A Different Small Group Learning Method - POGIL

by Amy Nathanson, Pharm.D., PGY1 Community Pharmacy Practice Resident, University of Maryland School of Pharmacy

Small group learning with an active component is incorporated in many curricula today. Have you been in a class where you had small group breakout sessions to discuss a case or apply learned concepts?  Many of us would answer yes.  Have you been enrolled in a course which was taught exclusively using a small group learning method?  Likely fewer would say yes.  Have you heard of or been enrolled in a process-oriented guided-inquiry learning (POGIL) course?

POGIL is a student-centered small group method of education.  The goal of this educational method is geared to develop the learner’s critical thinking and communication skills while keeping the student actively engaged in the learning process.  Students work in teams of four.  Using course materials and equipped with “guided” questions from the instructor, students explore an idea, (hopefully) grasp a concept, and then apply it.¹  The instructor’s role is to serve as a facilitator and, therefore, will not answer questions if s/he believes the students have enough information to come to a conclusion.²

This method of learning was initially developed for science courses and was prompted by an understanding the needs of industrial employers.³  A survey was conducted and concluded that “employers would like chemistry-trained employees whose education includes greater preparation in communication, team skills, relating applications to scientific principles, and problem solving, without sacrificing thorough preparation in basic science concepts and experimental skills.”³

I am fortunate to have participated in a POGIL course taught by one of the founders of this methdology.  It was an introduction to chemistry course taught at Franklin & Marshall College.  Reflecting back on the course, I remember it was very different from the typical lecture-base courses and, at the time, only a few courses were taught in this manner.  I enjoyed working with other students and remember favoring certain roles over others.  As a group we taught ourselves the key concepts of chemistry.

After discussing various small group teaching methods during the Educational Theory and Practice course, I have been reflecting on my experiences in this course and how it is unique.  POGIL utilizes carefully crafted learning materials to provide information to students systematically with leading questions to promote critical thinking to arrive at the best conclusion.  In each small group students have defined roles and responsibility that rotate weekly.  The roles include:

Manager- delegates responsibilities and keeps team focused, resolves disputes and ensures full member participation

Recorder- writes up group answers to turn in

Spokesperson/presenter- presents report to class

Analyst/reflector- identifies strategies and methods for problem solving, identifies positive attributes of the team

Every student is expected to learn the material on a daily basis and ensure that all group members have learned it too.

Unlike other small group learning environments such as Problem Based Learning (PBL), POGIL is more structured.  Every member of the group has an assigned role.  PBL is less structured and requires more independence of each student.¹ There are never lectures in a POGIL course, whereas occasionally there is a lecture in a PBL course.

This method of learning is rewarding to students because it actively engages them in the learning process. It’s more rewarding to the instructors as well because there is constant feedback from students.  Instructors have greater awareness of how the class is doing by getting this feedback.⁴

In my pharmacy education at University of Maryland we have small group case-based learning activities.  These cases often included leading questions to encourage critical thinking and further application of knowledge and guidelines of disease states and therapies.  However, the groups were often too large, consisting of 10-12 students, making it difficult to effectively work as a team.  And as is typical with most group work, certain people become the leaders or “managers” for every session, and other members of the group assumed roles that they were naturally comfortable with.  This is a problem that POGIL addresses by creating small working groups and assigning student roles.

These small group learning activities take a substantial time commitment from instructors and more effort on the part of the student too.  This likely explains why small group facilitated learning is not commonplace.  However there is a place for this methodology and I believe it can be used more in pharmacy education.  The skills POGIL works to enhance are necessary skills in pharmacy:  communication and team work with patients and other health professionals are critical skills that every pharmacist should master. 

References

1. Eberlein T, Kampmeier J, Minderhout V, Moog RS, Platt T, Varma-Nelson P, White HB.  Pedagogies of Engagement in Science: A Comparison of PBL, POGIL and PLTL. BAMBED. 2008; 36(4):262-73. 

2. POGIL Guided Inquiry Classroom [Internet]. Lancaster: Franklin & Marshall College. The POGIL Project. C2010 [Cited 2010 Nov 19]

3. Hanson DM. Instructor’s Guide to Process-Oriented Guided-Inquiry Learning. Lisle, IL: Pacific Crest. 2006. [Cited 2010 Nov 19] 

4. POGIL [Internet]. Lancaster: Franklin & Marshall College. The POGIL Project. C2010 [Cited 2010 Nov 17]

Interprofessional Education: Building a Bridge to Interprofessional Cooperation

By Susan Montenegro, Pharm.D., PGY1 Pharmacy Practice Resident, Union Memorial Hospital

Many schools boast having an “interprofessional culture,” which (apparently) they define as having more than one health professional school located on the same campus. But simply having schools across the street from each other, sharing a cafeteria, and hosting a few campus-wide social events, does not come close to building the relationships needed for optimal patient care. Many students in the health professions are taught a structured approach to managing a patient. So interprofessional education (IPE) shouldn’t be so difficult – should it? How can educators from different schools build bridges and encourage students to make the journey? How do we encourage the healthcare system to sustain these bridges?

