by Jessica Biggs, Pharm.D., PGY2 Pediatric Pharmacy
Practice Resident, University of Maryland School of Pharmacy
If you are a teacher
reading this blog now, I’m sure you would agree that some students seem more
motivated than others. While this may be the case, not all students respond the
same way to motivators. In other words, motivation is not fully explained by HOW motivated students are, but also by WHAT is motivating them. Are they
studying diligently for that pharmacology test with the hopes of getting an A
to please their parent? Are they studying because they have a genuine interest
in the topic? Or is it a combination of these factors? Autonomous motivation,
or a desire to learn due to a genuine interest, has been associated with
greater effort and higher academic performance.1,2 Unfortunately,
many educators fail to create an environment that fosters learner autonomy.
According to the
self-determination theory (SDT), some learners are motivated primarily by controlled
motivation. Others are motivated more by
autonomous motivation. Controlled
motivation refers to a student learning something due to external pressures
(such as a parent or teacher), internal pressures (such as guilt or stress), or
to gain a reward (such as a passing grade or screen time).3 This form of motivation can be seen in B.F.
Skinner’s behaviorism studies.
Behaviorists often use a system of rewards (and punishments) to motivate
learner participation. On the opposite end of the spectrum,
autonomous motivation refers to learning that resulted from a genuine, internally
perceived personal value or interest.3 Simply put, controlled
factors are not the primary, or sole, source of motivation. In reality, for most students, the source of motivation is not so
black and white. Motivators often overlap.
What exactly does the
term “autonomy” refer to? Autonomy is synonymous with volition. When students are autonomous, they act on
their internal desire to align the learning activities with their sense of
self.3 It is important to note that autonomous learning does NOT require students to work alone or without assistance.
At this point you may
be thinking: How is it possible for
students to be autonomously motivated? There’s
no way that they will be interested in absolutely everything I teach? Autonomous motivation is still possible even
if the student is not truly interested in the subject matter because autonomous
learners are able to identify the value and personal importance of what they
are learning.3 For example, as a pharmacy resident, I am not genuinely
interested in learning how to perform open-heart surgery. I do not wish to be a surgeon. On the other
hand, I would gladly accept the opportunity to shadow a cardiac surgeon
performing open-heart surgery because I see the value in understanding the
complexity of the heart and the cardiac anatomy. This kind of knowledge would be relevant so
that I better understand the cardiac medications that I work with and would be
useful during my patient education sessions. I am able to see the value in this
Even though I am early
in my career, I already see the importance of fostering a sense of learner autonomy.
In medical education, autonomous learning has been associated with enhanced
learner effort, superior performance academically, as well as reduced learner
exhaustion.1,2 Since I was
given opportunities to act autonomously both as a pharmacy student and as a
first-year resident, I can attest that I have more energy to take on learning
tasks that align with my goals and my performance is better.
So how can we support
this type of learning? Small group teaching, problem or case-based learning,
and a gradual escalation in learner responsibility and tasks are all appropriate
methods.3 Asking students to lead patient case discussions in a
small group environment (with other students or pharmacy residents) is an
effective tactic. With increased autonomy however, it is also essential to
provide constructive feedback, acknowledge students’ perspectives, and ask for
learner goals and preferences.6 All of these learning opportunities
should be done in a structured manner with an appropriate level of learner
challenge because allowing a student to “run wild” with their own learning is
not what is meant by autonomous learning.
Admittedly, it is
often a struggle to achieve a balance between fostering learner autonomy and
providing adequate supervision. How can a resident (or pharmacy student) gain
real-life experience, including the opportunity to take care of patients
autonomously, while also being appropriately supervised to ensure patient safety?5
Many teachers struggle with this
balance and some micro-manage student activities when it comes to patient care.
