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.

Inspiring Students - My Path Towards Nuclear Pharmacy

by Amber Mae Todd, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

If someone had told me in my first year of school that I was going to choose nuclear pharmacy for my career, I would not have believed them. I would have never guessed that I would spend the next two summers learning how to elute technetium from a generator at 2 am, or discussing the properties of medronate while watching the sunrise. What could have happened that changed my perspective so much. I went from having no clue about where I wanted to go, to falling in love with any drug that sets off a Geiger counter. There had to be one very inspiring teacher in my life for this to transpire.

I have often wondered what qualities an inspiring teacher possesses. What does it take to inspire a student? One study by van der Zee and de Jung entitled “Teachers as a Source of Inspiration in Catholic Schools”, defines inspiration in the following way:

… inspiration may be regarded as mental causation of perlocutionary effects that, through the outstanding qualities of the source of inspiration, may motivate people, on the basis of suitable aptitudes, to have certain thoughts and desires and to perform certain actions.¹

In other words, inspiring teachers, using the special qualities that they possess, can change the actions and perceptions of their student(s). In my opinion, this is the definition of what it means to teach. A teacher should always leave a lasting impression on their students' perceptions. I believe the student should walk away from the experience changed in some positive and profound way. It was certainly the case for me; I was never the same after crossing paths with my teacher.

What qualities make a teacher inspiring? Certainly enthusiasm, patience, empathy, and the ability to explain a subject proficiently are important qualities.¹  van der Zee and Jung describe the teacher as a leader. They contend that a teacher must inspire their students in the same way a leader of an organization would inspire their followers.  Some of the leadership qualities that they point out include: vision, charisma, promoting intellectual stimulation (challenging a student), and being a role model. I do not believe a teacher must have all these attributes to inspire. However, having a few of these characteristics are probably necessary. In my case, my teacher was enthusiastic, patient, and proficient at explaining details. He challenged me and he was an excellent role model. His enthusiasm helped me to see the significance and life-changing nature of every radiopharmaceutical we made.

There are other factors that can affect the inspiration process. In Barbara Davis’ chapter entitled “Motivating Students” in the book Tools for Teaching, she points out several classroom strategies that can help motivate learning and inspire students.² These include: making students active participants in learning, hold high but realistic expectations of your students, help students set goals for themselves, and explaining to students what they need to do to succeed.  These methods can help boost student confidence and help students to begin working and thinking independently.

My teacher inspired me. His proficiency at explaining concepts was amazing; this included his patience in repeating points where I was confused. A teacher who can explain things clearly is easier to follow. This will provide a greater understanding that leads to confidence and the ability to complete tasks successfully. Challenging a student can help increase that student’s confidence, as well as teach them to “work outside the box.” Challenges can show them that they can apply their understanding to new and stressful situations.  Lastly, my teacher was a role model.  The purpose of a role model is “to trigger a thought, an assurance, a vision, a character and a way of life, which can serve as the impetus for a students' personal and professional growth.”³ My teacher did that.  He showed me night after night what a great nuclear pharmacist could look like. It’s an image I took to heart.

It is no small thing to change a student’s perceptions.  Often, an inspired student will remember the lessons the teacher bestowed on them for the rest of his/her life. It takes a unique set of attributes to inspire someone.  I was lucky to find a teacher who had so many of them. He inspired me to take the path to nuclear pharmacy. When we become teachers, we must try to inspire our students … and change the path they take in their lives.

Sources:

1. van der Zee T, de Jong A. Teachers as a source of inspiration in catholic schools. Journal of Empirical Theology 2009 06;22(1):7-29. 

2. Gross Davis Barbara. Tools for Teaching. Hoboken: Joey-Bass, An Imprint of Wiley. c1999. Motivating Students.

3. Meetu. Teachers as Role Models. [Internet] BrightHub. 2010 Apr 5. [cited 2010 Oct 29] Available from: http://www.brighthub.com/education/special/articles/17266.aspx

Application of the Socratic Method in Health Professionals Education

by Stacy Elder, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital

The Socratic Method is a widely used term for teaching via question and answer dialogue between a teacher and a student. However, the Socratic Method has undergone many changes since its first documentation by Plato, a student of Socrates.  Health professional instructors frequently employ various forms of this style of teaching in order to explore the critical thinking of their students and trainees. Analysis of the Socratic Method in the healthcare setting is a prime example of the evolution and contemporary utility of this mode of teaching.

