Spiral Integration in Pharmacy Education

by Hanson Walker, Pharm.D., PGY1 Community Pharmacy Resident, University of Mississippi School of Pharmacy

As new medications, therapies, and healthcare practices are constantly evolving, there is an increasing need to develop a curriculum that allows students to not only acquire foundational knowledge but also learn how to most effectively put this knowledge into practice.  Pharmacy and other health professional schools must constantly evaluate and adapt their curricula to best fit both the volume and breadth of information that must be disseminated and the changing learning preferences of each new generation of learners.  Changing an entire curriculum is certainly a major undertaking; however, it can be accomplished using principles of curricular design.

While learning often occurs by starting with the most foundational information and building towards the full scope of knowledge needed by a practitioner, when designing a curriculum one must start with the end in mind and reverse the process (aka backward design).  If we start with a long list of all the discrete bits of knowledge a healthcare professional needs to know and attempt to incorporate them as we move forward in the curriculum, the result will be a disheveled mess with no demonstrable flow and likely poor learning outcomes. On the other hand, if the overall structure is established at the inception of the curriculum, deciding first what the practitioner must be able to do, and then assembling the bits and pieces that together form the profession’s knowledge base, it can then be integrated throughout the curriculum.  But how? How can we best integrate the plethora of information into a cohesive whole that prepares students for their future careers?

Integration of knowledge has long been a goal of curriculum developers, and this integration has historically occurred across two dimensions.  The first, horizontal integration, includes multiple topic areas (for example, pharmaceutics, pharmacology, medicinal chemistry, pharmacotherapeutics) whereby instructors deliver material related to the topic (e.g. a disease state) in parallel.  Thus similar-level material in each of the subjects is taught concurrently.  This approach can take many forms ranging from multidisciplinary (each discipline works separately), to interdisciplinary (commonalities between disciplines are leveraged to reach a common understanding of a topic), and transdisciplinary (disciplines are so interwoven as to be nearly indistinguishable).  The second, vertical integration, involves the introduction of increasingly complex material across time, where students are presented with basic, foundational knowledge and concurrently introduced to related clinically-oriented foundational experiences in order to bridge the gap between theory and practice.  The complexity of theory and practice experience build over time.  Spiral integration fuses these two concepts together.

In spiral integration, horizontal and vertical integration are merged to form a metaphorical spiral.  In theory, basic concepts are revisited with increasing complexity at various touchpoints throughout the curriculum.  This allows new knowledge and ideas to be correlated with previously learned concepts.  But, there are challenges to the implementation of such an approach. Overcoming these challenges requires both foresight by the curriculum designers and effective implementation by the faculty.

Let’s take a look at a concrete example of how spiral integration might be implemented.  At its core, spiral integration is basically a curriculum structure that involves the layering of concepts from multiple disciplines, with the complexity of the information increasing with each passing year.  In this type of curriculum, basic and clinical sciences are interwoven from the beginning, allowing the student to understand the relationships between pharmaceutics, medicinal chemistry, pharmacology, pharmacotherapeutics, as well as the social and administrative sciences.   Let’s take a closer look at how a specific instructional approach could be spirally-integrated.  Problem-based learning (PBL) is a common teaching methodology within healthcare education, and, like many other educational strategies, it can be used throughout a spirally-integrated curriculum.  PBL cases would be used beginning in the first year of pharmacy school, yet these cases would not focus heavily on therapeutic knowledge that the students have yet to develop but rather on social determinants of health, nonadherence, and healthcare communication.  In this way, students are introduced to some foundational concepts without being overwhelmed by the breadth of knowledge expected of a pharmacist.  Once students progress to the second year, concepts related to therapeutics would be included in patient cases, while reinforcing previously covered concepts learned within the curriculum.  During the third year, students would be given increasingly complex cases with greater emphasis on more complicated aspects of care.  Finally, in the last year of the curriculum, students progress from the fabricated cases to the real-world experiences (aka advanced practice experiences), where all of the knowledge they have gained is put into practice.

