December 14, 2011

Preparing Pharmacy Students for Residency Training

by Diane E. Hadley, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Maryland School of Pharmacy

Over the past few years, I have been asked at three different pharmacy schools by first year students “What can I do to become the perfect residency candidate?”  Perhaps the better question is, what we can do as pharmacy educators and schools of pharmacy to prepare students to “put their best foot forward” for the ASHP Midyear Clinical Meeting (ASHP MCM) and residency interviews?  As the demand and the competitiveness for pharmacy residency training increases, acquiring accurate information about residency training and preparing students for the interview process becomes increasingly important.  In most doctor of pharmacy programs, students learn about residency training and preparation methods primarily by informal methods through peers as well as preceptors during advanced pharmacy practice experiences (APPE’s). Although beneficial, it may leave the prospective residency candidate with incomplete information regarding the type of residency to pursue and may not adequately prepare students for the interviewing and matching process.  Would a more formal approach, such as a pre-residency curriculum, be more effective than the current informal methods?

Experiential learning is a crucial part of the doctor of pharmacy curriculum that exposures students to current pharmacy practice models.  Ideally, APPE rotations should serve as an introduction to residency training.  Unfortunately, schools don’t control the “hidden curriculum” taught during APPE rotations.1  An article published in Academic Medicine, observed that values such as professionalism was often taught informally more often by peers during off hours instead of traditional methods from an instructor.2  This article illustrates how the “hidden curriculum”  is often driven by peer influence.  This notion is further supported by an article published in Clinical Orthopedics and Related Research Journal.3   Indeed, informal one on one and group interaction can impact opinions, most often in a negative way.3  Thus information and attitudes about residency training may be acquired through a “hidden curriculum” and these may be driving decisions related to residency training that are not envisioned or endorsed by the school.1,2,3  Thus a formalized pre-residency curriculum may help diminish the potentially negative influences of the “hidden curriculum.”

An article published in American Journal of Pharmaceutical Education supports the potential benefits of developing structured pre-residency instruction at the University of Buffalo School of Pharmacy.4 The author surveyed sixty-eight pharmacy students that attended either the ASHP MCM in 2007 or 2008  or both.4 Prior to attending ASHP MCM, students attended a one hour presentation and receive a handout regarding the residency process.4  The educational seminar included information about residency terminology, benefits of attending the ASHP MCM, time management,  and the pre-during-post ASHP MCM meeting residency selection.4 The survey asked about the helpfulness of the structured educational event and had an impressive 97% response rate.4 A majority of the students, 73%, ranked the educational event as extremely helpful in preparation for the ASHP MCM.4   A 2010 survey of seventy-one colleges of pharmacy showed that sixteen pharmacy institutions now have a pre-residency program in their pharmacy cirriculum.5   Of these sixteen schools, nine provided information on their pre-residency curriculum.5  The curriculums offered a variety of traditional and non-didactic learning activities including: lectures on residency training, pre-residency pathways, mentoring programs, and research project development.5

Schools of Pharmacy should provide residency information using a structured approach.  Such instruction has become crucial because the American College of Clinical Pharmacy has proposed that residencies become mandatory for pharmacists who work in direct patient care roles by the year of 2020.6  As leaders in our profession, we need to take action to formalize the instruction about residency training to keep students well informed.  We need to reduce the likelihood that students will make ill informed decisions based on misinformed that practitioners or peers may have given.  Ideally a pre-residency curriculum should be created that incorporates didactic presentation on the ASHP MCM meeting and residency interviewing process, encourages experimental learning rotations that increases a student’s preparedness for residency training,  a pre-residency mentor, and opportunities to get involved with clinically oriented research projects.  A combination of all these elements would provide a sturdy foundation for students to become the “perfect residency candidates.”