In these situations learners may feel their ability to make their own choices
and decisions, one of the important aspects of autonomy, is compromised.1
As a second-year
pharmacy resident I have witnessed the progression of learner autonomy, both as
a learner and now as a supporter of students who seek greater autonomy. Personal
experience has proven to me that practicing in an environment that fosters
autonomy will give a learner the best chance to shine and demonstrate their intrinsic
motivation. It is the job of educators to support learner autonomy – to help
students view the materials they are studying or the tasks that they are completing
as opportunities that will pave the way to the future goals that they hope to
- Kusurkar RA, Croiset G,
Galindo-Garre F, Ten Cate TJ. Motivational profiles of medical students: association with study
effort, academic performance and exhaustion. BMC Med Educ. 2013; 13:
- Kusurkar RA, Ten Cate,
TJ, Vos CM, Westers P, Croiset G. How motivation affects academic performance: a
structural equation modelling analysis.
Adv Health Sci Educ. 2013; 18: 57-69.
- Kusurkar RA and Croiset
G. Autonomy support for autonomous motivation in
medical education. Med Educ Online. 2015; 20: 27591.
- Deci EL, Ryan RM. The “what” and “why” of goal pursuits: human needs
and the self-determination of behavior.
Psychol Inq. 2000; 11: 227-68.
- Hoffman BD. Using self-determination theory to improve
residency training: learning how to make omelets without breaking eggs. Acad Med.
2015; 90: 408-410.
- Cate TJ, Kusurkar RA,
Williams GC. How self-determination theory can assist our
understanding of the teaching and learning processes in medical education. AMEE Guide.
2011; 33: 961-973.
By Virginia Nguyen, Pharm.D., PGY1 Community Pharmacy
Practice Resident, Johns Hopkins Outpatient Pharmacy
We’ve all heard it before. There’s a right time for everything — and learning
is no exception. Research has shown that there are some physiologic reasons why
some people are ‘morning people’ and some are ‘evening/night people.’ Our individual circadian rhythms affect our
attention, executive functioning, and memory.1,2 Some studies have
shown that those who are left brain-dominant perform better in the morning
while those who are more right brain-dominant perform better in the afternoon.3,4
While it is interesting to note how some may perform better in the
morning compared to others, it is impossible for an instructor to optimally
time a presentation or lecture to coincide with every learner’s physiological
predilection. What is more important for educators to focus on are the factors
that they can control that will maximize learning. Below are a few tips
and tools for educators to make the most of their learner’s time and attention.
Keeping it short
In the day and age of social media, texting, and email alerts going
off on a smartphone, laptop, and/or tablet, chances are instructors are
perpetually competing for their learner’s attention. A recent Microsoft study found
that the human attention span has decreased from 12 seconds in 2000 to 8
seconds in 2015.6 In order to make every second count, be sure to
start your educational activity with a hook to gain the audience’s attention.
If you aren’t able to gain their attention off the bat, there’s small chance
you’ll be able to sustain it for the entirety of your instructional activity.
Studies have shown that adults can only sustain attention for about 20
minutes at a time. Experiencing multiple
stimuli during those 20 minutes help to maximize and maintain attention.7
Think about movies or the NFL RedZone- both of these sources are able to grab
the audience’s attention by producing multiple stimuli (different angles and
clips) every few seconds or 1-2 minutes at the most. The effect multiple
stimuli enables the learner to stay focused longer than if a single stimuli is
used for minutes on end.
For most lesson plans, showing multiple movie or football clips isn’t
feasible; however, breaking up the lesson plan by creating different stimuli
related to the instructional objectives can help the audience recharge and stay
engaged. Consider for every 4-5 minutes of instruction, there should be a
change. Perhaps interrupting the lecture
with a discussion question, active learning technique, or different way to
present the material. Use media clips or pictures to break up the monotony of
your PowerPoint presentation. Using different stimuli not only maximizes the
audience’s attention but also their ability to learn.