The classic Socratic Method involves dismantling prior ideas in order to free the mind to think about a topic without the constraints of preconceived notions. By definition, this method deconstructs all prior thoughts on a topic and leaves the learner without a satisfactory answer to the primary question. Socrates taught that the only person who cannot learn, is the person who thinks he already knows the answer, so it is logical to remove prior beliefs in order to make way for the creation of new ideas. An example of the classic Socratic Method is observed in Meno, where Socrates asks Meno to define virtue. They discovered that they could not define virtue and, furthermore, virtue could not be taught. Meno learned that even this common term, when broken down to its fundamental parts, was actually not definable. As you might imagine, it was an Earth-shattering revelation for Meno to realize that it was impossible to trust even the most basic beliefs. The abolishment of prior beliefs on a subject is the deconstructive phase of the Socratic Method.

Once the student’s mind is freed from the constraints of prior beliefs, the teacher is free to bring forth new ideas during the constructive phase.  Notably, the teacher’s role in this scenario is to help the student clear away previous ideas in the deconstructive phase so that he may build new ideas in the constructive phase. Socrates stressed the importance of humility on the part of the teacher, due to the need to create a safe environment for the student to have these revelations. He believed that the teacher served to help the student do his own learning and asking questions was his method to facilitate that goal.

The classic definition of the Socratic Method is not always practical for teaching health professionals.  After the abolishment of the definition of virtue during Meno’s lesson with Socrates, Meno suggested a paradox that no one could ever question anything if definitions are impossible. Science, in general, does not accept the impossibility of defined answers, making the classic Socratic Method incompatible with the field of science. Also, healthcare does not generally involve discussion of abstract ideas. Established definitions of terms used to describe conditions and disease states are a critical part of healthcare learning. Standard, well-accepted “truths” in medicine make it possible to advance patient care by using the outcomes from research in a specific subset of patients in order to apply the highest level of decision making to patient care. However, the Socratic Method is still utilized in healthcare teaching, in a modified form.

The modern Socratic Method differs from the classic method by establishing that knowledge is recollection. Another of Socrates’ theories was that a student can only learn that which he already knows. Therefore, the teacher’s role is to facilitate the production of a constant progression of defined knowledge from the students pre-existing stores. In general, the teacher asks direct questions that have a predefined range of answers, allowing the student to answer correctly before moving on to the next step in the construction of an idea. If the student is unable to answer the question at hand, the teacher is responsible for guiding the student to a point where he/she can conquer the question.  This is accomplished by helping in the student/trainee recollection prior knowledge required to answer the question.  The modern Socratic Method is compatible with the training of health professionals, and it remains within the scope of Socrates’ belief that a student can only learn things that he already knows.

Using the Socratic Method is more than asking a lot of questions. In contrast to “pimping,” the Socratic Method requires the teacher to create a nurturing environment and ask helpful questions to achieve the desired lessons for the student.  Teachers must recognize that these probing questions can expose ignorance … and this can invoke fear in the student.  But Socrates described the role of the teacher as similar to a midwife, in that they facilitate by clearing the way for the student to bring forth new knowledge without intimidation. In any setting, finding the balance between using progressive questions to provoke deep thought while maintaining a comfortable environment for learning is the key to using the Socratic Method of teaching.

References

1    Maxwell, M. Introduction to the Socratic Method and its Effect on Critical Thinking. [Accessed on 9/30/10].

2    Fritts, HW. Are We Socratic Teachers? Trans Am Clin Climatol Assoc 1979;90:109–115.

3    Gordon, LA. Is the Socratic Method Illegal? Am Surg 2003;69:181-182.

4    Oh, RC. The Socratic Method in Medicine-The Labor of Delivering Medical Truths. Fam Med 2005;37:537-539.

I Finally Earned My Doctorate!!! Wait…Can I Find a Job?

by Mina Kim, Pharm.D., PGY2 Pain and Palliative Care Resident, University of Maryland School of Pharmacy

By Jeff Parker
Available from floridatoday.com

This cartoon depicts an unfortunate reality over the past 2 years.  Due to the economic recession, many graduates have found themselves without jobs or having to take positions outside of their career choices.  Many people who were employed found themselves jobless with no promising options for re-employment.  The once abundant pharmacist employment market diminished as well due to a number of factors:  1) the recession, 2) increasing number of pharmacy graduates, and 3) delayed retirements.  Just a few years ago, every pharmacy student walked across their graduation stage with a diploma in one hand and a few employment offers in the other.  Now, finding employment after graduation has become a daunting challenge due to the tight market in all fields, including pharmacy practice.

A solution that many adults have turned to during times of economic recession has been more education. With the increased competitiveness for jobs, the need for additional education to boost one’s resume and career has become a necessary measure.  An article about continuing education (post-secondary education) in the New York Times, stated that most college graduates will experience five to seven job changes during their career and thus need more education to remain competitive.   Continuing education institutions also follow the job market to create programs in fields that are growing and will have job opportunities.  Some career counselors no longer encourage adults to simply follow their passion but to take into consideration practical values such as the availability and salary of jobs when making career decisions.

