Mastering the Fundamentals of Precepting

by Sahil Sheth, Pharm.D., PGY-1 Pharmacy Practice Resident, Suburban Hospital

Residency training is a unique experience in the life of pharmacists. They are expected to demonstrate and develop clinical knowledge, organizational skills, and interpersonal communication while practicing pharmacy for the first time.¹ Therefore, effective teaching in this setting is essential. It requires flexibility, time commitment, and devotion to the resident. Preceptors need to address the resident’s desires as well as have flexible teaching methods and approaches.² This can be difficult because many preceptors are new to their roles and are developing their teaching skills. In one recent study, thirty percent of pharmacists indicated that they have been a preceptor for less than two years and over fifty percent had been a preceptor for less than five years.³ Using appropriate preparation techniques, effective teaching methods, and honest feedback strategies can help alleviate potential problems between preceptors and their trainees. Moreover, implementing these fundamentals can help the resident succeed.

Preparation and planning are key components of a successful practice-based teaching and learning experience. At the beginning of the clinical experience, preceptors should meet with the resident to discuss the resident's learning style, learning goals, and career aspirations so that the experience can be tailored to meet the resident’s needs. For example, a critical care preceptor can tailor major presentations such as journal clubs and patient cases in infectious diseases for a resident who is interested in applying to a PGY-2 Infectious Diseases residency. In addition to tailoring the rotation to residents’ interests, preceptors should outline day-to-day activities as well as longitudinal projects that the resident is expected to complete by the end of the experience. For instance, the preceptor can create a flow sheet outlining pre-rounding, discharge counseling, and follow-up tasks that needed to be completed each day. As a result, there is no miscommunication regarding the daily requirements and expectations.

Preceptors should teach critical thinking skills so that the resident becomes a detective able to gather relevant evidence, reflect on the information gathered, and manage patient interactions and follow-up.⁴  This can be done using different teaching styles. The two general preceptor approaches are the “sink or swim” method and the “manipulated structure” method.⁴ In the “sink or swim” method, the resident is assigned a panel of patients and is expected to manage those patients independently with no visible support from the preceptor.⁴ This includes pre-rounding on patients, attending interprofessional care rounds, performing medication reconciliations, and following up with interventions. There is minimal support from the preceptor besides providing “back up.” The “manipulated structure” approach involves selection of patients accompanied by preceptor consultations before and after interprofessional patient care rounds.⁴ Using this teaching strategy, the preceptor’s determines what the appropriate patient volume and complexity is based on the resident’s current level of skill and future developmental needs. There are several important factors that influence the selection of teaching approaches, but the most important factor is the resident’s prior experience. New residents (in July and August) will likely flounder if the “sink or swim” method is used, whereas residents in the final half of the residency year will likely thrive and appreciate the independence. It is important to select an approach that best fits the resident’s current skills and to conservatively advance the level of independence.

In addition to effective preparation and use of appropriate teaching methods, providing constructive feedback is essential to the resident-preceptor relationship. It is important for preceptors to provide ongoing feedback to residents – not just during the midpoint and final evaluation.¹ Moreover, feedback should always be done in a manner that helps the resident to perform better in the future.¹ Detailed and specific examples can help residents understand their strengths and weaknesses. For example, saying “You were lackluster today” is not sufficient. Instead, a more complete explanation like “Your medication reconciliation was incomplete for 5 out of the 10 patients that you followed today.  Be sure to ask about over the counter medication use in the future” is constructive. Preceptors can also conclude feedback sessions by asking the resident to reflect on the lessons learned.  This can help residents refocus and renew their efforts to perform better in the future.⁴

It is imperative for preceptors to prepare for the arrival of residents (and students), to use effective teaching methods, and to provide honest but constructive feedback. Developing a framework with these fundamental principles in mind will make the teaching and learning experience better for everyone. The roles and responsibilities of preceptors may differ, but the basic skills and teaching approaches are the same.

References

1. Anderegg SV, Christenson JC, Padgett CP. An accelerated, practice-based model for fostering precepting skills in pharmacy residents. Hosp Pharm. 2014;49(8):713-6.
2. Vaughn L, Baker R. Teaching in the medical setting: balancing teaching styles, learning styles and teaching methods. Med Teach. 2001;23(6):610-612.
3. Hartzler ML, Ballentine JE, Kauflin MJ. Results of a survey to assess residency preceptor development methods and precepting challenges. Am J Health Syst Pharm. 2015;72(15):1305-14.
4. Burns C, Beauchesne M, Ryan-krause P, Sawin K. Mastering the preceptor role: challenges of clinical teaching. J Pediatr Health Care. 2006;20(3):172-83.

