Breaking down the primary literature: the role of the journal club

by Emily C. Pherson, Pharm.D., PGY1 Pharmacotherapy Residency, the Johns Hopkins Hospital 

As pharmacy students, we have courses where we are instructed on the key elements of a research study and we are tasked with trying out our literature evaluation skills by writing evaluations of major drug trials. As pharmacy residents, we are faced with reviewing multiple pieces of primary literature nearly every day in order to find the best data we can to inform the drug treatment decisions we are making for our patients. Leading journal clubs has helped me develop the skills I need to break down the primary literature.

As a pharmacy resident at Johns Hopkins, I was excited to discover that the first record of a medical journal club was one founded in 1875 by Sir William Osler, a renowned physician with Hopkins roots. He originally described the journal club as facilitating the distribution of unaffordable periodicals, and later evolved it into a book and journal club that met over dinner to discuss the latest in medical research.¹ 

A journal club is a teaching tool that helped me digest large amounts of information in limited amounts of time. When I started to think more about how I could conquer breaking down the necessary information in a journal article for a journal club, I realized that an easy way to do this would be to apply Gagne’s 9 events of learning, one of the many educational strategies we have been exploring in the Educational Theory and Practice Course.

To really engage participants in a journal club, you need to gain their attention. I find that applying the journal article to a patient case is a good way to get participants to relate to the content. It is also important to emphasize that at the end of the journal club, all attendees should understand the clinical implications of the data presented. This is always a recurring key objective for a journal club. It also important to give a bit of background on the disease state or therapy being addressed in the article as a way to stimulate recall of prior learning and help the attendees draw on information they already know about the topic. As far as presenting the content, a 2004 overview in the American Journal of Health-System Pharmacy points out three key steps to providing adequate discussion about an article.² First, the presenter must determine the relevance of the study (something I accomplish by laying out my objectives). Next, the validity of the trial must be determined. This is where the patient population, the study design and how the study was conducted are all evaluated. Lastly, the results must be evaluated. Askew suggestions that you list all of the efficacy endpoints of the study and then calculate the relative risk reduction and the absolute risk reduction.² Other important things to look at include the statistical analyses. It may be helpful to calculate the number needed to treatment (NNT) and/or the number needed to harm (NNH). It is also important to consider if the study was adequately powered to assess the defined outcomes.² 

In order to provide learning guidance and engage learners, its helpful to prepare some discussion questions to get the conversation started. These questions should be focused on the application of key study findings. If you started the journal article with a patient case, this can be a good time to bring the case back into discussion.

Its also important to have an evaluation tool available to assess the learners performance and provide feedback on the presentation. A 2007 article in the American Journal of Pharmaceutical Education provides an extensive evaluation rubric that was piloted with pharmacy students. In addition to the rubric, the students were also provided with an outline of important considerations for each section of the study. The authors provide a truly comprehensive tool that’s very useful for providing feedback to learners.³ 

The last event that Gagne proposes is that we must enhance retention and transfer knowledge. At the conclusion of every journal club, its important to summarize the discussion and talk about how the information can be applied in practice.  Some days later, I invariably find myself applying what I’ve learned during a journal club to specific patient cases I see on my rotations.  I encourage participants to think about when they might use the information in the journal article again.

I would challenge any educator who is faced with the task of discussing the primary literature with learners, to considering using a journal club format and applying Gagne’s 9 events of learning when conducting them. 

References:

1. Greene WB. The role of journal clubs in orthopaedic surgery residency programs. Clin Orthop. 2000;373:304–310.
2.  Askew JP. Journal club 101 for the new practitioner: Evaluation of a clinical trial. Am J Health-Syst Pharm. 2004;61:1885-1887. 

3.  Blommel ML and Abate MA. A rubric to assess critical literature evaluation skills. Am J Pharm Educ. 2007;71:1-8.

Pharmacists Education: B.S.Pharm to Pharm.D. — the Evolution of a Profession

by Ashley McCabe, PharmD, PGY1 Community Pharmacy Resident, University of Maryland School of Pharmacy 

If you or someone close to you has recently graduated from pharmacy school, you know the Doctor of Pharmacy (Pharm.D.) degree is the degree that all pharmacists now earn.  However, not every pharmacist in the pharmacy world has a Pharm.D.  In fact, the education of pharmacists has evolved as the profession has transformed.  The Pharm.D. degree is a relatively new standard in the profession.  As someone who works in a community pharmacy setting, where more pharmacists have a Bachelor of Science in Pharmacy (B.S.Pharm) rather than a Pharm.D., I am intrigued by the differences between the two degrees and how professional education has changed over the years.  I intuitively understood that the doctorate required more years of school but, why did the doctorate become the standard? As a student of education, I wondered what drove educators to alter the curriculum so drastically.  More importantly, as we are undergoing another phase of healthcare reform, it is vital to look at that process, in the event that education will need to transform again based on the needs of the profession and the patients we serve. 

