Teaching Residents to Conduct Residency Research Projects … and Get Published

by Samuel O. Adeosun, PhD, PGY1 Pharmacy Practice Resident, St. Dominics Hospital

One of the requirements for successful completion of pharmacy residency is the completion of a data-driven project. This is a requirement under the American Society for Health-System Pharmacists (ASHP) accreditation standards for both PGY1 and PGY2 residencies. While most programs do not require that the project be submitted for publication in a peer-reviewed journal, they usually require that the project be written up in a standard manuscript format and submitted to the program director or committee.¹ However, publishing residency research projects has several advantages. Publishing promotes visibility, for both the resident and the residency program, in the field and may attract collaborators who have similar interests. A published project also promotes a sense of accomplishment. Furthermore, the experience makes the publishing process less intimidating. Moreover, publishing residency research broadens career opportunities (even beyond academia) and early career publication success has been associated with faster career advancement.^2,3 Very importantly, the dissemination of research findings is crucial as findings that are never published are of no value to the research community.  Even negative findings have value and should be disseminated. Unfortunately, despite the requirement and the many potential benefits, the publication rate for resident research projects since 1981 has been low and appears to be trending downward.⁴

There are many reasons why the publication rate is low including time limitations, knowledge gaps among residents and preceptors about conducting research, and lack of mentor support during or after the residency.^5,6 Time is often considered a major problem because a 12-month residency is perceived to be too short to conduct a meaningful research study.^6,7 However, perhaps the most important issue is that no time is specifically allocated for research or instruction about research in most programs. In one survey 80% of residency program directors (RPDs) agreed that research is important to make good patient care decisions but only 44% agreed there should be an equal emphasis on research as on clinical skills.⁵ Although some programs have a designated research month, research must be done longitudinally. Another important limitation is the lack of mentorship and support. Many preceptors are not well trained in research methods or are not motivated (or incentivized) to publish, especially in non-academic settings.^8,9 Thus, for a new pharmacy graduate, conducting a research project is a daunting task because they lack the experience and the support and there is limited time allocated to conducting it. 

A well-designed strategy to address the training needs of residents to conduct research, while also providing sufficient guidance and time, was developed and implemented at the University of Utah in partnership with Intermountain Health.¹⁰ This involved the formation of a resident research committee (RRC) that included two clinical pharmacy specialists, two pharmacy administrators, and one drug information pharmacist. The committee provided oversight and assistance to residents so that they could achieve research goals and complete their projects by the end of the residency year. Before the arrival of the residents in June, the group distributed research overview, guidelines, and deadlines to the incoming residents. Residents were also encouraged to start thinking about their research topic and were scheduled to complete their institutional review board (IRB) training before the residency program started. During the first week of orientation, the RRC gave presentations on formulating research ideas and helped residents refine their ideas based on several factors including data availability, novelty, and alignment with institution initiatives. By the end of August, residents presented their research proposals to the department and data collection commenced after IRB approval. Residents were required to present preliminary results from their projects at a national professional meeting in December. The findings and analyzed results were presented to mentors in April. Preceptors’ feedback were incorporated before residents presented their final project to the department and at the residency conference in May. Finally, a manuscript was submitted to the RRC and residents were encouraged to submit their projects for publication. 

It is worth noting that the core elements of this instructional design is learner support and distributed effort. This is not just a deadline-driven program as support and learner feedback provided at every step. The support included helping residents to navigate the health system in order to get the resources and data they need. Also, the RRC enlisted the help of a statistician during the project development and data analysis stages. This is quite important as most residents (and preceptors) feel statistical analysis is daunting and a major barrier.⁷  Surprisingly, although only 1.5% of RPDs believe their residents have sufficient knowledge regarding statistical analysis, little to no training is provided during pharmacy residency programs and statisticians are not usually enlisted.¹¹ 

The approach developed and implemented by the University of Utah and Intermountain Health proved to be very effective. Within the four years since the program started, all the residents completed their research projects within the allotted 12 months, far more resident research papers were submitted to peer-review journals, and the anticipated publication rate increased to 31%. 