Given the seemingly clear benefits of a spirally-integrated curriculum, it would seem that this type of structure would basically be educational canon, but it is not without controversy.  Detractors may argue that while there is significant theoretical value for spiral integration, there is little evidence to support its effectiveness.  This is at face value a true statement, but it is nonetheless a misleading one, as the lack of evidence is in large part due to the difficulty of performing such a study rather than any substantial reasoning or evidence against the concept.  On the other hand, evidence shows that students in an integrated curriculum exhibit heightened retention of foundational information and improved application of learned material to real-world practice.  Due to this combination of theoretical soundness and evidence (albeit limited), integration across domains of knowledge with increasing complexity over time increases our chances of producing graduates ready to enter the workforce as well-informed, competent practitioners.

References

Rockich-Winston N. Toward a pharmacy curriculum theory: spiral integration for pharmacy education. International Journal of Medical Education 2017;8:61–2.

Husband AK, Todd A, Fulton J. Integrating science and practice in pharmacy curricula. Am J Pharm Educ 2014;78(3):Article 63. 

Pearson ML, Hubball HT. Curricular integration in pharmacy education. Am J Pharm Educ 2012;76(10):Article 204.

Schwartz AH, Daugherty KK, O’Neil CK, et al. A curriculum committee toolkit for addressing the 2013 CAPE outcomes. Curriculum SIG Writing Group. 2014.

Life-Long Learning - Not Just Content Expertise but Teaching Strategies Too

By Rachel Rossi, PharmD, PGY1 Pharmacy Practice Resident, Magnolia Regional Health Center

At every stage of my education, a variation of the same refrain surfaced over and over again: you must become a lifelong learner! As a young student, it really didn’t seem relevant to me as I was only concerned about the present class, academic year, or course of study. However, as a new graduate and licensed professional, I now have continuing education requirements and “life-long learning” has new meaning for me. While continuing education is a requirement, it is important to keep up with the up-to-date practices and ideas in your field of study.  Most pharmacists think about learning about new drugs on the market and the latest treatment guidelines from the premier healthcare societies. But what life-long learning related to other professional responsibilities?

As a resident, for the first time, I have had the opportunity to precept pharmacy students. This responsibility has opened up my eyes to the challenges my professors must feel keeping students engaged while (simultaneously) ensuring all the most important information is adequately covered. Which teaching method(s) should be used? Should instructors go the traditional route, in which concepts are shared directly through written materials or a lecture, or through learner-centered activities? While the traditional methods are comfortable in that the instructor maintains all of the control and knows what will be covered, the students don’t always benefit from that teaching style. Thus, the emergence of student-centered learning. So, if student-centered learning is desirable, why don’t more professors use it in their classrooms? Although resources and time are certainly important variables, lack of exposure to new and creative ways of teaching may be an explanation for some. For teachers, continuing education in their subject matter is important but keeping up with the latest teaching methods is also essential.

The On the Cutting Edge Program is a national program established in 2002 for the purpose of bringing together geoscience undergraduate faculty to share teaching strategies and research as well as provide seminars and workshops for teachers to actively learn about new teaching tools.^1,2  These workshops serve as resources for teachers in the science field to learn from each other and gain insight into new teaching practices. From 2002 to 2012 over 2000 faculty and 800 postdoctoral fellows and graduate students have participated in the On the Cutting Edge program which included over 100 workshops and professional development events.³

Researchers measured the impact of the On the Cutting Edge Program on geoscience faculty, focusing on four questions: 1) Has there been a measurable change in undergraduate geoscience instruction moving from teacher-centered lecture to student-engaged teaching practices? 2) What role does learning about teaching play in supporting these pedagogical changes? 3) Is faculty participation in Cutting Edge associated with increased use of student-engaged teaching practices? 4) What impacts do participants recognize as coming from the workshops?³ In order to assess these questions, 120 participants from the On the Cutting Edge program were interviewed at several time points.  In addition, nationwide surveys were sent to 10,000 geoscience faculty in 2004, 2009, and 2012. Each of these surveys garnered over 2000 responses from faculty from both four-year and two-year institutions.