Taking physical and mental breaks are just as important. There’s a
reason why the MLB created the 7th inning stretch, and it’s not just
so we can sing ‘Take me out to the ballgame.’ Studies have shown that physical
activity can help to boost energy levels, attention, and academic performance.5
Although recess has been phased out of schools across the country, consider
giving the audience a physical recess or break from the material to digest and
recharge. The audience doesn’t necessarily need to run laps around a track or
do jumping jacks, but simply getting up to walk around will help your audience
get back on track (no pun intended).
You, as the instructor, are not the only one accountable for
maximizing audience attention (spoiler alert: the audience member is also
responsible for this). While it’s impossible to sync instructional activities
to account for all left and right brain-dominant audience members, what is
possible is encouraging each audience member to identify times during the day they
are most attentive and to use that time to enhance their learning. Depending on
the audience member’s ‘peak’ time for being most awake and attentive, recommend
they use this time to focus on tasks that require his or her full attention and
problem-solving skills. For the avid coffee drinker, it’s best to think of it
this way: save the tasks that require a high level of thinking once your cup of
coffee has kicked in.
While we can’t teach a lecture or activity to match the physiologic
and biochemical changes of each student, we can make sure that what we teach
captures their attention and energy- no matter what time that is. Depending on
the length of your instructional activity, consider the impact of grabbing your
audience’s attention, interjecting active learning strategies every few
minutes, and incorporating breaks to maintain it. Encourage your audience members to identify
times that they are most awake and attentive and to use that to their advantage
in completing learning tasks.
- Schmidt C, Collette F, Cajochen C, et al. A time to think: Circadian
rhythms in human cognition. Cogn Neuropsychol 2007;24(7):755-89.
- Wile AJ, Shouppe GA. Does Time-of-Day of Instruction Impact Class
Achievement? Perspectives in Learning: A Journal of the College of Education
& Health Professions, Columbus State University 2011;12(1):21-25.
- Klein, J. Attention, scholastic achievement and timing of lessons.
Scandinavian Journal of Educational Research 2001;45(3):301-309.
- Millar K, Styles B, Wastell D. Time of day and retrieval from longterm
memory. British Journal of Psychology 1980;71:407-414.
- Singh A, Ulijtdewilligen L, Twisk JW, et al. Physical activity and
performance at school: a systematic review of the literature including a
methodological quality assessment. Arch Pediatr Adolesc Med 2012;166(1):49-55
- Watson L. Humans have
shorter attention span than goldfish, thanks to smartphones [Internet].
London (UK): The Telegraph, Telegraph Media Group Limited. 2015 May 15 [cited
2015 Oct 23].
- Islam K. Attention Span
and Performance Improvement [Internet]. Cary (NC): Training Industry, Training
Industry, Inc. 2013 1 Mar [cited 2015 Oct 24].
by Jueli Li, PharmD, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center
The objective structured clinical examination (OSCE) is an authentic assessment, where learners are evaluated in a realistic, simulated real-world setting that requires the student to apply their knowledge and skills in a problem-based learning environment.1-3 Although OSCEs are implemented differently at different health professional schools, they all include a series of stations in which standardized patients portray a part in an interactive clinical case scenarios. Students are graded based on a set of items on a checklist that are intended to assess students’ ability to problem-solve.2,3 An overall impression rating is also given to the students and knowledge is indirectly measured based on the response to the case scenario.2,3 At my pharmacy school, students were evaluated using OSCE each spring semester as a part of our pharmacy practice laboratory course. During the first year, students were assessed on one OSCE case and by the time they complete their third year, students are assessed on a series of five case scenarios. Each scenario focused on a different aspect of patient care, including medication reconciliation, patient counseling, documentation, and other pharmacy-related tasks.
The OSCE was initially described in the 1970s as an objective evaluation of clinical competency and has since then been used in the United States Medical Licensing Examination, the Medical Council of Canada Qualifying Examination, as well as the Canadian Pharmacist Qualifying Examination.4,5 OSCEs are used during the professional education of many health professions including dentistry, optometry, nursing, and more. Starting in 2007, the United States pharmacy school accreditation board, Accreditation Council for Pharmacy Education (ACPE), included OSCE as an option for schools to provide simulated clinical experiences.6 Since then, there has been a surge in the number of pharmacy schools who have implemented them.