Teaching From Your Strengths

by Jane Kim, Pharm.D., PGY1 Pharmacy Practice Resident, Kaiser-Permanente Mid-Atlantic

 “What are your strengths and weaknesses?” is a common interview question. Employers ask this question not to identify what the candidate brings to the table, but rather to see if the candidate has an awareness of his or her own unique strengths and weaknesses. When given the opportunity to focus on one’s strengths, individuals are six times more likely to be engaged in their jobs and three times more likely to have an excellent quality of life.¹ As an educator, leveraging your strengths to enhance student performance will not only benefit you in becoming a more effective teacher, but will advance your students’ skills and knowledge as well.

You cannot be anything you want to be –

but you can be a lot more of who you already are.

– Tom Rath, StrengthsFinder 2.0

A powerful tool that identifies an individual’s potential for building strengths is the Gallup Organization’s Clifton StrengthsFinder questionnaire. Created by educational psychologist Don Clifton and Gallup, StrengthFinder characterizes 34 strengths that describe what people do well (Theme Quick Reference Card). By completing an assessment consisting of 177 questions, your top five strengths and the areas with the greatest potential to develop are identified. The strengths philosophy states that individuals will benefit more by building on their talents rather than spending the same amount of time correcting their weaknesses.²

What is a strength? A strength is the ability to provide consistent, near-perfect performance in a given activity. By investing skills and knowledge in a “natural” talent, it becomes a strength.¹ By having an awareness of your strengths, you can apply them to develop your teaching philosophy and style, and subsequently build aspects of the instructional design process such as preparation, instructional methods, presentations, and evaluations around your strengths. Strengths-based education involves intentionally discovering one’s own strengths as well as students’ strengths and applying them systematically to teach effectively.³ For example, one of my top five strengths is “Context,” meaning I like to create a framework and to put facts into perspective. An enjoyable lesson for me would involve breaking down a patient case and presenting the key points in the context of the case. Not only would it be enjoyable, it would be easier for me to teach with real-life illustrations rather than lecturing about a disease state with no relevant examples. Applying your unique strengths will allow you to create an environment for learning that taps into all of your greatest potential. In addition to using your strengths in the teaching process, actively modeling your strengths is a lesson in itself.³ Albert Bandura’s social learning theory states that complex behaviors can be produced only through the influence of models.⁴ Another strength of mine is “Analytical” — meaning I am methodical and rational in the way I think through things. If I can teach using my analytical strengths, students will be more likely to appreciate the importance of facts, data, and details in assessing a problem.

We teach who we are.

– Parker Palmer, The Courage to Teach

Similar to having an awareness of your own strengths will help you in your journey as an educator, helping students to discover their own strengths will facilitate their journey as learners. Engagement is a principle highly sought after by employers and educators. William Kahn defines personal engagement as “harnessing of organization members' selves to their work roles; in engagement, people employ and express themselves physically, cognitively, and emotionally during role performances.”⁵ Engagement can be assessed using well-validated Gallup Workplace Audit, of which one of the 12 items asks if employees have an opportunity to highlight their strengths.  In a meta-analysis of 198,514 employees in 36 companies, engagement combined with overall job satisfaction leads to positive business-unit performance outcomes such as profitability and productivity.⁶ If utilizing one’s strengths makes an employee more engaged, it can certainly do the same to promote student engagement. Through positive and specific feedback, creating an awareness of their strengths will give students a sense of confidence and self-efficacy.

Creating meaningful activities that allow for development of one’s strengths is a hallmark of strengths-based education. A study involving 1,250 students from five schools of pharmacy that used StrengthFinders 2.0 found that the top five themes among 99.5% of the students were one of the following: Achiever, Harmony, Learner, Responsibility, and Empathy.⁷ These results provide valuable insight in guiding educational activities for pharmacy students. To leverage this knowledge, pharmacy education should reinforce these strengths to develop exceptional pharmacists who are both empathetic and responsible to their patients. The University of Minnesota College of Pharmacy developed a strengths-based instructional program to enhance awareness of strengths, foster strengths-based decision making, and increase application of strengths by students. After completing the Clifton StrengthsFinder, students completed workshops, reflections, and participated in discussions related to strengths. During advanced practice professional experiences, pharmacists provided feedback on strengths activities for students. When asked if discussing strengths with the student helps to support the student's ability to identify a role in pharmacy aligned with his or her talents, 86% of pharmacists responded positively. When asked if strengths discussions helped to support the student's leadership development, 95% of pharmacists responded positively.⁸ If educators endeavor to identify students who do not possess certain qualities, pairing students with complementing strengths can be valuable strategy.

