September 16, 2014

Relationships Matter: Lessons for Teachers, Managers, and Clinicians

by Joey Mattingly, PharmD, MBA, Assistant Professor, University of Maryland School of Pharmacy

Teacher quality is often cited as one of the most important variables in student achievement and this quality varies significantly.1,2  Are we stuck with a predetermined stratification of teacher talent, or is it possible to dig deeper and identify ways to improve organizational environments to achieve gains in teacher quality?  This post attempts to break down an important variable in education, the teacher-student relationship, and identify strategies for individuals and institutions to create environments that improve this exchange.

Figure 1
From a process analysis perspective, learning is an exchange between teacher and student(s) that takes place through a dyadic relationship (See Figure 1).  Since the student (member) essentially reports to the teacher (leader), this dynamic reflects organization reporting structures described in business literature.  The Vertical Dyad Linkage (VDL) and Leader-Member Exchange (LMX) theories were created to examine the impact of these relationships on important business outcomes such as efficiency, profitability, employee turnover, and job satisfaction.3,4  In the clinical setting, we see research on the patient-doctor relationship (PDR) model and impact on healthcare outcomes and patient satisfaction.5,6  While all of these theoretical models are being studied by researchers in various fields, there are a few common threads that we can all learn from (See Figure 2). 

Figure 2
John Maxwell simplified the importance of empathy in his book The 21 Irrefutable Laws of Leadership through a quote he often shared with his employees, “People don’t care how much you know until they know how much you care.”7  A physician may be brilliant and considered a leader by peers, but a patient’s decision to continue the patient-doctor relationship is significantly influenced by whether or not the patient perceives that the physician actually cares.8  An educator who displays empathy toward students is able to build a positive classroom climate, stimulate growth, and cultivate more productive learners.9 

Multiple studies have demonstrated the importance of respect and the relationship between teacher-student.10-12  Teachers that respect their students, managers that respect their employees, and healthcare professionals that respect their patients are able to build stronger relationships.  Listening is a great way to demonstrate respect.  Students’ perceptions of their professor’s respectfulness are also associated with stronger student self-confidence and motivation.12

Top-down accessibility and availability has been cited as an important variable in the dyadic relationship.  One of the components of the VDL and LMX theories within management is the “high quality” and “low quality” relationships that develop between supervisor and subordinate(s).  Dansereau, Graen, and Haga described this phenomenon as employees being divided into the “in group” or the “out group” in terms of relationship quality.  They found that leaders devoted more time, attention, and support to subordinates within the “in group” even though employees in the “out group” needed more support.3  Building strong relationships with students, employees, or patients requires time and making oneself available.

A Leader’s Dilemma
While evidence supports the need for leaders to incorporate empathy, respect, and accessibility into interactions with subordinates, profit- and efficiency-maximizing strategies are often not conducive to relationships building.  An organization wishing to gain economies of scale through growth will increase the number of members reporting to each leader in the organization.  Similarly, a teacher may see class size grow from year to year or a physician may be required to see more patients in order to increase revenues (aka “Do more with less”).

On the flip side, a 1:1 student-teacher ratio would not be practical (and too costly) to implement in most cases even though it would definitely allow the teacher to focus all efforts on one subordinate.  So what is the answer?  Is there a magic number of subordinates that would allow teacher, manager, and physician to build strong relationships with the members they serve? 

The Right Span
If we want to improve the quality of our teachers, managers, and physicians, then we need to consider ways to build an optimal span of control.  Dr. Harold Koontz identified several underlying factors for leaders to consider.13  For example, employees require different levels of training based on abilities and experiences.  A manager of a new location of a retail franchise with a high percentage of recently hired employees may be unable to adequately supervise 10 direct reports while a manager of a more established location with more experienced employees may be able to manage 15 people.  When applied to education, a professor leading an undergraduate course on basic microeconomic principles may have an easier time managing 100 students in a large lecture hall as compared to a professor managing a doctorate level course focused on an in-depth analysis of the Nash Equilibrium and other non-cooperative game strategies in economics.  A doctorate level student actually has more training to do the “job” of learning and one would expect a graduate school professor would be able to “manage” more students, but the complexity and intensity of training actually requires more instructional effort and thus limiting the professor’s span of control.  Understanding the variables that influence a leader’s span of control may help determine the right number of subordinates for each teacher, manager, or physician.