1. Gardner S. Car Keys, House Keys, Easter Eggs, and Curricula. Am J Pharm Educ. 2010; 74 (7) Article 133.
3. Gofton W and Reghr, G. What We Don’t Know WE Are Teaching: Unveiling the Hidden Curriculum.  Clin Orthop Relat Res. Number 449. Augest 2006. Pages 20-27
4. Prescott WA. Program to prepare pharmacy students for their postgraduate training search. Am J Pharm Educ. 2010; 74 (1) Article 9.
5. Dunn B, Ragucci K, Garner S, et al.  Survey of Colleges of Pharmacy to Assess Preparation for and Promotion of Residency Training. Am J Pharm Educ, 2010. 74 (3) Article 43.
6. Murphy JE, Nappi JM, Bosso JA et al. American college of Clinical Pharmacy Vision of the Future: Postgraduate Pharmacy Residency Training as a Prerequisite for Direct Patient Care Practice. ACCP Position Statement. Pharmacotherapy 2006; 26 (5): 722-733.

December 8, 2011

Bridging the Multicultural Divide

by M. Amjad Zauher, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy 

I still remember the thoughts running through my mind as I walked into my first class in my undergraduate program. Here I was, in a new country, coming from Colombo, Sri Lanka, a city with a population of over five million, to Clarion County, Pennsylvania, with a population of twelve thousand. I was clearly an outcast – from the color of my skin to my accent, everything was different. Rural Pennsylvania seemed far from welcoming. All I knew was the British educational system. Multiple-choice exams were a foreign concept and I was accustomed to completing all assignments by hand.  Graphing calculators were used in science fiction movies, not in college classrooms. I had to quickly learn how things worked in America.

As the semester rolled on, some professors were exceptional in helping me, explaining what was expected, and how to complete required assignments. More importantly, they brought down that invisible wall in the classroom that made me feel ostracized from everyone who was not like me. I was by no means unique; they were doing this for all the students, whether they were from down the road or from half way around the world.

To bridge the cultural divide that often separate students who come from diverse backgrounds, educators can incorporate techniques such as these:
  • During the first class, have the students say something about themselves.  If its a bigger class, have them write specific information on note cards (city of birth, hometown, hobbies, etc.) for later discussion.
  • Take time, either before or after class, to talk to students about how they are handling the change in academics, atmosphere, and society. Get to know more about each person’s background, ethnicity or culture.
  • Small group projects, in or out of class, promote interaction between students and increase the amount of discussion with classmates with whom they would not ordinarily interact.
  • BaFa BaFa!
Although I can only speak about my own experience as an international student, I believe I represent minorities in many classrooms. Minority enrollment in colleges and schools of pharmacy across the United States have increased from 10.6% to 14.0% between 1988 and 2002.1  And the number of students enrolled at the University of Maryland School of Pharmacy who come from minority backgrounds is greater than 50% (Asian = 45%, African American = 10%, and Hispanic = 2%).2 However, little to no data is available regarding the diversity of pharmacy students in other aspects (e.g. socioeconomic status, sexual orientation, physical ability).

Why is it important that diversity be addressed? It is not simply a matter of making students from various backgrounds feel more comfortable within the classroom, but rather how it shapes us as pharmacists down the road. In 2005, immigrants made up 11.5% of the US population, an increase from 4.7% in 1970 with, approximately 1.5 million immigrants arriving to the United States each year.3 People from different cultures have their own health beliefs and as pharmacists, it is our duty to understand and address the belief systems of our patients. The more experience and practice we get as students through interaction with a diverse group of people, the better prepared we will be at resolving health disparities.1 

Here are a couple of specific classroom-based examples I found to be beneficial to help address students of diverse backgrounds:

Professor Deborah Ball at the University of Michigan pointed out some techniques she employs during her lectures to engage students.4 These include: maintaining eye contact with students throughout the classroom (not just in the front row), initiating “small talk” among the students (by posing questions and having neighboring students discuss), and asking for opinions from different students in every class.