A similar approach adopted by Kaiser Permanente Colorado in partnership with the University of Colorado School of Pharmacy significantly improved residency research publication rates.  The residency research committee included personnel with specialized clinical research training (including PhDs).  The committee provided the residents with refined and ready-made research ideas and residents participated in an educational program with 18-hours of didactic instruction on research design. This approach increased the publication rate to 86.1% (previously 47%) and shortened the time to publication to 23 months (previously 30 months).¹⁵

Another important issue is the quality of the study design. A majority of RPDs and residents perceive this to be major barrier to publication.⁷ To address this problem, alternative approaches to research and scholarly activities have been suggested. These include conducting high-quality retrospective studies or writing comprehensive reviews that have much higher acceptance rates rather than performing time-consuming prospective studies that are unlikely to have generalizable results.¹² Such an approach led to much higher publication rates (72-82%) in some residency programs.^13,14 

Research is critically important to inform evidence-based practice and all pharmacy residents should receive training about how to conduct research. However, most residency training programs ignore best practices in instructional design and fail to teach residents how to conduct research.  Few programs provide instruction and ongoing support. Consequently, most residents never develop the interest and skills needed to conduct scholarly work and successfully publish their project results.⁸  Following an instructional design process based on clearly stated program goals and objectives, learner needs assessments, well-developed instructional materials, and ongoing learner feedback and support can significantly increase project completion and publication rates.

REFERENCES

1. Accreditation Standards for PGY1 Pharmacy Residencies - ASHP. https://www.ashp.org/Professional-Development/Residency-Information/Residency-Program-Directors/Residency-Accreditation/Accreditation-Standards-for-PGY1-Pharmacy-Residencies. Accessed February 8, 2020.

2. Vouri SM, Stranges PM, Burke JM, Micek S, Pitlick MK, Wenger P. The Importance of Research during Pharmacy Residency Training. Curr Pharm Teach Learn. 2015;7(6):892-898. doi:10.1016/j.cptl.2015.08.018.

3. Stranges PM, Vouri SM. Impact of resident research publication on early-career publication success. Am J Health Syst Pharm. 2016;73(12):895-900. doi:10.2146/ajhp150567.

4. McKelvey RP, Hatton RC, Kimberlin CA. Pharmacy resident project publication rates and study designs from 1981, 1991, and 2001. Am J Heal Pharm. 2010;67(10):830-836. doi:10.2146/ajhp090090.

5. Weathers T, Ercek K, Unni EJ. PGY1 resident research projects: Publication rates, project completion policies, perceived values, and barriers. Curr Pharm Teach Learn. 2019;11(6):547-556. doi:10.1016/J.CPTL.2019.02.017.

6. Bookstaver PB, Felder TM, Quidley AM, Ragucci K, Nappi J, Draper HM. Pharmacy residents’ barriers to scholarly pursuits. Curr Pharm Teach Learn. 2015;7(1):40-46. doi:10.1016/J.CPTL.2014.09.003.

7. Irwin AN, Olson KL, Joline BR, Witt DM, Patel RJ. Challenges to publishing pharmacy resident research projects from the perspectives of residency program directors and residents. Pharm Pract (Granada). 2013;11(3):166-172. http://www.ncbi.nlm.nih.gov/pubmed/24223082. Accessed August 31, 2019.

8. Ellis JJ, McCreadie SR, McGregory M, Streetman DS. Effect of pharmacy practice residency training on residents’ knowledge of and interest in clinical research. Am J Heal Pharm. 2007;64(19):2055-2063. doi:10.2146/ajhp070063.

9. Stranges PM, Vouri SM. Impact of co-investigators on pharmacy resident research publication. Pharm Pract (Granada). 2017;15(2):928. doi:10.18549/PharmPract.2017.02.928.

10. Dick TB, Moorman KL, MacDonald EA, Raines AA, Cox KDM. Defining and implementing a model for pharmacy resident research projects. Pharm Pract (Granada). 2015;13(3):562. doi:10.18549/PharmPract.2015.03.562.

11. Newsome C, Ryan K, Bakhireva L, Sarangarm P. Breadth of Statistical Training Among Pharmacy Residency Programs Across the United States. Hosp Pharm. 2018;53(2):101-106. doi:10.1177/0018578717746416.

12. Barletta JF. Conducting a successful residency research project. Am J Pharm Educ. 2008;72(4):92. doi:10.5688/aj720492.

13. Cabanas G, Bridgeman MB, Hermes-DeSantis ER. Publish or perish: Success with publication in pharmacy residency training. Curr Pharm Teach Learn. 2018;10(12):1647-1651. doi:10.1016/J.CPTL.2018.08.017.