Reducing class size or number of patient visits may be difficult from a business perspective, but that doesn’t mean our hands are completely tied.  Knowing how Koontz’s factors influence a teacher’s span of control can help them improve educational outcomes, whether through advocating for appropriate class size changes or applying techniques to improve information exchange.  Improving the quality of communication and the clarity of plans helps simplify the instructions for each subordinate and reduces the amount of time the teacher needs to spend communicating.  Utilizing technology may also help leaders gain efficiencies to tackle their workload.

Identifying strategies to improve the different vertical relationships within organizations should be a top priority.  Developing stronger connections based on a foundation of empathy, respect, and accessibility could help schools, businesses, and health-systems reach desired outcomes. 

For more posts written by Dr. Joey Mattingly, please visit Leading Over The Counter, a blog dedicated to leadership and management topics for pharmacists and other health professionals.

  1. Riley RW. Our teachers should be excellent, and they should look like America. Education and Urban Society. 1998; 31:18-29.
  2. Slater H, Davies NM, Burgess S. Do teachers matter? Measuring the variation in teacher effectiveness in England. Oxford Bulletin of Economics and Statistics. 2012; 74:629-645.
  3. Dansereau F, Graen G, Haga WJ. A vertical dyad linkage approach to leadership within formal organizations: a longitudinal investigation of the role making process. Organizational Behavior and Human Performance. 1975;13:46-78.
  4. Thomas CH, Lankau ML. Preventing burnout: the effects of LMX and mentoring on socialization, role stress, and burnout. Human Resource Management. 2009;48:417-432.
  5. Mikesell L. Medicinal relationships: caring conversation. Medical Education. 2013; 47:443-452.
  6. Weng HC. Does the physician’s emotional intelligence matter? Impacts of the physician’s emotional intelligence on the trust, patient-physician relationship, and satisfaction. Health Care Manage Rev. 2008; 33:280-288.
  7. Maxwell J. The 21 Irrefutable Laws of Leadership. Nashville, TN: Thomas Nelson; 2007.
  8. DiMatteo RM, Prince IM, Taranta A. Patient’s perceptions of physicians’ behavior: determinants of patient commitment to the therapeutic relationship. J Community Health. 1979; 4:280-90.
  9. O’Brien LM. Caring in the ivory tower. Teaching in Higher Education. 2010; 15:109-15.
  10. Lammers WJ, Smith SM. Learning factors in the university classroom: faculty and student perspectives. Teaching of Psychology. 2008; 35:61-70.
  11. Micari M, Pazos P. Connecting to the professor: impact of the student-faculty relationship in a highly challenging course. College Teaching. 2012; 60:41-47.
  12. Komarraju M, Musulkin S, Bhattacharya G. Role of student-faculty interactions in developing college students’ academic self-concept, motivation, and achievement. J of College Student Development. 2010; 51:332-42.
  13. Koontz H. Making theory operational: the span of management. J of Management Studies. 1966; 3:229-43.

Grade Inflation: What Is It and What Can We Do?

by Brittany Lovko, Pharm.D., PGY1 Pharmacy Practice Resident, Suburban Hospital

Have you noticed that it’s getting easier to get an A in high school or college?  If you are student in (or recently graduated from) a rigorous curriculum like pharmacy, it may not have seemed so easy earning that “A”, but studies show it’s true. Grade inflation, first identified in the 1960s, is a growing problem in public and private institutions, including pharmacy schools.1 One study published in 2003 reviewed grade point averages at the University of Arkansas pharmacy school over a 20 year period and found a significant upward trend.  Grades increased by approximately 1% per year!1  From a teacher's perspective, this might be perceived as a positive sign. Shouldn't the goal be to educate students so that they’re all achieving the highest grade possible? Perhaps. But numerous studies have shown that student performance hasn’t really increased over the past 40 years based on indicators such as standardized test scores and scholastic aptitude tests.2

One might ask why grade inflation matters.  Grade inflation depreciates the value of an “A” and diminishes the meaning of a high grade point average.  How will students be able to set themselves apart if more (perhaps most) students graduate with a similarly elevated GPA? There is also some concern that grade inflation is leading to a culture of academic entitlement.3  Furthermore, graduates may have a false (inflated) sense of their knowledge and skills – and may not be able to delivery the standard of care expected in the health care today.3  So what can be done to curb this growing trend?