I envision the answer to this question to be a three step process analogous to constructing a bridge to connect two places. Step 1 is putting together a blue print and building a structure.  As with any improvement process, first you need to put everything down on paper so everyone can see it. How will the bridge be built? Who will build it? Who will pay for it? Why is the bridge necessary? What are the benefits? A plan must be made and a proposal submitted to garner the support of the university, and secure the funds needed, to build the structure. Once these things are secured, those in charge of the project can begin to lay the foundations.

The American College of Clinical Pharmacy (ACCP) released a White Paper on IPE which describes considerations relevant to IPE.¹  Fundamentally, it is important for students to understand the knowledge and skills that other members of the healthcare team possess. Students must also realize that different professions take different approaches to patient problems in terms of assessment and evaluation. The paper describes several examples of IPE models.  Each approach has its strengths and future IPE programs can be optimized by building on these examples.

Creighton University Medical Center in Omaha, Nebraska has a number of IPE initiatives.² Collaborative Care Seminars are held one half-day each semester and involve students in dentisty, medicine, nursing, occupational therapy, pharmacy, physical therapy, and social work.  During these seminars, students are encouraged to reflect on what their own profession’s contributes to patient care and how to work together and understand what other professions have to offer. The Medical Center also offers a clinical conference and grand rounds series during which case-based discussions are led by panelists from the various health professions. This allows students to learn and observe how to participate in similar discussions once they start clinical training.

Step 2 is convincing the students to take the journey across the bridge. Students will only make the journey if they understand the importance of arriving at the destination. Where are they going? Why are they being asked to cross into unknown territory and away from familiar and safe ground? What are the benefits?

Another example from Kings College in London involves pairing a fourth year pharmacy student and a third year medical student to work together.³  Both students are starting their clinical year of training, so they have similar amounts of clinical experience and knowledge of therapeutics. Each student pair is assigned a patient with the objective of obtaining a medical and medication history.  The student pair is then instructed to organize the information and present it to a group of faculty and students.  They are expected to summarize the patient problems, the rationale and appropriateness of the treatment regimen, and how to monitor the patient for efficacy and adverse effects.  The results of this activity have been positive, with the medical students learning how to be more proficient at collecting the medical history of a patient and the pharmacy students being more proficient at collecting and managing the patient’s medication history. This type of activity is promising to demonstrating to health professionals early during their training how to maximize patient care by relying on the strengths of different professions.

A post-course questionnaire administered after the student pair activity found that 95% of pharmacy and medical students agreed or strongly agreed that it was useful to learn with other disciplines; 88% agreed or strongly agreed that there were equal contributions from both students; and 83% agreed or strongly agreed that more sessions were needed.³  This data shows that, given the opportunity, students are willing to meet other professions half-way and see the benefit in doing so.

Step 3 is ensuring that the destination (on the other side of the bridge) exists ... developing and continuing to foster the types of working environments where recent graduates can continue to use the skills they learned during IPE. This may require more time to develop as it will require holistic support. Not all clinicians have experienced IPE and many may feel threatened by the changes it will require. However as more programs move in the direction of IPE and as more workplaces emphasize the importance of inter-professional teams, the bridge built by educators will become stronger, producing a brighter and more promising future to optimize patient care.

In 2001, the Institute of Medicine released a report addressing the gaps in health care in the U.S. and how to redesign the health system. Titled, “Crossing the Quality Chasm: A New Health System for the 21^st Century,” this report stated that health care needs to be safe, effective, patient-centered, timely, efficient, and equitable.⁴  Included in the report were 10 general principles meant to guide improvements to meet these health care needs. One principle, stated quite simply and directly, “Cooperation among clinicians is a priority.” Thus, it is clear that our healthcare system needs to move towards interprofessional cooperation and that IPE will play an important role in making that future a reality.

References

1.  American College of Clinical Pharmacy. ACCP white paper. Interprofessional education: principles and application. A framework for clinical pharmacy. Pharmacotherapy 2009; 29: 145e-164e. [Accessed September 26, 2010].