14. Hasegawa GR. Publication of residency projects: Another perspective. Am J Heal Pharm. 2012;69(1):77-78. doi:10.2146/ajhp110525.

15. Olson KL, Irwin AN, Billups SJ, Delate T, Johnson SG, Kurz D, Witt DM. Impact of a clinical pharmacy research team on pharmacy resident research. Am J Heal Pharm. 2015;72(4):309-316. doi:10.2146/ajhp140214.

Choosing Wisely: Face-to-Face and Web-Based Instructional Methods for Continuing Education

by Megan Davis, Pharm.D., PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

Continuing education programs play an important role in a pharmacist’s development. Healthcare practitioners should be self-directed learners and continuing education (CE) provides them with a way to keep their knowledge and skills current. Moreover, CE is required by law to order to maintain professional licensure. CE programs are offered through a variety of methods. Two of the most common are face-to-face and web-based methods. Web-based instruction uses the Internet as the primary method of information delivery.¹ Many terms are used interchangeably to describe web-based learning. These include online learning, computer-assisted learning, and e-learning. For the purpose of this essay, web-based learning is defined as learning that does not take place in a live environment, that is, the instruction and learning are happening at different times (asynchronous delivery). Face-to-face learning, on the other hand, is live interaction that occurs in-person between a learner and a teacher — that is, the instruction and learning are occurring at the same time and in the same place. The problem with these methods, however, is that neither is very effective in terms of behavior change.²

The effectiveness of continuing education is typically assessed in terms of learner reactions and satisfaction, sometimes by testing for knowledge changes, but rarely are patient outcomes or changes in practice measured. For example, knowledge can be measured via pre-test and post-test scores. But a change in knowledge may not lead to practice change and improved patient outcomes. None-the-less, while there is some debate about how effective CE is, healthcare practitioners should understand the advantages and disadvantages of the face-to-face and web-based methods.²

Potential Advantages and Limitations of Face-to-Face Instruction

Face-to-face learners have the opportunity to perform and practice techniques while receiving feedback and guidance from the instructor. In today’s world, I realize the popularity of platforms such as YouTube, where the audience is able to learn how to do just about any task by watching tutorial videos. However, I argue that this web-based instruction is not as effective as learning how to perform the activity in-person with feedback from an instructor. Face-to-face instruction can provide the learner with real-time, on-the-spot feedback, whereas non-live web-based instruction does not.

When learners and instructors meet face-to-face, it’s an opportunity network and connect with others in your profession. This initial forming of relationships is easier in a face-to-face environment where one is able to connect with others between sessions, during breaks, or at dinner. Pharmacy, like nursing and medicine, is a small world and connecting and building relationships is best accomplished through face-to-face interactions and continuing education that takes place at local, regional, and national meetings.³ In my personal experience, I have made countless lasting relationships by attending face-to-face continuing education programs. Social media platforms, which are web-based, do allow for continued connection once the face-to-face interaction has occurred, but I do not believe that it can replace the initial contact, conversations, and networking that face-to-face allows.

However, face-to-face instruction typically does not take into account the individual’s learning preferences. As we know, learning is not a one size fits all format. In web-based instruction, the learner can seek out different instructional methods (readings, videos, podcasts) — one’s that are most conducive to their learning style. In face-to-face instruction, the learner can’t select the instructional method — the instructor chooses. 

Also, live instruction generally does not evaluate learning using a valid assessment at the conclusion of the education. Credit is awarded based on attendance. By not assessing improvements in knowledge or skill, it difficult to assess whether any learning has occurred. Some live programs incorporate audience response (aka clicker-type) questions throughout the program, but answering these questions correctly is not a requirement for credit.