One’s strength is a combination of one’s talents, knowledge, experience, and skills. This strength should be cultivated and given much more attention than one’s shortcomings. Recognizing these strengths, applying them, and then reflecting on them will make for better educators and engaged learners.

Five Principles for Strengths-Based Education³

1. Measure strengths. Use an assessment to determine unique strengths to provide learners and educators an awareness of their skillsets.
2. Individualize the learning experience to each student. Help students apply their strengths to individual goals as part of the developmental process and provide feedback that emphasizes strengths. When possible, tailor teaching methods to meet student needs and interests.
3. Network with personal supporters of strength development.  Establish connections with friends, family members, and professionals who encourage excellence.  
4. Deliberately apply strengths in and out of the classroom. Create opportunities for students to showcase their strengths and guide students to utilize strengths independently.
5. Develop strengths through novel experiences or focused practices. Invest time and effort in new experiences to elevate skills and knowledge of existing strengths.

References

1. Rath T. StrengthsFinders 2.0. New York, NY: Gallup Press; 2007.
2. Asplund J, Lopez SJ, Hodges T, et. Al. The Clifton StrengthsFinder 2.0 Technical Report: Development and Validation. The Gallup Organization 2007. Available from: Accessed January 31, 2016.
3. Lopez SJ and Louis MC. The Principles of Strengths-Based Education. J Coll Char. 2009;10(4):1-8.
4. Bandura A. Social Learning Theory. New York, NY: General Learning Corporation; 1971.
5. Kahn WA. Psychological conditions of personal engagement and disengagement at work. Acad Manage J. 1990;33(4):692-724.
6. Harter JK, Schmidt FL, and Hayes TL. Business-unit-level relationship between employee satisfaction, employee engagement, and business outcomes: a meta-analysis. J Appl Psychol. 2002;87(2)268-279.
7. Janke KK, Farris KB, Kelley KA, et al. StrengthsFinder signature themes of talent in doctor of pharmacy students in five midwestern pharmacy schools. Am J Pharm Educ. 2015;79(4): Article 49.
8. Janke KK, Traynor AP, and Sorensen TD. Refinement of strengths instruction in a pharmacy curriculum over eight years. Am J Pharm Educ. 2011; 75(3):Article 45.

How to Quietly Engage Introverts in the Classroom

by Nicole Hollinger, Pharm.D., PGY1 Pharmacy Practice Resident, University of Maryland Medical System

I recently graduated from professional school and stepped out of the classroom as a student - hopefully for good. As a learner, I always quietly engaged in classroom activities, rarely raising my hand, terrified of being called on and speaking through a racing heart whenever forced to do so. I participated in classroom discussions by listening, processing, answering, debating – but only in my own head. When I reached high school, I began to overcome my fear of speaking and began to verbalize the thoughts in my head out loud – but only when I was 1000% sure of the answer. When I ventured off to college, I regressed into my old habits. I could probably count on one hand the number of times I raised my hand in college, let alone the number of times I actually spoke out loud, in those daunting lecture halls. Moreover, I only raised my hand because participation points required me to do so. I envied the students who had the courage to speak up and concluded that my classroom personality was inadequate. Not because I wasn’t engaged in the classroom activities; but because I was unable to present my thoughts orally to the class. On the other hand, I tended to thrive in small group discussions where there weren’t 100 pairs of eyes focused on me all at once. I always attributed my classroom behavior to my self-proclaimed introverted personality. I always wished that I could participate in more overt ways and engage in classroom discussions, until now.

Not surprisingly, surveys show that the majority of educators believe that ideal learners are extroverts.¹ Now that I am experiencing classrooms for the first time as the instructor, I am invested in assuring all personalities types benefit from the experience. There is no “right” way to participate in classroom activities.  Rather, participation can occur in ways that allow all learners to perform to their best and, perhaps more importantly, in a way that is most comfortable for the learner. I believe that instructors have the responsibility to accommodate all types of learners by incorporating a variety of tactics that allow expression and participation, and here I will provide some tips for feasible application of this concept.