Although the survey respondents were not all participants in the program, several general conclusions were drawn from the data collected. Teaching strategies were categorized by estimated class time spent on interactive activities, questions, and discussion.  If greater 20% of class time spent on these activities, the class session was considered student-centered learning. The frequency of utilizing these strategies was also measured, and teaching styles were categorized as frequent use if the strategy was used on a weekly basis or in nearly every class or infrequent use if it was never used or used once or only several times.

The research found there was an increase in student-centered teaching strategies from 2004 to 2012 based on the results of the survey data.  Faculty who were “education-focused” (those who reported significant activity related to improving teaching) showed more frequent use of student-centered learning strategies compared to faculty who were “research-focused” (those who reported significant geoscience research activity).³ These findings are important because it correlates continuing education for teachers who moved toward more student-engaged classroom experiences.

In addition, the researchers compared the teaching strategies of survey respondents that participated in the On the Cutting Edge program to those that did not. They found that participants in the program workshops and those who use the website were 1.5 times more likely to spend at least 20% of class time on student-centered strategies compared to respondents that did not participate in the workshops or use the website. They were also able to show that no matter what faculty member classification (e.g. education-focused or research-focused) those that attended a workshop or used the website were more likely to use student-centered strategies than those that did not.³

The conclusions drawn in this study are important for both faculty and healthcare practitioners that precept students. While keeping up with the most up-to-date information in your content area/discipline is necessary, it is also important to know how to engage students with the material. Most healthcare professionals have not had formal courses on how to be a teacher or faculty member, so engaging in workshops and seminars on how to bring innovative teaching skills to the classroom is especially important. For faculty who exclusively use traditional methods, are they lifelong learners? Are they seeking opportunities to learn new things about teaching?  This study highlights that even experts in a field can gain for continuing education experiences related to teaching strategies and class organization. As part of the self-evaluation that accompanies lifelong learning, I believe finding and using programs like the On the Cutting Edge should be part of the teachers’ repertoire to continually strive to be a better teacher. Only by reassessing current practices and seeking out new ideas can the best educational opportunities be created.

References:

1. SERC. About the On the Cutting Edge Program. (SERC, 2018); available from: https://serc.carleton.edu/NAGTWorkshops/about/index.html 
2. SERC. Overall Philosophy of Cutting Edge Workshop Design. (SERC, 2016); available from: https://serc.carleton.edu/NAGTWorkshops/about/design.html 
3. Manduca CA, Iverson ER, Luxenberg M, et al. Improving undergraduate STEM education: The efficacy of discipline-based professional development. Sci. Adv. 2017;3: e1600193.  Available at:  http://advances.sciencemag.org/content/3/2/e1600193.ful

Entrustable Professional Activities: Building Core Skills and Expectations

By Andrew Mays, PharmD, CNSC, Clinical Pharmacy Specialist, University of Mississippi Medical Center

As a preceptor for student pharmacists, pharmacy residents, and medical fellows, I sometimes ask myself if I am providing my trainees the best training to prepare them for practice.  While each individual has different professional goals, it is my responsibility to ensure that each trainee has been adequately prepared for the professional roles they will have in the future.  Sometimes, my perspective is clouded by a trainee’s background or career ambitions.  Precepting trainees from multiple professional programs often make it difficult to meet each institution’s unique requirements.  This can leave preceptors with questions about what each student’s experience must include or what to skills to focus on.  Entrustable professional activities (EPAs) provide preceptors a common structure for practice-based experiences.¹

Healthcare is constantly evolving and training programs for each healthcare profession must change to meet the needs of patients. This evolution also impacts the education of students within professional programs.  To maintain consistency, leaders within health professions education must determine how to evaluate student progression and determine when a trainee is ready for practice.  EPAs give preceptors a set of expectations and leads to appropriate and effective feedback.  EPAs also address potential differences between schools and postgraduate training programs.  EPAs can be leveraged to determine trainee competency in “real-life” clinical settings.^1,2