Lastly, the face-to-face methods can be inconvenient and costly, especially when travel is involved. This is important for busy professionals who may not have the time to seek out and attend live programs.³

Potential Advantages and Limitations of Web-based Instruction:

Web-based instruction provides a way for learners to complete CE programs on their own time and any location with Internet access (which is practically everywhere nowadays). With 24-hour, flexible access, web-based instruction is both convenient and accessible. It also allows for a greater variety of topics from which to select. Learners have the ability to seek out programs that align with their professional interests. These programs can be accessed through numerous professional organizations, Universities, and medical education companies.  Lastly, most web-based programs test the learner’s understanding of the material at completion of the course and often include critical thinking and problem-solving exercise to determine if the learner retained the information presented.³

Unfortunately, technical problems are inevitable with both web-based and face-to-face instruction. When technical problems are encountered, learning is hindered and learner satisfaction declines.⁴ Technical problems are more difficult to overcome with web-based instruction due to the dependence on technology to deliver the instruction. Technical issues are a bit easier to address during face-to-face programs because the instructor is still able to communicate with the audience and can use alternative methods, like providing paper handouts, if the instructor has planned ahead.⁴

Comparing the changes in pre-test and post-test scores, one study found that the face-to-face and web-based methods were equally effective with regard to the knowledge gained after the topic was presented.³ This is not surprising as both delivery methods seem to achieve similar knowledge gains in aggregate across many studies. That is, pre-test and post-test scores are significantly better after the instruction is completed. However, what studies have not yet demonstrated is the effectiveness of instruction in terms of practice change. This means that it is still unknown if CE leads to behavior change or improves patient outcomes regardless of the instructional method used.²

With the Internet playing a vital role in our lives now, it is safe to say that web-based instruction is here to stay.⁴ By exploring the advantages and limitations to both face-to-face and web-based methods, we are better able to choose the method that is most effective for what we, as individual learners and educators, are trying to accomplish. In many states, regulatory boards require that a portion of continuing education be completed via live face-to-face instruction.³ I believe when we combine the two methods and are cognizant of the advantages and limitations of each, we are more likely to achieve our continuing education goals.

References:

1. Cook, D. Web-based learning: pros, cons and controversies. Clin Med 2007; 7:37-42.
2. Rouleau G, et al. Effects of E-learning in a Continuing Education Context on Nursing Care: Systematic Review of Systematic Qualitative, Quantitative, and Mixed-Studies Reviews. J Med Internet Res 2019; 21(10):e15118. 
3. Brown, L. Continuing Education Showdown: Online Learning vs. In-Person Seminars. Acupuncture Today 2013; 14(12).
4. Khatony, A. et al. The effectiveness of web-based and face-to-face continuing education methods on nurses’ knowledge about AIDS: a comparative study. BMC Medical Education 2009; 9:41. 

Building Authentic, Meaningful, and High-Quality Team-Based Learning Activities

by Megan Harlow, PharmD, PGY1 Pharmacy Practice Resident, University of Mississippi Medical Center

In pharmacy school I participated in many team-based learning activities. As an introvert, I found it challenging to be thrown into a (seemingly) random group and try to work toward a common goal with people who may not care about the end result as much as I did. None-the-less, some team-based learning activities were satisfying learning experiences and I actually had fun working with others applying our knowledge to a (seemingly) real-life situation. Some of these experiences are by far my favorites in pharmacy school.

Team-based learning is a type of small-group learning that requires student preparation prior to class and devotes class time to application exercises. Before class starts, students complete a pre-class activity (reading, watching videos, etc.) to learn about the key concepts that will be needed during the in-class activity.¹ The class starts with each student taking a test to assess his/her readiness after which the same test is completed by students as a team. At some point, either during or after the group readiness test, the instructor reveals the answers. Depending on the testing procedures employed by the instructor, the groups may find out if their answers are correct during the testing process. For example, one of my classes used scratch-off answer cards. The correct answer had a star next to it to indicate that the answer was correct. Computer methods for scoring the group readiness test can also be used. Students have the opportunity to appeal the correctness of any answers with which they disagree. After the testing is finished, a short presentation may be given whereby the instructor hones in on concepts students struggled with on the test.

Image from: Sultan Qaboos University medical journal 12(3):336-43

After the readiness testing, students then work in small groups on application activities.  These activities present the student groups with a problem for which they are require to select a specific course of action.¹ All teams report their decisions at the same time.  This gives the students an opportunity to see how other teams have managed the problem differently. The teacher does not tell students the answer but rather guides the teams as they work through the problem toward their own solution.¹ The theoretical basis of this instructional method is grounded in constructivist learning theory, whereby the active involvement of the student is essential to the process. Students are encouraged to use their life experiences and knowledge while trying to solve the assigned problem.^1,2