When looking at the profession of pharmacy, the economy has prompted many changes.  Numerous graduating students now choose to take one or two years to complete a residency and boost their Curriculum Vitae (C.V.).  The hope is that with additional training and experience will make them more qualified/marketable and be able to obtain the position they desire.  Of note, in 2006, ACCP stated that by year 2020, a residency should be mandatory for pharmacists involved in direct patient care.  Direct patient care was defined as pharmacist’s observation of the patient and contributions to the selection, modification and monitoring of patient-specific drug therapy.  Whether or not this is feasible or necessary is a separate issue; but there is no doubt of the increasing demand for residency training – both among employers and graduating students.  As the job market remains competitive, having a residency for many clinical positions is becoming a minimum requirement.  Paradoxically, while the poor economic conditions incentivize more students and pharmacists to pursue residency training, institutions have a limited ability to increase the number of residency positions due to financial constraints.

Pharmacists who already have a position in clinical practice feel additional pressure to obtain board certification through the Board of Pharmacy Specialties.  In a recently published article by Connor et. al in the American Journal of Health System Pharmacists, the benefits of board certification include “increased therapeutics knowledge, enhanced professional and clinical opportunities…greater marketability and monetary compensation.”  Although it has not been common for pharmacists to lose their jobs in this recession, as they look towards promotions, new career opportunities, and even tenure, experience is no longer sufficient.  To supplement their C.V.s, board certification is one avenue for pharmacists to demonstrate that they have attained (and are maintaining their) advanced knowledge.

Compensation (monetary and other rewards) has always played a role in influencing career choices and goals.  The economic recession has had a key role in the encouraging continuing education.  A struggling economy serves as a stimulus for people to pursue further education to remain competitive in their profession and pharmacy is no exception.  A Pharm.D.alone is no longer enough for pharmacists to secure a satisfying position or get promoted.

I fear (and this fear is possibly shared by other residents) that all the effort, energy and time exerted into my education and training (8+ years of post-secondary education and training!) will still not be enough for me to secure my “dream job.”  But I can only keep my fingers crossed – and demonstrate that I’m qualified, ready, willing, and able to make substantial contributions.

References:

Greenhouse S.  Learning Curves on the Career Path.  The New York Times [Internet]. 2010 Aug 25  Education.  [cited 2010 Oct 17]

Connor KA, Hamilton LA.  Pursuing Board of Pharmacy Specialties Certification.  Am J Health Syst Pharm 2010;67:1146-1151.

Bright DR, Adams AJ, Black CD, Powers MF.  The Mandatory Residency Dilemma: Parallels to Historical Transitions in Pharmacy Education.  Ann Pharmacother 2010;44.  Epub  2010 Oct 5.

[Editor's Commentary:  Dr. Kim's essay expresses the fears of many graduates today - not only in pharmacy but nursing, medicine, and other health professional fields too.  While a significant shortage of health professionals remains and will continue to grow as our population ages, the short term impact of the worse economic downturn in over 75 years has had ripple effects that has impacted even the most stable areas of employment.  According to some experts the current pharmacy job market has grown tight due to two competing factors:  1) increased number of graduates (which we need to meet future demand!) and 2) a very significant delay in retirements.  In other words, people who normally would have left the workforce aren't (and this is a moral dilemma the profession must address if the over-abundance of highly qualified practitioners continues for very long).  Of course the employment prospects for Dr. Kim and her well-trained brothers and sisters is far brighter than most ... but still, its all a bit unsettling when compared to the prospects just two or three short years ago.  There is little question that medication use is more problematic (and costly) than ever and the need for caring and well-qualified professionals, like Dr. Kim, is greater than ever. However, Dr. Kim's essay points to an important adult learning principle.  Adults are motivated to learn by relevancy and applicability.  The economic downturn has made training and credentials (like residencies and board certification) more relevant and applicable!  The motivations to learn often vary at different stages of life.  In the early stages of one's career, acquiring the "right" credentials for the "dream job" is often most important.  In mid-career, the desire to expand one's skill set beyond the core professional domains is often motivated by changes in responsibility.  In the later stages of one's career, cultivating deeply personal qualities (e.g. mentoring skills, religious faith) or engaging in new pursuits (e.g. playing the fiddle, photography) begin to emerge as motivations to learn and change.  So while a recession and the poor job market may seem like it has little to do with educational theory and practice, the motivation to learn is driven by many factors.  Needless to say, the prospects of unemployment and a mountain of debt is a strong motivator!  -S.H.]