OSCEs are a valid method to evaluate pharmacy students’ performance. In an observational single-cohort study conducted in the United Kingdom which compared multiple-choice exams to OSCEs, the investigators found that student performance on the multiple-choice exam was only moderately correlated with the outcome of an OSCE (r=0.6). The study showed that OSCE assessed a student’s knowledge and skill, while multiple choice examinations are only able to assess a student’s knowledge.2 These results were further corroborated by another observational study in the United States, where the authors found a very weak relationship between OSCE scores and written examination scores (r=0.15; p=0.24).
A survey of students and faculty have found that the OSCE method was view favorably, particularly in terms of realism. Furthermore, more than 75% of students rated OSCEs as an appropriate way to measure their knowledge, communication, and clinical skills. The results showcased the value of utilizing OSCEs to provide a more comprehensive assessment for problem-based learning as well as building critical thinking, communication abilities, and clinical judgment.3
In 2010, a study sampled 108 pharmacy schools in the United States and found a great deal of variability with regard to how pharmacy schools implemented OSCEs. Many schools indicated that cost and increased faculty time commitment were barriers to implement OSCEs. In order to create valid exams, a consortium of faculty are needed to develop authentic case scenarios and validate checklists. It is also important to provide training for standardized patients and examiners, and to have an adequate amount of space or stations.5
Fortunately, there is a wealth of information on how to implement OSCEs. The Association of Standardized Patient Educators (ASPE) has an OSCE toolkit.7 A paper by the Medical University of Vienna in Austria provides detailed guidance document on how to develop and implement OSCEs.8 Both documents recommend adequate planning in the pre-assessment phase to determine available resources, resource allocation, test logistics, and an “examination blueprint” or a test plan that includes the objectives, goals, and competencies that the OSCE cases will assess. Once those points have been discussed, realistic cases and grading checklists need to be developed. Additionally, it is important to provide detailed instructions – not only to the students, but also the standardized patients. This includes the grading checklists and embedded instructions in the written cases scenarios. To decrease inter-rater variable, the Medical University of Vienna suggests providing standardized patients and graders a frame of reference for a “gold standard” student and identifying standards for pass and fail. The ASPE OSCE toolkit contains a to-do list for developing the cases, instructions on how to implement the OSCEs, how to set the grading checklists, as well as an actual case example, which could be very helpful for any institution.7
The integration of OSCEs into the curriculum allows students an opportunity to develop their critical thinking abilities, communication skills, and knowledge base in a more realistic setting. Current literature suggests that OSCEs evaluate more than just knowledge and complement traditional assessment methods. Schools interested in improving or initiating the use of OSCEs at their institution can find ample resources for guidance.
- Mueller J. The authentic assessment toolbox: Enhancing student learning through online faculty development. J Online Learning and Teaching. 2005 Jul:1(1):1-7.
- Kirton SB and Kravitz L. Objective structured clinical examinations (OSCEs) compared with traditional assessment methods. Am J Pharm educ. 2011 Aug 10: 75(6): Article 111.
- Salinitri FD, O’Connell MB, Garwood CL, et al. An objective structured clinical examination to assess problem-based learning. Am J Pharm Educ. 2012 Apr 10: 76(3): Article 44.
- Harden RM, Stevenson M, Downie WW, et al. Assessment of clinical competence using objective structured examination. Br Med J. 1975; 1: 447-451.
- Sturpe DA. Objective structured clinical examinations in doctor of pharmacy programs in the United States. Am J Pharm Educ. 2010 Oct 11: 74(8): Article 148.
- Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 2007 Jul 1.
- Association of Standardized Patient Educators. Pharmacy OSCE toolkit. [Internet]. (cited 2015 Oct 29).
- Preusche I, Schmidts M, Wagner-Menghin M. Twelve tips for designing and implementing a structured rater training in OSCEs. Med Teacher. 2012; 34: 368.