Through my investigation, this is what I discovered.  The B.S.Pharm degree was the norm until 1997 when the Accreditation Council for Pharmacy Education (ACPE) re-evaluated the needs of entry-level pharmacists and patients.¹   The changes made were based on recommendations for healthcare provider competencies identified by the Institute of Medicine (IOM).  In 2000, the new ACPE standards went into effect.  Therefore, if you graduated pharmacy school in 2003 or later, the doctorate became the entry-level degree.  As the profession and medical care in general evolved, so did the education of the pharmacist.  The doctorate of pharmacy put more emphasis on medication management – and this proved important when the Medicare Modernization Act passed in 2003.¹ Pharmacists needed to employ their cognitive skills to an ever expanding population in need.

 Pharmacy practitioner Paul W. Abramowitz clarified this concept perfectly in his Harvey A. K. Whitney Lecture by describing the transition of pharmacy practice throughout his career.² He painted a picture of pharmacy practice in 1974, the start of his career, as more humble clinically with limited inter-professional exchanges.  He continued with how the profession morphed as pharmacists became more involved in acute care settings and as the repertoire of medications expanded along with medication-related problems and the pressure to make cost-effective decisions.  Moving into the current practice model, he expanded his story by describing how curriculums now require one year of advanced practice experience in order to fit into the new healthcare model of inter-professional care.  Thus, Mr. Abramowitz helped answer how the doctoral degree evolved, but there is definitely more to it than that.  What were the educators thinking? 

In a recently published article by former dean of the University of Maryland School of Pharmacy, Dr. David A. Knapp, highlighted the thoughts of educators, policy makers, alumni and other stake holders at the time of the transition.³ The article illustrates the lengthy debate and political upheaval that the all-Pharm.D. inspired.  Support from research studies and practice analyses done by both sides of the debate exemplified how difficult the transition really was.  Faculty and staff members at the school were burdened by trying to put additional requirements into a 5 year program.  Adding 2,000 supervised practice hours and 6 months of externship into a packed course load with limited elective opportunities stressed an already bloated curriculum.  However admirable it was, an all-PharmD was despised by many employers, pharmacists, and state legislators who saw a doctoral education as costly and unnecessary, amongst many other perceived undesirable characteristics. But as we all know, in the long run, the all-Pharm.D. transition occurred. 

From an educator perspective, the necessity of transitioning from 5 years to 6 years of education was related to a needs analysis.  The transformation was inspired by the evolving advance clinical roles pharmacists were taking on.  These roles were first explored by practitioners and educators in the 1960’s, 70’s, and 80’s.  In the current economic and political climate, the pharmacy profession is facing different challenges.  Educators and practitioners are sure to have opinions on the topic, but none are as potentially influential as the current students who will become the future of the profession.  Therefore, a needs analysis of the current students could hold the key to where professional education needs to go. 

With the transformation of pharmacy education in mind, as highlighted by Mr. Abramowitz and Dr. Knapp,^2,3 I believe it is fair to question where this evolutionary trend in pharmacy education will lead.  This is especially vital when considering the perceived needs of current students as they begin their careers in pharmacy.  Will it be residencies for everyone in order to enhance the retention and transfer of the advanced knowledge and skills first taught in school?  I believe that assessing the needs of the learner, in this case pharmacy students, as well as the needs of our patients should provide the data we need to make informed decisions about the future of pharmacy education and training. 

References

1. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Accreditation Council for Pharmacy Education. Chicago; 2006.

2.  Abramowitz PW. Harvey A. K. Whitney Lecture: The evolution and metamorphosis of the pharmacy practice model.  Am J Health-Syst Pharm. 2009; 66:1437-46.

3. Knapp DA. The rocky road to educational change: Adopting the entry-level Pharm.D. at Maryland, 1989-93.  J Am Pharm Assoc 2011; 51:712-719.

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.”

References:

1. Gardner S. Car Keys, House Keys, Easter Eggs, and Curricula. Am J Pharm Educ. 2010; 74 (7) Article 133.

2. Stern DT. In Search of the Informal Curriculum: When and Where Professional Values are Taught. Acad Med. 1998:73:S28-S30.

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.

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. 

References

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

2. University of Maryland School of Pharmacy – Fact Sheet.

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.

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. 

References:

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.