Normative vs. Criterion Grading4
There are two main types of grading systems – norm-referenced and criterion-referenced.  Normative grading is based on the direct comparison of a student to his/her peers. Thus, in a class of 20 students, you could decide that 5 would be assigned A's, 8 would be assigned B's, 5 would be assigned a C, and 2 students would get a D (or perhaps an F) based upon how each student's performance compared to the class average.  Normative grades are probably best suited for those courses that do not require absolute mastery of the subject matter.  Criterion-referenced grading, on the other hand, involves comparing the student's performance to a standard set by the teacher (or a standard established by some governing body).  This grading system is the most widely used.  We are all familiar with the percentage-based grading scheme where a score of 90% or above earns an “A”, an 80-89% earns a “B”, and so forth.  However, these cut points may or may not represent “mastery” of the material.  If criterion-based grading is to be used as recommended for courses that require mastery of the material, some experts recommend using a pass/fail system.4

Standardized Tests5
Another way to remedy grade inflation could be by using a well-accepted, national standard, as determined by standardized tests. The Pharmacy Curriculums Outcomes Assessment (PCOA) is a nationwide, standardized pharmacy assessment tool that can be used to measure academic progress of pharmacy students. This 220 question multiple choice test was created based upon the ACPE accreditation standards. The test is given annually to all professional students at participating institutions and the results are then reported both as a scale score and a national percentile rank.  The problem with this tool is that it still has not been widely implemented, in part due to the cost of administering the exam (which must be absorbed by the student or school).  If the PCOA were universally adopted, a new means to evaluate students could be established.   Colleges / schools of pharmacy could potentially move away from the traditional grading scheme and evaluate their pharmacy students in a more meaningful way. 

Numbers Instead of Letters4
Have you ever stopped to consider how arbitrary the traditional cut points are for each letter grade?  These cut points are not grounded in empirical data; rather, they are de facto “standards” merely because individual course instructors have repeatedly adopted them. Thus, letter grades can be misleading.  For example, two students who score only one percentage point apart in the course could end up with two different letter grades.  Some educators have recommended we stop converting these numbers into letter grades. Instead, we should report the class mean on a transcript next to the student's score to allow a more meaningful comparison.  Another normative approach would be to report each student’s class rank on his/her transcript. Both these methods would allow for students to be compared to each other.

Student Accountability for Learning3
For better or worse, the culture in which we live has put undue emphasis on the achievement of high letter grades. Thus, students will seek to achieve high grades and may pressure faculty members to reward them with high grades. This culture of academic entitlement refers to the growing anecdotal evidence that more and more students view their education as a commodity for purchase, meaning that they should be the ones in charge of dictating its path. This attitude can not only lead to grade inflation but also result in decreased faculty morale, disrespectful student behavior, and altered classroom practices. It is important that faculty members encourage students to take responsibility for their learning and professional development and not rely on educators to give them the grade they feel they “need” to succeed.

While grade inflation is certainly not an issue that can be fixed by a single teacher, or even by all teachers at a single institution, these principles are important to consider when choosing how to evaluate students.


  1. Granberry MC, Stiegler KA. Documentation and analysis of increased grade point averages at a college of pharmacy over 20 years. Am J Pharm Educ. 2003;67(3):Article 77.
  2. Rojstaczer S, Healy C. Where A is ordinary: the evolution of American college and university grading, 1940-2009. Teachers College Record. 2012;114(7):1-23.
  3. Cain J, Romanelli F, Smith KM. Academic entitlement in pharmacy education. Am J Pharm Educ. 2012;76(10):Article 189.
  4. Weil RR, Kroontje W. Grade inflation: causes and cures. J Agron Educ. 1977:29-34.
  5. Scott DM, Bennett LL, Ferrill MJ, Brown DL. Pharmacy curriculum outcomes assessment for individual student assessment and curricular evaluation. Am J Pharm Educ. 2010;74(10): Article 183.

August 24, 2014

Stop Re-Reading … and Try Self-Testing!

by Amanda Schartel, Pharm.D., PGY2 Ambulatory Care Resident, University of Maryland School of Pharmacy

Take a minute and think back on the hundreds of quizzes, tests, and other assessments you have taken during your years in school.  Remember the countless hours and late nights you put in trying to learn everything in time?  Now think about how much of that information you actually remember days, weeks, months, and years later.  If you’re like me, you probably realize just how much of that information you have forgotten.  While you put in a lot of time and effort studying, the information learned was all too soon forgotten.  This is due, in part, to the ineffective and inefficient study strategies that most of us employ.  As students progress on to college and graduate school, poor study habits becomes a bigger problem as the material becomes increasing complex. This problem is particularly important for students training to become healthcare professionals given the fast pace at which medical information changes.1