 

The purpose of this essay is not to deter instructors from encouraging oral discussions nor is it to cater to introverts so that they are not challenged in the classroom; it is simply to allow multiple forms of expression so as to accommodate the range of personalities in every classroom. Before we dive into ways to accomplish this goal, we must understand a few things. First, what are the fundamental differences between introverts and extroverts? Of course there are varying degrees of introversion and extroversion, but for simplicity sake the basic difference lies in the place from which they attain their energy. For the introvert, energy comes from reflection and thought. For the extrovert, it stems from social interaction. Second, what does it mean to engage a student? For extroverts, engaging means verbalizing their thoughts through speech, whereas for introverts it tends to be non-oral forms of expression. Introverts appreciate self-reflection and independent time to work. Personally, I savored the “work on your own time” activities because I had more time to process the information or questions posed.  Which brings me to some quick tips to engage the quiet learners in the room.

To begin, patience is critical when hoping to engage an introvert. Give them time to develop their thoughts internally prior to asking them to express it, whether it be an oral discussion or a written assignment. For oral discussions, this can be done simply by waiting at least 10 to 15 seconds before calling on someone in the class.² The extrovert hand will go up immediately, the introvert needs time to process what was asked, and additional time to work up the courage to raise their hand.

Second, Emily Klein and Meg Riordan share an idea of rethinking the participation grade in their essay Participation Penalizes the Quiet Learners.³ They believe that the instructor should promote evidence of learning as a means of participation. Participation points should not be awarded to any learner who chooses to express themselves, but rather only to those who bring meaningful ideas or questions to the discussion. Reward quality, not quantity.

Finally, utilize strategies that allow the learner preparation time before sharing. Think-pair-share is an excellent technique that creates a safer environment for the introvert. This gives them the time to first think through the topic then rehearse what they want to say before speaking up in front of the whole class.² Another option is to use an online discussion board or social media. Posting reflections challenges the introverted learner to share ideas in a virtual group setting, but they have more time to formulate their thoughts and work through their fear prior to participating. Any time you allow time for reflection, preparation, and rehearsal, you exponentially increase the likelihood of engaging the introvert, as these are the learning strategies they value most.

As I’ve learned from my experiences, teaching is complex, challenging, and ever evolving. Optimally engaging every learner in the classroom is a significant undertaking, but I would argue not unattainable. However, if we continue to employ unimaginative, “old-school” teaching methods that consider the extrovert the ideal student, we are doing a disservice to introverted learners. Activities in the classroom should challenge all types of learners. Promoting deep thought or self-reflection engages the introvert while at the same time challenging the extroverts. The classroom should be designed to encourage all learners, not expect the learner to conform to a rigid structure.

References:

1. Meisgeier C, et al. Implication and Applications of Psychological Type to Educational Reform and Renewal. Proceedings of the First Biennial International Conference on Education of the Center for Applications of Psychological Type, Gainesville, Florida. 1994.
2. Cain S, Klein E. Engaging the Quiet Kids. Independent School Magazine [Internet]. Fall 2015.
3. Klein EJ, Riordan M. Participation Penalizes the Quiet Learners: Making the Case for Standards Based Grading. Quiet Revolution [Internet].
4. Cain S. The power of introverts [video]. Long Beach (CA): TED Talk; 2012.

Addressing Lapses in Professionalism

by Beth Flippin, Pharm.D., PGY1-Pharmacy Practice Resident, VA Maryland Health Care System

Professionalism in the health professions has been defined as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”.¹ Professionalism serves as the basis of a contract between patients and healthcare providers. Teaching professionalism has become a core concept in health professional education, both in the didactic and experiential setting. However, with advances in medical technology and increased utilization of social media, it can be difficult to ensure that learners are maintaining expected standards of professionalism.

Common Professional Lapses2

· Lack of initiative to assume responsibility / role · Misrepresentation or falsification of actions / information · Failure to take responsibility for actions · Abuse of privileges · Inadequate rapport with patients · Insensitivity · Disrespectful language · Inappropriate interactions with groups · Lack of professional appearance

So how should lapses in professionalism be addressed and corrected? One study published in the Academic Medicine Journal found that the most effective methods were to address lapses in a timely manner and to provide constructive feedback rather than punish the learner.³ Several tips for approaching learners who have a lapse in professionalism have been published.⁴  

