of every curriculum.

References

1. Chike-Harris KE, Durham C, Logan A, et al. Integration of Telehealth Education Into the Health Care Provider Curriculum: A Review. Telemedicine and E-Health [Internet], Published online April 3, 2020. https://doi.org/10.1089/tmj.2019.0261
2. Telehealth. American Pharmacists Association. Accessed February 05, 2021.
3. Aungst TD. Integrating mHealth and Mobile Technology Education Into the Pharmacy Curriculum. Am J Pharm Educ 2014;78: Article 78119.
4. Educators discuss integrating telehealth in student curriculum. American Medical Association, January 2021. Accessed February 12, 2021.
5. Telehealth Visit Etiquette Checklist. American Medical Association. April 2020.  Accessed Feb 15, 2020.

Benefits and Concerns with Educational Handovers

by Elizabeth Sykes, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-North Mississippi

Most health professional are familiar with hand-off or handover reports which occur at the beginning and end of a shift, when a patient is transferred from one unit to another, or when there is a change in a patient’s condition.  Handovers occur between nurse to nurse, nurse to physician, nurse to a pharmacist, and even from pharmacist to pharmacist.  These handovers occur within and across all disciplines so that patients receive the most appropriate care.  Handovers are very important for patient safety and continuity of care.  It has been shown that poor or inaccurate handovers may lead to delayed and inappropriate treatment, medical errors, and inaccurate assessments and diagnoses.  Perhaps an educational handover between teachers and educational programs can have similar benefits?

An educational handover, the sharing of appropriate learner performance information between teachers and preceptors to support the learner’s ongoing training and development, is a potentially valuable way to support learning over time.¹ In this way, feedback about performance problems can be made based on multiple, longitudinal observations.¹  Benefits of educational handovers may include improved learning through more tailored feedback and support, improvements in a supervisor’s ability to assess learners related to specific competencies, increased assessor accountability, and improved patient safety through the early identification of weak or problematic behaviors.² 

However, not everyone agrees that educational handovers are useful, valuable, or appropriate.  Despite the potential benefits of an educational handover, there are some concerns associated with it.  Informing future teachers or preceptors about potential performance problems may introduce bias into the assessment process and it may lead instructors to treat some learners differently or label them. This could then lead to both the learner and the assessor acting in ways and viewing the learner’s performance through a lens that lines up with prior assessments. In addition, an educational handover may violate a learner’s right to confidentiality and privacy.²

A study performed at McGill University examined the potential bias from an educational handover on workplace-based assessment scores in medical education.  When given handover reports mentioning weaknesses, the hypothesis was that supervisors would provide lower assessment scores and more negative comments than those who did not receive learner reports.  This was a mixed-methods randomized, controlled, experimental study.  All participants viewed two videos of a simulated resident-patient encounter and then assessed the residents’ performance using the mini-Clinical Evaluation Exercise (mini-CEX).  The two videos viewed them in the same order.    The participants were randomized into three groups that differed based on the educational handover condition: no education handover report (control group), educational handover report indicating weaknesses in medical expertise, and educational handover report showing weaknesses in communication.  Participants had to complete a questionnaire that included questions about basic demographic variables (age, gender), clinical and educational variables (specialty, years of experience supervising, years of experience assessing), and mindset.  An analysis of variance was used to compare mean scores, percentages of negative comments, comments focusing on medical expertise, and comments focusing on communication across experimental groups.³

Seventy-two supervisors completed the study with 21 participants in the control group, 21 in the educational handover group indicating weakness in medical expertise, and 30 participants in the group receiving the educational handover indicating communication weaknesses.  No differences were detected in demographic characteristics, rater experience, or mindset across the three groups.  There was no effect of the handover report on assessment scores (F(2, 69) = 0.31, P = 0.74) or percentage of negative comments (F(2, 60) = 0.33, P = 0.72).  However, the participants who received a report indicating communication weakness generated a higher percentage of comments about communication skills than the control group (63% vs. 50%), P = 0.03).³ 

	Control Group (no handover report) n = 21	Medical Expertise Weakness Group n = 21	Communication Weakness Group n = 30
Mean score for Video 1	5.6 (4.9-6.2)	5 (4.2-5.8)	4.9 (4.5-5.4)
Mean score for Video 2	4.8 (4.2-5.4)	5 (4.4-5.6)	4.9 (4.4-5.5)
Mean score for both videos	5.2 (4.6-5.7)	5 (4.4-5.6)	4.9 (4.5-5.3)

This study suggests that an educational handover can lead to more targeted feedback without influencing scores.  Further studies are needed to examine the influence of reports of various performance levels, areas of weakness, and learner behaviors.³ 