2.  Interprofessional Education. Creighton University Medical Center. [Accessed: November 22, 2010]

3.  Greene RJ, Cavell GF, Jackson SHD. Interprofessional clinical education of medical and pharmacy students. Medical Education. 1996;30:129-133.

4.  Institute of Medicine.  Crossing the Quality Chasm: A New Health System for the Twenty-first Century.  Washington, D.C.: National Academy Press, 2001.

Taking Learning Outside the Classroom

by Olabode Ogundare, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

Do you remember those schools days when the weather was so nice outside and you wish your class was also outside so you could really enjoy the fresh outdoors as well as learn? How about those last days of spring semester when your school still had the heat on and it was unbearable for you to learn anything … but if you were outside it probably would have improved your attention span? Well, if you agree with these statements, then taking learning outside of the classroom might be just what you need to help improve your learning experience!

Outdoor education is relevant to educational theory and practice because it is an instructional method. Outdoor education is a type of instructional style that dates back to the early 1940s. It involves the use of outdoor learning settings to cover subject matter through hands on learning experiences. Outdoor education is still practiced in today’s educational system and can involve educational activities outside of the classroom such as field trips, field work, camping, or simple observation of the environment. What differentiates outdoor education from the more ‘traditional’ instructional methods is that it incorporates several of the different learning styles into its teaching method, thus allowing students to have an individualized learning experience that correlates with how they learn.  Outdoor education plays a significant role in shaping the education of children and may help enhance their learning.¹

In an article from Education.com titled, Environmental Education Programs Help Kids Connect to the Earth, Peter Bergstrom discussed how many adults feel that there is a steady decline of appreciation for nature in recent years. He emphasized that it is important especially for children to get in touch with nature because in his words, “fundamental to discovering who you really are, that you are not a person apart from nature, but a part of nature." If take a look at our education system, the amount of outdoor time children are allotted gradually declines overtime as they progress through their education. I think being able to connect with nature helps to develop critical skills that are not taught in the classroom setting. Outdoor educational programs similar to Bergstrom’s, help “kids recognize that they are smart in a different way from classroom smart,” which highlights that outdoor learning helps students engage beyond the norms of the classroom and enhance their learning experience.²

A study by the California Department of Education showed that six graders’ science knowledge test improved by 27% after participating in an outdoor educational program. Feedback received from the students showed that a majority of them felt that their participation in the outdoor education program actually changed them. When one student was asked whether he benefited from the program, the student responded, “Yes, because I learned more; I like science a lot because it helped me to protect the environment even more.” This demonstrates that outdoor educational programs really can enhance one’s learning experience and help students perform better academically.^3,4

The study entitled Effects of Outdoor Educational Programs on Children clearly demonstrates the potential role outdoor education may have on shaping the education system in years to come.⁴ Educators need to realize the students they encounter have different learning styles and it may not excel when traditional classroom-based methods are used.  Outdoor education is an alternative for students who seek to be engaged and have an active role in their learning experience. Most importantly, outdoor education programs have shown to improve academic performance in students.  Educators should be inclined to incorporate this instructional method as part of their teaching style to enhance their students’ learning.

References:

1.  Outdoor and Environmental Education. [Internet]. [Online: Education.com, Inc]; [Periodically updated; cited 2010 Nov 10] 

2.  Boutis, Nick.; Krisko, Beth. A Life Shaping Week: The Outdoor Education Experience [Internet]. [Online: Education.com, Inc]; [Periodically updated; cited 2010 Nov 8]

3.  What Does Environmental Education do for Children [Internet]. [Online: Education.com, Inc]; [Periodically updated; cited 2010 Nov 10]

4. Effects of Outdoor Education Programs for Children in California. American Institutes for Research. January 31^st 2005: 33-41

What is the Target?

by Angela L. Bingham, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

What is the target?  To answer this question, student pharmacists must be given a clear description of what they should be able to do after completing a learning experience.  Regardless of the field of study, instructors should give their students explicit instructional objectives.

In the “Required and Elective Educational Outcomes, Goals, and Objectives for PGY1 Pharmacy Residency Programs,” the American Society of Health-System Pharmacists (ASHP) defines educational goals, educational objectives and instructional objectives.¹  Educational goals are “broad sweeping statements of abilities.”  Achievement of educational goals is determined by assessing the learner’s ability to perform educational objectives.  Instructional objectives further narrow the focus by outlining the “knowledge and skills required for successful performance of the educational objective.”  Instructional objectives are helpful to educators and students by identifying areas for improvement to meet educational objectives.¹

Beyond providing students direction, instructional objectives help improve quality and efficiency.  According to Dr. Louis Vontver, “Instructional objectives should delineate specifically what the student is expected to do or know in terms of the student’s ability to demonstrate his skill or knowledge.”²  Objectives can only be measured effectively if they are simple.³  Measurement of complex outcomes and goals can be problematic because of the multi-factorial nature of the assessment needed.  Instructional objectives narrow the focus and help control for variables.