The American Association of Colleges of Pharmacy’s Academic Affairs Standing Committee recently developed the Core Entrustable Professional Activities (EPAs) for New Pharmacy Graduates.³ EPAs are units of professional practice and descriptors of work that are independently executable, observable, and measurable in process and outcome.  These core EPAs were identified as activities or tasks that all new pharmacy graduates must be able to perform without direct supervision when entering practice or post-graduate training.⁴

Recently published research in the American Journal of Health-System Pharmacy looked at the validity of the Core EPAs for New Pharmacy Graduates.⁵ This prospective study asked experienced pharmacy preceptors to complete a 28-item survey that included questions regarding the Core EPAs, the EPA role categories, and respondent demographics. These practitioners supervised students on introductory and advanced pharmacy practice experiences.  To be eligible for the study, the respondents must have supervised at least 6 students over the previous 24 months. The participants in this study represented diverse backgrounds and practice settings. Respondents were full-time, part-time, and volunteer/adjunct faculty and practiced in acute care, long-term care, ambulatory care, and other diverse pharmacy practice settings.

Respondents consistently agreed (>75%) that the EPA statements were pertinent to pharmacy practice and reflected activities that pharmacists are supposed to do in every pharmacy practice setting.

The results of this study show that experienced highly-credentialed preceptors agree that the EPA statements are valid expectations.  Moreover, the EPA statements are focused, observable, and transferable to multiple settings.  However, this study did not survey new practitioner, staff pharmacists, or administrators – groups that might have different opinions about the relevance and applicability of the EPAs.  Also, students and residents were not included in this study.  The viewpoint of pharmacy students or residents may give important information in order to determine the feasibility of the EPAs during training.

EPAs describe the activities that encompass the day to day activities of healthcare professionals.  One important element that has not been adequately addressed is the concept of “trust.”  How will preceptors determine whether a trainee can be “entrusted” to perform these activities?  And if trainees do not demonstrate an adequate level of ability, what is an appropriate intervention?

Along with identifying the critical skills needed to care for patients, EPAs empower preceptors to tailor rotations to better prepare students for practice.  As the use of EPAs increases and students are more consistently prepared for practice, postgraduate training programs should witness a more consistent baseline of knowledge and skill for entering residents.  This will not eliminate students having variations in clinical experiences, but it will allow for post-graduate training programs to build on the expected core.

References

1. Pittenger AL, Chapman SA, Frail CK, et al. Entrustable Professional Activities for Pharmacy Practice. Am J Pharm Educ. 2016 May 25;80(4): Article 57.
2. Association of American Medical Colleges. Core Entrustable Professional Activities for Entering Residency: Curriculum Developers’ Guide. https://members.aamc.org/eweb/upload/Core%20EPA%20Curriculum%20Dev%20Guide.pdf (accessed October 15, 2018).
3. Haines ST, Pittenger AL, Stolte SK, et al. Core Entrustable Professional Activities for New Pharmacy Graduates. Am J Pharm Educ. 2017 25;81(1): Article S2.
4. American Association of Colleges of Pharmacy. Core EPA Domains and Example Supporting Tasks (Appendix1).
   
   https://www.aacp.org/resource/entrustable-professional-activities-epas (accessed October 8, 2018).
5. Haines ST, Pittenger AL, Gleason BL, et al. Validation of the entrustable professional activities for new pharmacy graduates. Am J Health-Syst Pharm. 2018;75: e661-8.

Time-Variable, Competency-Based Education: Benefits and Challenges

by Kelsey Dearman Beatrous, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

Health professions education has traditionally used time, along with practice-experiences and exams, to determine when a student “graduates” and is deemed ready for practice.  Time — measured in semesters and credit hours — sets the pace of learning for students.  But does time and credit hours assure that all learners are ready for practice?  Clearly not.  Is there a better way?  In contrast, competency-based education (CBE) assesses how much students have learned before they progress forward in the curriculum instead of focusing on the amount of time spent completing formal instruction.¹ Competency-based learning allows the student to progress at his or her own pace.  The student completes the degree by demonstrating that he or she has mastered the knowledge, skills, and attitudes necessary to become a health professional.