Competency-based medical education (CBME) is becoming the cornerstone of medical education programs.  But the transition from undergraduate medical education to graduate medical education is not a smooth process.  It has been suggested that an educational handover at the end of medical school might help with this transition and would help students become more prepared to care of patients.  The Medical Student Performance Evaluation (MSPE) is submitted in early October each year, and there is very little information provided about the final year of medical school.  In April 2018, the American Medical Association’s Accelerating Change in Medical Education consortium developed five recommendations for developing an educational handover that would be provided to residency programs at the end of medical school.  The 5 recommendations are: (1) The purpose of the educational handover is to provide performance data to guide continued improvement in the learner’s ability and performance, (2) the process used to create an education handover should be philosophically and practically aligned with the learner’s continuous improvement, (3) the educational handover should be learner-driven with a focus on individualized learning plans that are co-produced by the learner and his/her coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest inadequate infrastructure to support learner improvement.

Despite these recommendations, there are still challenges with educational handovers between educational programs.  Medical schools would have to develop a curriculum for educational handovers that focuses on assessing individuals' performance.  These should include authentic workplace-based assessments coupled with a formative feedback process.  The Family Educational Rights and Privacy Act (FERPA) regulations apply to educational handovers.  Even though medical school graduates transfer from one educational setting to another, FERPA protects the privacy of learners in both contexts.  Thus, any educational handover will need to comply with FERPA.  Medical schools would need to develop a standardized process to support meaningful communication.  Lastly, creating an educational handover should support a successful transition.  Gathering assessments and adjusting each trainee’s experience during the first few months of a residency would be challenging.  But to be truly effective, the content of the educational handover should be used to implement learner-specific curricular modifications.⁵

Health profession educational programs should have some form of handover, but many of them don’t, or they may lack the appropriate framework.⁴  I believe educational handovers would help prepare learners (students and residents) for the next step in their career.  It can provide future preceptors and employers with information about the learners’ past performance and how they should tailor experiences to help address potential weaknesses.  Educational handovers may lead to some bias, but I believe with appropriate training, preceptors and residency program directors can learn to appropriately use this information to address learner needs. 

References 

1. Guidelines for Educational Handover in Competence by Design. Royal College Committee on Specialty Education: 2018 May 
2. (Gumuchian ST, Pal NE, Young M, Danoff D, Plotnick LH, Cummings BA, et al. Learner handover: Perspectives and recommendations from the front-line. Perspect Med Educ. 2020;9:294-301. 
3. Dory V, Danoff D, Plotnick LH, Cummings BA, Gomez-Garibello C, Pal NE, et al. Does Education Handover Influence Subsequent Assessment? Acad Med. 2021;96:118-125.
4. Gordon M, Hill E, Stojan JN, Daniel M. Educational Interventions to Improve Handover in Health Care:  An Updated Systematic Review. Acad Med. 2018;93(8):1234-1244. 
5. Morgan HK, Mejicano GC, Skochelak S, Lomis K, Hawkins R, Tunkel AR, et al. A Responsible Educational Handover: Improving Communication to Improve Learning. Acad Med. 2020;95:194-199.

Deep Learning Strategies

by Grace Orman, PharmD, PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

We have all been there. The night before a big test. Maybe the week was busy. Maybe time got lost. Maybe this was the plan all along — to wait until the last minute. The next handful of hours are dedicated to quickly reviewing weeks’ worth of lectures and somehow manage to retain all those details to successfully pass the test. You may be great at cramming. You might even pass that test. But will you remember the information in a year? A month? Even this afternoon?

This is an example of surface learning. A form of learning where there is no understanding or application, only rote memorization.¹ The information gathered during “cramming” or last-minute studying for a test is not elaborated nor is the knowledge applied in any way. Often, the information is retained for only a brief period of time, if at all.² Surface, or shallow learning, is maybe the first step when learning new vocabulary or concepts, but it should not be the last step. Surface learning might get a student through an exam, a class, and maybe even a series of courses. But as teachers, we should encourage students to get beyond shallow learning and provide them with strategies for deep learning.³

Healthcare workers should possess a broad knowledge base, flexibility, problem-solving ability, and be pro-active.¹ Rote recall of an expansive fund of knowledge is not enough to excel in the professional and personal world post-graduation.² The ability to retain core knowledge is the minimum requirement in the world today. The ability to communicate knowledge and integrate that knowledge to solve problems is critical.  Moreover, all health professionals must be in charge of their own continuing education as knowledge is constantly evolving.^3,4 Thus deep learning is needed.  The fundamentals must be applied and repeated to re-enforce concepts. To achieve deeper learning, we have to change the way we educate. There are a handful of strategies to help facilitate deeper learning. These strategies align with three domains: cognitive, interpersonal, and intrapersonal.