A cultural competence lesson that I hadn't experienced until coming to the University of Maryland was the BaFa’ BaFa’ cultural simulation game.3  The game involves splitting the class into two groups (Alphas and the Betas).  The rules of the game are explained to each group seperately. The Alpha group was a relationship oriented society with strict rules about social behaviors, whereas the Beta group was a trading society that communicated via a complex language. Gradually, members were exchanged between the groups without explanation of how to communicate with the members in the other group. Once everyone had attempted to communicate with the opposite group, the class met as a whole and discussed the experience. Fun as it was to try and figure out what was going on, an incredibly valuable lesson was learned: the feeling of being in a “foreign” culture. We discussed misconceptions that we might have developed through our brief “clash of cultures” and we talked about our past experiences. I was easily able to relate to the exercise but many of my peers had never personally experienced this sensation. 

We live in a world that, with every passing moment, is having its cultures intertwined.  This is resulting in an amalgam of ideologies from all corners of the globe. Teachers will need to implement their own method for breaking down cultural barriers, whether it is through a cultural competence lesson (such as in the BaFa BaFa experience) or creating an “open floor” style of classroom where everyone has an equal say (such as Dr. Ball's small talk exercise). The ability of an educator to communicate with students in a manner that is transcendent is imperative if we want all students to be successful. As an international student being in a classroom where I felt initially separated from the group, a teacher who was able to bridge the gap brought us together. 

1. Nkansah N, Youmans S, Agness C, Assemi M. Fostering and Managing Diversity in Schools of Pharmacy. Am J Pharm Educ. 2009; 73: Article 152
3. Westberg SM, Bumgardner MA, Lind PR. Enhancing cultural competency in a college of pharmacy curriculum. Am J Pharm Educ. 2005; 69: Article 82
4. Arthur F. Thurnau Professors/Engaging Students in the Classroom and Beyond [Internet]. Ball D. Engaging Students in Larger Classes. Center for Research on Learning and Teaching: University of Michigan; 2000.

December 1, 2011

To Pass/Fail or to Not Pass/Fail

by Maisha Haque, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy 

One of the most talked about topics among my friends in pharmacy school is grades! This led me to research a very relevant question:  should pharmacy schools adopt pass/fall grading criteria for their courses?  Or should they stick with a traditional A through F system of grading? The type of grading system can cause changes in classroom behavior and perhaps the outcomes of student learning. As future educators I think it’s very important for us to understand the different grading systems in order to maximize the learning environment. This blog essay covers the summaries of three articles I found regarding the effects of different systems for assessing student performance. 

In the first article, the researchers studied the benefits of a pass-fail grading system on stress, mood, group cohesion, and test anxiety. This prospective study was conducted at the Mayo Clinical College of Medicine in Rochester, Minnisota.1  The Mayo Clinic College of Medicine recently changed over their grading system from a 5-interval grading system to pass-fail grading system. This allowed the authors to compare the graduating class of 2005 (which experienced the traditional grading system) to the class of 2009 who experienced only the pass/fail grading system. The two groups were compared at three time points:  at the end of their first year, the end of their second year, and after step 1 of their licensing exam.1 The results showed that the students graded on the pass-fail system had significantly less perceived stress and greater group cohesion.  The authors also observed that letter grades represented extrinsic rewards (such as when someone else tries to motivate you to do something) rather than intrinsic rewards (internal and personal motivating factors).  Thus, traditional grading systems, by their nature, tend to transform intrinsically motivated learners into extrinsic learners.1 

In another study, the authors examined the student’s perspective on the two grading systems and the affect they have on student motivation.2 A questionnaire was given to law students whose curriculum changed from pass-fail to a letter grade system. The responses revealed that students believed there was a higher concern for their standing in relation to other students and their position in the eyes of the professors.  There was also more competition in letter graded courses than there was in pass/fail courses.2  The respondents indicated that students were less embarrassed to ask questions in a pass/fail classroom.2   This seems like a very important learning tool that was somewhat inhibited under a letter grade system. The authors concluded that students were more oriented towards social comparisons and competition in a letter graded class … and less oriented towards task mastery.2 