The Accreditation Council for Pharmacy Education (ACPE) also highlights the importance of objectives to facilitate learning.  ACPE states, “specific criteria should be developed to enable faculty and students to assess progress midway through the experience and at its completion. Students should be provided the opportunity to demonstrate achievement of stated competencies as assessed through the use of reliable, validated criteria.”⁴

When I was a student pharmacist, I was involved in a project that examined the role of self-assessment tool to evaluate the value of instructional objectives.  During this research project, a self-assessment tool was constructed using educational objective and instructional objective statements from the “Required and Elective Educational Outcomes, Goals, and Objectives for PGY1 Pharmacy Residency Programs.”⁵  Students performed self-assessments using this tool and their responses were compared to scores assigned by the preceptor for educational objectives and instructional objectives.

Twenty 3^rd-year Doctor of Pharmacy candidates participated in the study.⁵  When comparing students’ self-assessment to the preceptor’s scores on the educational objectives, students were more likely to rate themselves higher for “accurately assess the patient’s progress toward the therapeutic goal.”  A significant difference was also seen when comparing “display initiative in preventing, identifying, and resolving pharmacy-related patient-care problems.”  In contrast, using instructional objectives improved the accuracy of student self-assessment.  There was no significant difference between student and preceptor scores for any of the instructional objectives.

As a result of this research project I concluded that, in order for students to understand course expectations, course syllabi must clearly outline the knowledge and skills needed to meet the educational objectives.⁵  Providing instructional objectives to students enable self-directed learners to achieve desired expectations.⁵ The learner and preceptor share a mutual understanding of the knowledge and skills required to meet an educational objective. ⁵

In addition to giving students greater clarity, instructional objectives also aid the instructor.⁵  When the learner and instructor understand the expectations, confrontation may be avoided at the time of evaluation.⁵

In an experiment conducted at the University of Washington Hospital in Seattle, Washington, medical students completing nights on obstetric call were provided with specific instructional objectives.²  Medical students were issued a document outlining objectives prior to nights on call.²  The medical students were instructed to read the document several times before each scheduled night and again during on-call period.²  The following morning, the students were expected to demonstrate fulfillment of the objectives.  Before implementation of objectives, the performance of the medical students during morning rounds were “highly erratic.”  After instructional objectives were provided as well as some instruction on how to use them, the students performed much better.  They were often able to fulfill all of the expectations after only one night in the delivery room.  Beyond guiding medical students, the instructional objectives also prevented misunderstanding by other members of the health-care team by clarifying the students’ responsibilities.²

When educators provide instructional objectives, students are more likely to find the target.  Well-written instructional objectives enable self-directed learners to achieve desired expectations.  Also, instructors may find assessment easier when clear instructional objectives are available.  Thus, instructional objectives are vital tools to both educators and students.

REFERENCES

1. Required and Elective Educational Outcomes, Goals, and Objectives for PGY1 Pharmacy Residency Programs. American Society of Health-System Pharmacists. 2008.  Available at: http://www.ashp.org/s_ashp/docs/files/

RTP_PGY1GoalsObjectives.doc. Accessed November 15, 2010.  

2.  Vontver LA. A Use of Instructional Objectives To Increase Learning Efficiency. Journal of Medical Education. 1974;49:453-454. 

3.  Norman HG. Schmidt GR. Effectiveness of Problem-Based Learning Curricula: Theory, Practice, and Paper Darts. Medical Education. 2000; 34(9):721-728.

4.  Accreditation Council for Pharmacy Education: Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Available at: http://www.acpeaccredit.org/pdf/ACPE_ Revised_ PharmD_ Standards_ Adopted_Jan152006.pdf. Accessed November 15, 2010.

5.  Bingham AL, Hess MM. Self Assessment as a Tool to Evaluate the Value of Instructional Objectives. ACCP Annual Meeting. Anaheim, CA. October 18, 2009.