While this instructional strategy sounds great, things don’t always live up to the ideal. Yes, when the activities are well-designed, students have the opportunity to acquire foundation knowledge and they get to apply those concepts to problems. Students are also learning how to work with others who may have different backgrounds and opinions from their own. However, some team-based learning activities aren’t well-designed and students don’t achieve the desired learning outcomes. This was a problem I faced several times during my undergraduate and pharmacy school years. Learning activities that are not well-designed lead to frustration among students and can cause group tension. One of the hardest parts of creating team-based learning activities is developing assignments that encourage deep thinking as well as engaged, content-focused small group discussion. The problems that the groups attempt to solve should be authentic and have clear application to their future roles.²

So, what makes a team-based learning activity effective? A recent study solicited the opinions of pharmacy educators who are experts on team-based learning to identify quality indicators for team-based learning activities. A two-rounded modified Delphi process was used whereby these experts were asked about the characteristics of strong team-based learning activities and how to create positive learning outcomes as well as enhance student satisfaction.² The first round of the Delphi process asked the experts a series of open-ended questions about team-based learning activities. These thoughts and opinions were then summarized and a series of best practice statements were formulated.  The investigators presented these statements back to the experts to measure their level of agreement.²

According to the expert panel, effective team-based learning activities must be focused and clear instructions must be provided to students.  Students should know what they are being asked to do and what they need to do to prepare for the in-class activity using the assigned pre-class background materials. The learning activity must be feasibly completed in the allotted in-class period but also appropriately challenging and complex. There also must be time allotted to providing effective feedback to each group. The content of the activity should be an authentic challenge in pharmacy practice and require the application of multiple domains of knowledge and/or skill.² The activity should encourage the group to pool their prior knowledge and life experiences together to solve a multifaceted problem. The activity should be clearly linked to an outcome or objective of the course but should also require students to apply their knowledge from other courses. In addition, a good team-based learning activity should prepare students for future assignments. Lastly, team-based activities should promote higher-level thinking, encourage group discussion, and require the involvement of every student in the group.²

Feedback is an essential component of team-based learning for both learning and long-term retention. Feedback should be included at each step of the process. The individual and group tests provide feedback on the students’ preparation for the activity. While working with their group, students receive peer feedback as well as feedback from the instructor on the group’s ability to prioritize, organize, and defend their approach to the problem.²

To illustrate these concepts, here’s a team-based activity I participated in during pharmacy school. The module was related to pain management. The syllabus provided explicit instructions on what should be done before coming to class. The class was assigned two presentations to review. We then took a quiz to assess our pre-class learning and the instructor gave a short lecture before beginning the team activity. The assignment was able to be feasibly completed in the class period and there were several facilitators to keep us on track. The subject matter included many new concepts for my classmates, so the problems were straight forward but challenging. We had access to evidence-based resources during the activity. During the assignment, each group was given feedback about their progress. We all understood how this activity was relevant to our future professional role as pharmacists and it required us to recall things we learned during pharmacotherapy courses earlier in the curriculum and apply them to a case. 

Some students may be resistant to this form of instruction at first. Over time student objections and concerns will likely subside. One study, which surveyed occupational therapy students about their perceptions of team-based learning, showed that students were significantly more satisfied with team-based instruction after the third trimester when compared to their opinions after the first trimester.  Moreover, students reported they were significantly more accountable for completing the pre-class assignments.³ These findings indicate that students need time to become accustomed to the team-based learning technique and must learn how to meaningfully engage in the in-class activity.

While team-based learning can promote higher-order thinking, problem-solving, and teamwork, these all depend on designing effective pre-class and in-class learning activities.  Students need clear instructions about what they need to do to prepare.  Feedback at each step of the process is important.  The instructional activities need to align with the course objectives.  And the in-class group activities should be relevant, sufficiently complex, but achievable in the allotted time.   By keeping these principles in mind, instructors can create authentic, meaningful, and high-quality team-based learning activities that have a lasting impact.

References

1. Brame C. Team-based learning. Vanderbilt University. 2020.
2. Janke K, Bechtol R, James S. Determining indicators of high-quality application activities for team-based learning. Am J Pharm Educ 2019;89(9): Article 7109. 
3. Carson R, Mennenga H. Team-based learning and the team-based learning student assessment instrument (TBL-SAI): a longitudinal study of master of occupational therapy students’ changing perceptions. Am J Occupational Ther 2019;73(4): 7304205010p1–7304205010p7.