The final paper examined whether a pass/fail system adequately reflects student progress or not.3 The primary purpose of any grading system is to measure student achievement and to establish the development of needed competencies.3  In letter-graded classes students are perhaps more motivate while a pass/fail class establishes only the minimum requirements.3  The authors contend that a letter grading system encourages the habit of always aiming for the best which would be a positive thing if translated into the work environment even when grades are not allocated. The interesting observation made by the authors is that faculty role modeling, selection of criterion, careful and inclusive selection of the qualities that are being assessed, and the use of criteria based grading system are more important contributors to student learning than whether or not letter grades are assigned.3 

After reading the different sides presented by these articles, it’s evident that there is not one clear winning strategy for student assessment.  Doctoral and graduate degree programs are always going to be very rigorous and stressful learning environments. The evidence indicates that the pass/fail system leads to less stress, increased group cohesion, and increased task mastery.  Thus I believe the pass/fail system should be adopted in all graduate schools. The competition and pressure to get good grades is commonly experienced during undergraduate education – thus people admitted to pharmacy (and medical and law) school have a proven ability to succeed in a competitive environment.  I believe once you start your graduate program the focus needs to be on learning rather than promoting competition between students. 

The most important principle, and the part that I think applies to this class, is that it’s the educator’s role to facilitate student learning, and this is based on how they teach, not grade.  Professors can balance the positive and negative aspects of both grading systems, but this requires understanding the effects of both systems. It’s up to the professor to maximize the benefits of both and leave the students with the best education possible. 

1.  Rohe DE, Barrier PA, Clark MM, Cook DA, Vickers KS, Decker PA. The Benefits of Pass-Fail Grading on Stress, Mood, and Group Cohesion in MedicalStudents. Mayo Clin Proc. 2006; 81(11); 1443-48.
2.  Michaelides M, Kirshner B. Graduate Student Attitudes toward Grading Systems. College Quarterly. 2005; 8(4).
3.  Miller BM, Kalet A, Van Woerkom RC, Zorko N, Halsey J. Can a Pass/Fail Grading System Adequately Reflect Student Progress? Virtual Mentor 2009; 11(11): 842-51.

November 30, 2011

Can Empathy in Patient Care Be Taught?

By Niki S. Mehdizadegan, Pharm.D., PGY1 Pharmacy Resident, Union Memorial Hospital 

I entered a patient’s room in the Anticoagulation Clinic.  A middle-aged lady wearing a colorful scarf was sitting quietly in her wheelchair. “Hello Miss. M! How are you doing today?” I said with a smile.  She remained quiet and barely raised her head. In the three seconds between saying hello to her and pulling the chair to sit in front of her I thought to myself: “Oh, she is so friendly! (sarcasm). Let’s see how this goes.” 

We often form our opinion of individuals in the first few minutes of meeting them.  Malcolm Gladwell, the author of the book Blink defines our ability to make a decision or form an opinion within a limited period of time of facing a situation as “thin-slicing.” 1  He explains that although in most instances having a limited amount of information can be sufficient in decision making, sometimes our unconscious prejudice and stereotypes can bias that decision. 

In a society with significant cultural and socioeconomic differences, it is inevitable that  as healthcare professionals we will interact with a diverse group of patients whose behavior, expectations, and lifestyles are vastly different from ours. The question is: can we teach health care professionals to be empathetic towards patients in spite of these differences? Empathy has been defined as the “ability to behave in a caring manner toward a patient while demonstrating to the patient that his feelings are understood.”2 

In one study that was a joint collaboration between two schools of pharmacy, the authors employed Patient Empathy Modeling (PEM) pedagogy to teach pharmacy students  empathy towards underserved patients.3  The students were enrolled at two schools of pharmacy located at a rural and an urban site in the United States (Purdue University School of Pharmacy and University of Connecticut School of Pharmacy).  Students were given a patient scenario simulating the life of a patient with multiple chronic illnesses who was coping with a socioeconomic, cultural, or communication barrier. The student then had to live the life of that patient for ten days.  For example, one student role-played “Jamie Illiterate” - a patient who had multiple chronic illnesses, had financial problems, and had a learning disability that prevented her from learning how to read. The student was given prescription vials labeled in unintelligible texts. Assignments during the 10 days included: (1) having a one-time counseling session with a pharmacist (role-played by another pharmacy student) which simulated the challenges a patient might encounter, (2) setting up pillboxes or other reminder systems to take medications (vials containing placebos were provided), (3) observing the surroundings and attempting to read signs and other everyday objects for half an hour each day and recording feelings in a journal, (4) preparing a list of resources for illiterate patients in the area where the student lived, and (5) developing a medication brochure for illiterate patients. 