Photo by Nubia Navarro (nubikini) from Pexels

CBE can also be applied to post-graduate training such as residency and fellowship programs. Currently, practice experiences within residency programs are typically limited to one calendar month and residents move forward each month to a new learning experience, even if they have not mastered the intended outcomes. Introducing CBE would require the resident to master the necessary competencies before “moving on.”  In theory, this is what should happen and what every program should strive for, right?

One program that has adopted a CBE curriculum is The University of Wisconsin-Milwaukee College of Nursing Bachelor of Science Nursing degree option, the UW Flexible Option BSN.² This program permits nursing students to complete their nursing degree by demonstrating their knowledge and skills instead of acquiring course credits.  Students are required to complete a variety of competency-based activities.  Successful completion can take as little or as much time as needed.

While CBE is intuitively attractive, it presents unique shortcomings that may make implementing it across health professional curriculums problematic. As Melissa Medina, Ed.D at the University of Oklahoma Health Sciences Center points out, scheduling introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs) is potentially problematic in CBE.³ These issues are not unique to pharmacy education, but apply to any professional degree program that requires rotations or practice-based experiences before graduation. In CBE programs, students will be ready to advance to their practice experiences at different times throughout the year. A student may be ready to begin a practice experience in June, for example, but without advanced planning, none of the practice sites affiliated with the college/school may be able to accommodate the student, regardless of how ready the student might be. In a CBE curriculum, practice experiences are also competency-based, and some students will likely need more time (or some less) at a practice site before being deemed “competent” by the preceptor to move forward. Although practice experiences are often completed in the later part of a curriculum, scheduling students for experiences that could start at any time during the year and would last for variable durations would be very challenging. It would be extremely difficult for school administrators to assign, accommodate, and predict the length of time students need to complete these experiences. Practice sites cannot accept an unlimited number of students and preceptors might be limited by specific student-preceptor ratio laws. This remains the biggest challenge to implementing CBE within degree programs.

Another potential drawback is that CBE may not suit all students.  Some students prefer lectures in traditional classroom settings.  Students who are less self-directed or require more assistance may fall behind in a competency-based program.  It might be more difficult for faculty to identify students who are performing poorly.

In the UW Flex BSN program, they have found a potential solution by providing adequate support to all students to ensure no one is left behind. Each student is assigned an academic success coach (ASC) when admitted to the program. The ASC guides the student through the entire program until graduation.² ASCs support their students in various ways including academic advising, general tutoring, and mentoring at least once a week as the student progresses through the program.

Another potential problem with CBE is the potential for a large gap in time between completion of the degree requirements and starting residency training. Currently, residency programs start on (or around) July 1st. In a CBE curriculum, if students complete their degree at their own pace, there may be large gaps between degree completion (in September, for example) and residency program entry. On one hand, it would give recent graduates more time to complete board exams and take time off before furthering their training. However, this may be less desirable for many recent graduates aiming to start and complete training as quickly as possible in order to earn a salary (and pay back student loans!). If CBE becomes commonplace, residency programs would have to be open to accepting and graduating residents at various times of the year.

Oregon Health and Science University (OHSU) is currently designing a medical education and residency program called Program to Accelerate Competency-based Education (PACE).  The school plans to enroll students in PACE in 2019.⁴ Students in PACE can begin an OHSU residency program in different specialties outside of the National Match process. Medical students would be allowed to graduate in any semester (spring, summer, fall, or winter) and then enter one of the various residency programs at OHSU at any point during the year. This program requires coordination between the professional degree program and residency training to accommodate trainees at various times throughout the year.