Pay Attention to the External Realities

by Kathleen Fuller, Pharm.D., PGY2 Pharmacotherapy Resident, University of Maryland

With the recent midterm elections, public education reform has again been the center of much media buzz. The documentary Waiting for Superman¹, directed by Academy Award-winning director Davis Guggenheim, identifies some of the major problems with the current American public education system, while also offering a glimpse of possible solutions. The film highlights the success of public charter school programs including the Harlem Children Zone (HCZ)² and the Knowledge is Power Program (KIPP)³. These programs are built on the concept that education must extend beyond the school day to correct for the external factors that influence how learning occurs in the classroom. While these programs have been developed for primary education, they offer lessons that are applicable to both adult and patient education.

The Knowledge is Power Program

"Every day KIPP students across the nation
 are proving that demographics do not define destiny."³

Started as single school in 1994 by Mike Feinberg and Dave Levin, the KIPP network now consists of 99 schools in underprivileged areas of 20 cities nationwide enrolling 26,000 students. The program is based on five pillars: high expectations, choice and commitment, more time, power to lead and focus on results. The programs are rigorous and both the school days and the academic years are extended. Curriculum is built around character, leadership and community involvement, as well as traditional subjects. But what may be most important, high expectations are placed on children who may otherwise not be expected to graduate high school or attend college.³

Over 85% of KIPP students enroll in college, compared to less than 40% of low-income students nationally. And 100% of KIPP 8^th grade classes do better on state tests for math and language arts than their district averages.³

The Harlem Children’s Zone

"A child is more than just the test scores they get inside a classroom.
They live in families and communities. And where those families
and communities are struggling we have a responsibility
to help those children."² – Geoffrey Canada

Recognizing that the unique struggles the children of Harlem, NY faced were contributing factors to the poor performance of the schools in that district, Geoffrey Canada founded the HCZ in 1997. The HCZ targets a 100 block area and serves over 10,000 children. Using a community based approach the program aims to "give poor children the things middle-class children take for granted".⁴ This includes programs that educate expectant and new mothers, pre-K programs, after school programs, fitness and nutrition education, internship placement, college preparatory programs with one-on-one counseling sessions, and public health initiatives.²

One of the public health initiatives provided free asthma screening in the HCZ and then deployed case managers to visit the homes of children identified as having asthma to educate on medical assistance programs and environmental trigger control. Counselors went as far as to assist tenants in contacting the building managers of apartment buildings to demand necessary repairs and rodent extermination.⁵ Far-reaching, all-encompassing interventions, such as this, characterize the work of the HCZ and impact every aspect of life for the children enrolled in this program.

An independent study compared winners of the HCZ enrollment lottery to those that entered the lottery but did not win. They concluded that "the effects in middle school are enough to reverse the black-white achievement gap in mathematics."⁶

Application to Adult and Health Education

While adult learners may not be as impressionable as the students targeted by the HCZ and KIPP programs, external factors certainly impact their educational performance.  The theories applied in these programs can be extended to adult education.

How many of the students in your program are the primary caregiver for children or parents? How many have jobs outside of your program? How many do not have the technological literacy or access to the technology necessary for your program? Ask adult learners to reflect on their experiences to identify perceived barriers to achievement.

Develop a technology primer course. Distribute literature regarding child or elder care services in your area. Create flexible deadlines that can accommodate rigorous work schedules. And finally the strategies need to be implemented and assessed.

The principles are even more important when educating patients. Patients present from tremendously varied backgrounds and living situations. It may be easy to tell your patient with heart failure to avoid prepackaged foods with high salt content. But it is harder to walk down the aisles at the discount grocery store and find such foods in the same price range. As the HCZ asthma program illustrates, educating patients to recognize environmental triggers is different than walking through their homes and coaching them on strategies to realistically modify these triggers.

While you or I may not be in a position to implement the types of sweeping change we have seen from Geoffrey Canada, Mike Feinberg and Dave Levin, each of us can start small by analyzing the students and patients we teach to identify how their external lives affect our educational efforts.

1. Guggenheim D (director). Waiting for Superman [Movie]. Paramount Pictures; 2010.

2. Harlem Children’s Zone [Internet]. New York (NY): Harlem Children’s Zone. Updated 2009.

3. Knowledge is Power Program [Internet]. San Francisco (CA): KIPP Foundation.

4. Sayles M. Geoffrey Canada [Internet]. New York (NY): The New York Times; 2010 Oct 12.

5. Perez-Pena R. An Everyday Struggle for Breath; Childhood Asthma Project Reaches out in Harlem. New York (NY): The New York Times; 2003 May 1.

6. Whitehurst GJ, Croft M. The Harlem Children’s Zone, Promise Neighborhoods and the Broader, Bolder Approach to Education. Washington (DC): The Brookings Institution; 2010 Jul 20.