The effectiveness of this pedagogical approach was quantitatively and qualitatively assessed using the Jefferson Scale of Physician Empathy for Health Care Professionals (JSPE).  In addition, the authors assessed student journal entries as well as a final reflection paper. JSPE is a validated tool which analyzes 3 factors related to empathy: perspective taking, compassionate care, and the ability to stand in a patient’s shoes. The scores of the students participating in patient scenarios improved after completing the assigned activities.  Three major themes were identified from student’s journal entries and reflective papers: (1) greater appreciation for the difficulty in medication adherence, (2) increased empathy for patients from different backgrounds, and (3) improved ability to apply the lessons learned to real patient scenarios during their advanced experiential rotations. 

My first impression of the lady that I saw that day in the anticoagulation clinic was perhaps not the most positive. However, during that office visit I discovered that she was diagnosed with acute deep vein thrombosis (DVT) that day and that she had been scheduled to have knee replacement surgery. Due to the DVT diagnosis, her surgery would now be postponed.  This meant that she would suffer from continued pain from severe arthritis. She also needed treatment for her DVT.  This would require an injectable medication for a few days followed by an anticoagulant that required frequent blood tests and monitoring for the next few months. That day I tried my best to be empathetic towards her. I told her that I realized how painful her arthritis can be (perspective taking) and that my mother suffers from arthritis too (the ability to stand in a patient’s shoes).  I told her that I was more worried about her going into surgery with a new clot in her leg than postponing the surgery.  It was important that she receive the best possible treatment so that she can recover and be the healthiest she can possibly be prior to her surgery (compassionate care). She smiled and nodded her head and said that she understood.

As the study I have cited demonstrates, pharmacy students can be taught to be empathetic by engaging in role-play and facing difficulties from a patient’s perspective.  Schools of pharmacy across the country have designed various activities to teach empathy in their curriculum. Empathy does not require a genetic predisposition, but rather facing situations similar to those faced by our patients.  It is through these experiences that we can learn to relate to the similarities that bind us together rather than the differences that divide us.

1. Gladwell, M. Blink. New York : Little, Brown and Co., 2005
2. Lonie JM, Alemam R, Dhing C, Mihm D. Assessing pharmacy student self-reported empathic tendencies. Am J Pharm Educ. 2005; 69:Article 29.    
3. Chen JT, LaLopa Jb, Dang DK. Impact of Patient Empathy Modeling on Pharmacy Students Caring for the Underserved. Am J Pharm Educ. 2008; 72: Article 40.

November 27, 2011

Teaching Across Generations

by Joshua Fleming, Pharm.D., PGY-2 Ambulatory Care Pharmacy Resident, The Johns Hopkins Hospital

“There are three things to remember when you are teaching:  know your stuff, know who you are stuffing, and then stuff them elegantly.” – Lola May

When you take a look at many pharmacy schools, you’ll notice students from different generations present within each class.  We are likely to see the middle-aged adult who has decided to go back to school. This middle-aged adult has made pharmacy their second career.  And they are likely to be sitting next to a 20-something student. This younger student has gone straight from high school, to college, and now pharmacy school.  This presents a challenge to us as we face a student body from multiple generations.  Their expectations in terms of preferred learning methods and teaching styles are often different. 

The generations we are most likely to encounter in our teaching careers include Generation X and Millennials.  Each of these generations differs slightly in their preferences and overall attitudes toward assignments.  In order to understand some of the differences between each generation, it is important to take a step back and review the events that shaped each generation.

Generation X (1964-1979)1:  People from this generation are the product of the work-driven Boomer generation.  They experienced single parent homes, the advent of MTV, the Challenger explosion, and were the first generation of latch-key children.  This is the first generation to use computers in their homes and to experience the Internet.  Gen Xer’s are driven by money, crave balance in their lives, are self-reliant, and value free time. 