Modeling professional behavior is one of the key remediation strategies.² Learners mimic their preceptors, regardless of whether the behavior is appropriate or not. Modeling involves all aspects of behavior in the practice setting, from one-on-one interactions with other professionals, patients, and caregivers; interprofessional team interactions, such as rounds or peer discussions; maintaining privacy; appropriate documentation, and adherence to timelines. Everyone must be mindful of the presence of learners in the experiential learning settings, because learners are observing the actions and demeanor all practitioners in order to help develop their own professional identity. Modeling appropriate professional behavior by all members of the interprofessional team serves as a link between didactic teachings and practical experience.⁴

The next tip is to acknowledge the hidden curriculum.  Instructional regarding professionalism in preclinical years is sometimes contradicted by unprofessional behaviors observed in the clinical settings.⁵ These observations are not just of the learners’ direct preceptor, but medical attending physicians, residents, social workers, pharmacists, nurses and any other personnel involved in patient care. It is important to acknowledge that learner’s may, at times, receive conflicting messages regarding professionalism from their observations.  Having conversations with the learner about lapses in professionalism committed by more senior practitioners can be a simple way to address inappropriate professional behavior so that the learner isn’t left with the impression that such behaviors are acceptable.

It is also important to be familiar with the institution policies and procedures for addressing lapses in professionalism.⁴ The institution or department policy should have clear procedures for how information regarding lapses should be documented, who should receive the information, and what the potential consequences are. This is beneficial for both the learner and the preceptor, as the expectations and consequences are clearly outlined at the beginning of the learning experience.

The next set of tip involves data gathering and fact checking. It is very important to ensure you have objective evidence to support the perceived lapses in professionalism.⁴  Because learners often model their behaviors based on observations, it is important to gather information from multiple sources that have had interactions with the learner and can provide first person testimony, documentation, or evidence of the learner’s behavior. This can also help to identify potential reasons behind the lapse, as well as ways to address the lapse in the future.

It’s important to have an experienced educator or mentor available for advice when needed. This person should have experience with learners in different types of situations. It’s important to clearly articulate your questions to your peer, as well as state how the learner expectations where outlined. The trusted advisor can provide perspective and help develop the plan for providing feedback to the learner.⁴

Next the preceptor should be ready to have a conversation with the learner regarding their professional behaviors. During the encounter, remember to be a good listener. Learners should have the opportunity to voice their perceptions of the situation. At times, perceived lapses may be a result of lack of understanding or misinterpretation of their role.  Be sure conduct the conversation in an environment where the learner feels safe, somewhere private and discrete so that the learner does not feel that they are being publicly reprimanded. Be care in your word choices. Use a non-accusatory approach. You don’t want the learner to feel attacked or become defensive about their actions. The preceptor should present to the learner the objective evidence gathered, then allow time for the learner to reflect. The preceptor should provide direct and explicit feedback to the learner. The learner should leave the encounter with a clear understanding of why the behavior is considered a lapse and how to improve in the future.⁴

Finally, the preceptor should close the loop.⁴ Preceptors should help the learner make a behavior change by ensuring the learner develops his/her decision-making skills. The preceptor can present hypothetical situations and have the learner voice the steps necessary to make a decision.  This is a helpful way to develop these problem-solving and ethical reasoning skills. Helping learners to recognize the impact that their behaviors may have on patient outcomes can also be motivational.⁴ Learners should be encouraged to continuously think about professional values and ways to develop their skills.

Know when to call for back-up. There are always going to be situations or learners who are difficult or when unexpected issues emerge. It’s important for the preceptor to know his/her limitations.

Addressing lapses in professional behaviors can daunting. The right tools can help preceptors feel more confident in addressing these lapses. Preceptors should have a plan to effectively address professional lapses in a timely fashion. Professionalism is vital to building a trusting patient-provider relationship, so it is important that future practitioners are aware of the importance of professionalism and how lapses can negatively impact relationships with patients and colleagues.

References:

1. Gibbs, T.  The changing face of professionalism: Reflections in a cracked mirror. Medical Teacher. 2015; 37:9, 797-798
2. Ainsworth, M. Medical Student Professionalism: Are we measuring the right behaviors? A comparison of professional lapses by students and physicians. Academic Medicine. 2006; 81(10); S83-S86
3. Ziring, D. How do medical schools identify and remediate professionalism lapses in medical students? A study of U.S. and Canadian medical schools. Academic Medicine. 2015; 90:(7) 914-920
4. Rougas. S et. Al. Twelve tips for addressing medical student and resident physician lapses in professionalism. Medical Teacher, 2015; 37:10, 901-907
5. Goldstein, E. Professionalism in medical education: an institutional challenge. Academic Medicine, 2006:81(10); 871-876