The cognitive domain is where the basis of deeper learning stems: the mastery of core academic content and incorporating critical thinking skills. The Hewlett Foundation defines the mastery of this domain as the skillset to “develop and draw from a baseline understanding of knowledge in an academic discipline and to transfer knowledge to other situations.” Thus fundamental knowledge is used and applied in new situations.^2,3,4 This would incorporate “problem-based learning,” where the student would need to know the basics of the subject but then apply it to a series of cases (simulated “real-world” situations). This not only merges together the student’s core knowledge but also draws upon their experiences and imagination. Incorporating internship opportunities outside of school is another great way to practice and solidify one’s fundamental knowledge in a real-world environment. Other strategies to enhance the cognitive domain are self-check quizzing and discussion boards.

The second domain to promote deep learning is the interpersonal domain. This domain requires communication and collaboration. The ability to effectively communicate complex ideas to others and to collaborate together is essential in the world post-graduation. Effective communication can be achieved through peer teaching and presenting information to others. This can also foster peer-to-peer review and feedback. Group projects with alternating leaders allow for both communication and collaborative effects, allowing students to see the benefits and outcomes of working together. Internships can also help foster this domain. Incorporating these into the curriculum, whereby students are placed in real-work environments several days a week could solidify collaborative work between team-mates and co-workers.

Lastly, the intrapersonal domain consists of learning how to learn over a lifetime. Continuing education is a critical component of a life-long learner. It is essential to stay “in the know” of new concepts, information, and guidelines in healthcare. Being able to develop a process for self-directed learning is a key to staying current throughout one’s career. Students must be responsible for determining own their goals and assessing their progress. This could be achieved by self-management and self-evaluations. Teachers can help the student find their strengths and weaknesses and help guide them to self-reflection after group work or other activities. Instead of enforcing strict deadlines, letting students progress at their own pace while encouraging deeper learning, can foster the skills needed to continue to grow outside of the classroom.⁴

To become deeper learners, students must be active and engaged in their learning. Bringing together these three domains — the cognitive, the interpersonal, and the intrapersonal — can have a profound impact not only on their academic performance but preparing students for the life they must outside of the classroom. As teachers and mentors, we want our students to thrive in life as well as in class. Providing students with strategies that foster deeper learning can prepare them for life.

References: 

1. Lombardi P. Instructional Methods, Strategies, and Technologies to Meet the Needs of All Learners [Internet]. Montreal: Pressbooks; 2019. [cited 2021 Jan 24].
2. Peng M, Chen C. The Effect of Instructor’s Learning Modes on Deep Approach to Student Learning and Learning Outcomes. Educational Sciences: Theory & Practice. 2019;19(3):65-85.
3. Hailikari T, Katajavuori N, Ylanne S. The Relevance of Prior Knowledge in Learning and Institutional Design. Am J Pharm Educ 2008;72(5): Article 113.
4. Huberman M, Bitter C, Anthony J, O’Day J. The Shape of Deeper Learning: Strategies, Structures and Cultures in Deeper Learning Network High Schools [Internet]. Washington, DC. American Institutes for Research. 2014, 1-38. [cited 2020 Jan 17]

Reducing Black and White Thinking: Constructing Partial Credit Multiple Choice Exams

by Lauryn Easley, PharmD, PGY1 Pharmacy Practice Resident, North Mississippi Medical Center

During my many years in school, exams were given primarily in the classic, multiple-choice question format. The form of assessment has been the gold standard for many years.¹ While multiple-choice question examinations aren’t perfect, many would argue that “if it’s not broken, don’t fix it”. However, I would argue there is one significant shortcoming for the single best answer, multiple-choice tests —students begin to assume there is only one correct answer. This has led generations of students to view concepts with a “black or white” mentality. You are either right or you are wrong.  This kind of thinking is not helpful. Life is more nuanced. We need to help students understand that the world and our knowledge is actually rather grey.

In a world full of possibilities, leading our students to develop black and white thinking causes them to misunderstand situations. They only see the two extremes and not the in-betweens.¹ Traditional multiple-choice examinations potentially stifle students’ creativity, as well as enable them to put forth minimal effort, thus producing lazy learners.^1,2 If students were made to explain their reasoning or defend their choices, we could move away from simplistic answers and move towards students better able to stand by their viewpoints and use evidence to support them.^1,2 Furthermore, multiple-choice exams inhibit the instructor’s ability to truly know whether the students fully grasp the concepts being taught. With traditional multiple-choice exams, students can guess the answers to most questions and still pass. A savvy test-taker might not actually comprehend the material.