Millennial (1980-2001)1,2:  This generation is also known as the “Nexters” or Generation Y.  This generation encompasses the majority of the pharmacy students today.  The events that shaped this generation include the Columbine shootings, Oklahoma City bombing, and September 11th tragedy.  This generation has grown up with technology and expects it in every aspect of their daily lives.  Millennials are self-reliant, mobile, addicted to media, brand-conscious, and family-oriented in times of crisis.   

A study that examined the attitudes of Generation X students in pharmacy school found that these students have a higher preference for professors that are friendly and warm.3  They also believe that grades should be based on knowledge and performance of a subject, and believe that the average grade for a course should be a B.  In a follow up study, researchers found that Generation X students were:  technologically literate, independent problem solvers, and more likely to believe that learning should be fun, crave stimulation, personal contact, follow rules after explaining significance.  Moreover, they were more likely to desire learning relevant to work, experiential leaning, feedback, evaluation, and expect immediate answers.4  The authors then designed a course that would meet many of these desires.   During the course the used games, engaged the students in small group and individual activities, provided an online site to support the course, learned students’ names, communicated via email, and provided ways for students to obtain instant feedback.  They then evaluated their performance in the “re-designed” course and compared the results to a traditionally designed course.  They found that when the course met as many of these expressed desires as feasible, the students performed better and student feedback was more favorable.

A meta-analysis published in 2009 focused on the challenges of Millennial students in the classroom.5  Millennial students have a slightly differing attitude towards learning and formal education.  These students have high expectations and have a tendency to be over-confident. They have been told to “shoot for the stars” by their parents and may come to class with a sense of entitlement.  Millenials have a strong desire for connection and will generally “multi-task” through assignments and during lectures.  Strategies used to reach this generation in the classroom include adding more hands-on learning activities, delivering lectures in short chunks, and using technology such as YouTube.

In a study by Borges and colleagues, a 16 personality factor assessment was given to 809 medical students at a single institution.6  The students’ responses were compared based on their generational cohort.  Millennial students scored higher in areas of rule consciousness, social boldness, and perfectionism.  Generation X students scored higher in self-reliance.  An additional study by Borges and colleges focused on the differences in motives of Generation X and Millennial medical students.7  In this study they found that Generation X seemed be driven more by power.  Millennial students were driven more by achievement and affiliation.

So, how can we best approach different generations of students and achieve our desired educational outcome?  Unfortunately, there is little literature about how best to meet the needs of a generally diverse classroom, but its seems wise to make sure that rules (e.g. course policies) are clearly defined and learning objectives are measureable.  Both Generation X and Millennials are comfortable with technology and expect to use it in the classroom.  On demand podcast lectures (and vid-casts) have been used at some universities followed by classroom case discussions.  This would meet the desire for technology and independent learning as well as giving the student an opportunity for social learning in the classroom.   Both of these generations have a strong desire to succeed.  As future educators its going to be challenging to provide the best education to students that have demanding expectations, but if you “know who you are stuffing”, it makes the task much easier. 

1.  King D. Defining a Generation:  Tips for Uniting Our Multi-GenerationalWorkforce. Career Planning and Management, Inc. Accessed 20 November 2011.
3.  Romanelli F, and Ryan M. A Survey and Reviewof Attitudes and Beliefs of Generation X Pharmacy Students. Am J Pharm Educ. 2003;67(1):72-79.
4.  Ryan M, Romanelli F, Smith, K, and Johnson MMS. Indentifying and Teaching Generation X Pharmacy Students. Am J Pharm Educ. 2003;67(2):1-6.
6.  Borges NJ, Manuel S, Elam CL, and Jones BJ. Comparing Millennial and Generation XMedical Students at One Medical School. Acad Med. 2006;81:571-576.
7.  Borges NJ, Manuel S, Elam CL, and Jones BJ. Differences in Motives between Millennial and Generation X Medical Students. Med Educ. 2010;44:570-576.