Student Perceptions and Use of Study Strategies
In order to help our students succeed, we must first identify what study strategies they currently use and what perceptions they have about effective ways to learn.  A survey of undergraduate students at a top university found that repeated re-reading was the most common study strategy (83.6%) with more than half of the students ranking re-reading as their preferred study strategy.  One of the least common study strategies used was self-testing (10.7%).  And the majority of these students avoided self-testing if they could not go back to re-read the material.2

These findings are similar to a study conducted by Hagemeier and colleagues who surveyed pharmacy students about their study habits.  They found that only 11.6% of students would self-test if they did not have the option of going back to re-read the material.  Half of the students reported that if they self-tested, it was to see what they had learned.  Only a third of the students believed self-testing helped them learn more.  The majority of students stated that spreading out study sessions was beneficial, but only 17% scheduled study sessions in advance and 60.2% reported that they crammed for exams.  

The majority of students state that their study habits are NOT based on formal instruction on how to study.1 This suggests that most students have never been trained to study in effective ways.  Interventions by educators may give students the tools needed to succeed.

(In)Effective Study Strategies
We now know that many students use re-reading as their preferred study strategy. But is this actually an effective way to study? Are there other study strategies that are more effective?
While re-reading is common, it has only modest benefits on learning.3  Re-reading is most effective when there is a short delay between readings.  It is not effective when the material is re-read immediately following the initial reading.  Re-reading is most useful for recall-based tasks, and its effects on comprehension are questionable.  In head-to-head studies, re-reading has been found to be inferior to several other study strategies, including self-testing, elaborative interrogation, and self-explanation.3  Students may be under the false impression that re-reading is an effective strategy because they are committing a great amount of time when using this strategy.  But this may be a “labor-in-vain” phenomenon, whereby spending extra time memorizing information does not promote meaningful learning.2 In a comprehensive review of learning techniques by Dunlosky and colleagues, re-reading, summarization, highlighting/underlining, keyword mnemonic, and imagery for text were identified as a low utility learning strategies.3  This was based on research showing that these techniques do not increase performance, lead only to short-term retention of information, and are only helpful for some students and in some contexts.3

So if these commonly used learning strategies are ineffective, which strategies would be more effective for students to use?  Dunlosky and colleagues identified two high utility strategies:  self-testing and distributed practice.3  Both of these strategies benefit learners of different ages and abilities, as well as increase performance across many tasks and contexts.2

The literature has described the concept of the “testing effect” since the 1600s.  It suggests that the act of retrieving information from memory increases long-term retention.1  Also, it has been proposed that self-testing may improve performance by enhancing how students mentally organize and process information.2  The testing effect is not just limited to formal assessments, but can also be seen when students practice recall on their own (i.e. complete practice problems, use flashcards).  In a study of first-year medical students by West and colleagues, researchers found that self-testing was a significant predictor of first-semester final grades and practical examination averages.4

Distributed Practice
We know that many students typically pack their studying into a short period of time before an exam.  While this may lead to short-term retention of the material, it has been shown that spreading out study activities over time, or distributed practice, has greater benefits and leads to long-term retention.  This may be because distributed study sessions force students to repeatedly retrieve previous knowledge, which is known to reinforce memory and retention.  Furthermore, when study sessions are spaced out, it forces the student to work harder to retrieve the information from memory and allows them to more accurately assess their understanding.3 Similar to self-testing, West and colleagues found that time management—including maintaining a study schedule—was a significant predictor of first-semester final grades and written examination averages.4

Help Students Adopt Better Study Habits
Given that many students use study strategies that are less than optimal, educators should provide guidance to students about the value of alternative strategies such as self-testing and distributed practice.  Furthermore, structuring instruction to encourage students to use these strategies, such as creating practice problem sets for self-testing, can help the students to become successful lifelong learners.

  1. Hagemeier NE, Mason HL. Student pharmacists’ perceptions of testing and study strategies. Am J Pharm Educ. 2011;75:Article 35.
  2. Karpicke JD, Butler AC, Roediger HL. Metacognitive strategies in student learning: do students practise retrieval when they study on their own? Memory 2009;17:471-9.
  3. Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Improving students’ learning with effective learning techniques: promising directions from cognitive and educational psychology. Psychol Sci Public Interest 2013; 14:4-58.
  4. West C, Sadoski M. Do study strategies predict academic performance in medical school? Med Educ. 2011;45:696-703.