Traditional multiple-choice tests can lead to “over-thinking” because the student assumes there is only one correct answer, even though other answer choices seem appropriate.² As a type-A, over-thinker, I would find myself reading a question and looking for additional details to help make a complex decision.  But sometimes I was making the question far more complicated than the teacher intended. Because of this, I would sometimes pick an “incorrect” answer simply because I misunderstood what the teacher was asking me. In traditional multiple-choice exams, I had no way of explaining my reasoning.  I was forced to choose one answer over another. For this reason, I rarely reviewed questions I answered incorrectly on a test because I did not like to rehash my errors. Looking back, this was not a healthy mindset. None-the-less, I think it’s an important question. Should we move away from traditional multiple-choice exams, and if so, what are some suitable alternatives?

There are, in fact, a few different options, including awarding partial credit for answers that are okay but less than ideal, utilizing select all that apply questions, and short-answer questions.^1,2,3

Partial credit focuses on awarding the most points to students picking the “most correct” or “best” answer but not fully penalizing students for picking an answer that may not have been the best option among the choices offered but is a reasonable option in some circumstances. Scoring questions in this manner can also help instructors move away from factual, straightforward, there is only one “right” answer to questions and move toward conceptual questions that require deeper thinking.^1,2  For example, a question might ask about various treatment options for a disease or problem. While the “best” or “preferred” option might be among the choices, the student might be awarded partial credit for an option that is effective and unlikely to cause patient harm. In this case, the answer choice the student picked could be awarded partial credit, rather than full credit. The instills the idea that some answers are better than others but there is a range of “acceptable” choices. Other advantages of awarding partial credit – it may be easier for instructors to create distractors for the question and there may be fewer post-exam arguments from students seeking credit for their selected answers.

 Duckor and Holmberg give the example below to illustrate the benefits of organizing answer choices into bins, where certain bins are worth partial credit and other bins are considered incorrect.³

When the time is taken to organize and categorize each answer choice, instructors will have a better grasp of how well their students understand the topic, where common misconceptions lie, and where clarification with additional instruction may be beneficial. 

Select all that apply questions always discouraged me as a student because they were treated as all-or-nothing questions at my school.  You had to select ONLY the correct options and not select the incorrect options in order to get credit.  If you selected (or didn’t select) 5 out of the 6 options correctly, you go NO points. In other words, a student who got 5 out of 6 options correctly received the same number of points as a student who got 0 out of the 6 options correct.  It seemly likely the two students' understanding of the material is VERY different, but in terms of performance on the exam, they both received the same score. While some national certification examinations score select all that apply questions as all-or-nothing, this is not conducive to learning and doesn’t acknowledge what students DO know about the subject matter. To encourage students, they should be granted partial credit for each correct response option chosen and, conversely, points should be deducted for each incorrect option chosen. So, for example, if a student was correct on 5 out of 6 options, the student would receive +5 – 1 = 4 points.  If a student had 3 out of 6 options correct, the student would receive +3 – 3 = 0.  Awarding partial credit while also subtracting points for incorrect answers prevents students from gaming the system and simply selecting all options just to get some points.

As a student, I’ll admit that I didn’t like short-answer questions. However, in employing this testing format, we allow students to show us how much they understand and we can get a glimpse of each student’s thinking.¹ Short-answer essay questions really require students to thoroughly prepare. The student is forced to formulate a response – they can’t rely on recall to select from a list of possible responses.  Short-answer essays can be combined with the multiple-choice format whereby the student must provide a rationale for the response they selected.  In this way, students must know the correct or “best” answers but also must defend their choice.¹  Points could be independently awarded for selecting the correct answer and for the rationale.  Or points might be awarded only when the correct rationale is provided.  This would prevent “guessing” the correct answer.

I think these testing formats would encourage more students to review their responses to questions on an exam and encourage them to fully grasp the concepts being tested. It could lead more students to dig deeper into the materials to assess why they missed certain questions and why the best answer was, in fact, better than the other choices.

While a majority of these testing options may require more time and effort for either preparing or grading examinations, they give us a much clearer picture of how our students are doing and how well they grasp the material.^1,2 More importantly, rather than reinforcing black and white thinking, these alternative exam formats promote critical thinking, encouraging students to weigh the merits of different options.

References: 

1. Harrnstadt D. Pivot away from multiple-choice testing [Internet]. Bethesda (MD): Walt Whitman High School, The Black & White; 2019 Mar 23 [cited 2021 Jan 28].
2. Berwick C. What Does the Research Say About Testing? [Internet]. San Rafael (CA): George Lucas Educational Foundation, Edutopia; 2019 Oct 25 [cited 2021 Jan 28].
3. Duckor B, Holmberg C. Two Strategies for Assessing for Learning: The Partial Credit Scoring Key and the Scoring Guide [Internet]. Alexandria (VA): Association for Supervision and Curriculum Development, Inservice; 2018 Jul 23 [cited 2021 Jan 28].