Several health professional degree programs want to move toward a CBE curriculum. Piloting competency-based principles in the earlier courses in a curriculum may be a place to start in degree programs that wish to convert to CBE. Hiring and training adequate personnel to ensure oversight of student performance and provide personalized attention will be necessary to meet the program’s and student’s needs. Professional programs that are closely associated with academic medical centers can work together to provide off-cycle clerkship and residency start dates like OHSU PACE program. However, planning and accommodating students for their practice experiences will remain a critical barrier to fully implementing CBE. For the time being, I believe that the didactic portion of the curriculum could be competency-based but practice experiences will still need to be planned and scheduled based on well-defined start and end dates. None-the-less, enhancing health professional curricula with competency-based elements in the didactic portion of the degree program can help ensure students meet the necessary competencies prior to beginning their practice experiences.

[Editor's Note:  For more information on this timely topic, check out the March 2018 Supplement to the journal Academic Medicine (open access):  Competency-based, Time-Variable Education in the Health Professions. There are a number of articles in this themed issue.] 

References:

1. Ten Cate O, Gruppen LD, Kogan JR, Lingard LA, Teunissen PW. Time-Variable Training in Medicine. Academic Medicine. 2018;93:S6-11. doi:10.1097/acm.0000000000002065
2. Litwack K, Brower AM. The University of Wisconsin–Milwaukee Flexible Option for Bachelor of Science in Nursing Degree Completion. Academic Medicine. 2018;93:S37-41. doi:10.1097/acm.0000000000002076
3. Medina M. Does Competency-Based Education Have a Role in Academic Pharmacy in the United States? Pharmacy. 2017;5(4):13. doi:10.3390/pharmacy5010013
4. Mejicano GC, Bumsted TN. Describing the Journey and Lessons Learned Implementing a Competency-Based, Time-Variable Undergraduate Medical Education Curriculum. Academic Medicine. 2018;93:S42-48. doi:10.1097/acm.0000000000002068

Using the ‘Answer Until Correct’ Assessment Method to Enhance Learning

by Zemen Habtemariam, Doctor of Pharmacy Candidate, University of Maryland School of Pharmacy

Ultimately the goal of teaching is for students to learn.  Not simply for purposes of doing well on a test or getting a good grade, but to encourage students to engage in learning, to see more than one interpretation of the answer, and to improve retention. However, in my experience, how we are assessed in the classroom is not always reflective of what we are supposed to learn or what we actually have learned. Therefore, using a method of assessment that effectively reflects the desired goal – that is learning — is attractive to me.

Let’s look at an example. In my pharmacy school, a common method of assessment is the multiple choice examination (MCE).  Indeed, it's the most widely used form of assessment at many schools.  During a MCE, students are presented with a series of questions and they are asked to pick the one best answer. While these tests have been used for a very long time and are “objective” measures of knowledge, they have their flaws – and may actually discourage learning. For starters, multiple choice examinations foster the short memorization of facts and not the long term retention of concepts. They often foster “binge and purge” behaviors. In addition, MCEs can provoke anxiety because the learner is often forced to deliberate between two arguably good choices. I know these flaws all too well.

However, MCEs are not the only testing method available. Another testing method that might effectively addresses the “flaws” of the MCE is the Answer-Until-Correct (AUC) method. Under the AUC procedure, examinees can select an option for the multiple-choice question.  If the selected answer is not the best choice, the students is permitted to select another answer.  And they can continue to select other answer choices until the best answer is revealed. This type of testing often awards more points for selecting the best response first and awards fewer points as the students additional choices. This method of testing can enhance learning principally by providing formative feedback. Formative assessment is an approach whereby students receive immediate feedback on their work. This can be a critical element for students to achieve deeper learning.¹ Epstein and colleagues² developed a tool using the AUC method on three multiple-choice examinations in an introductory psychology course. Not only did the study find that students taking these types of exams performed better on the course’s final examination, but students would have received higher scores (when compared to students who had previously taken the course) even if a traditional MCE approach had been used. In this manner, the AUC approach actually helped students to retain their knowledge.

In addition to improving student learning, the AUC method may also reduce test anxiety – something many students experience. One study examined the effect of anxiety on student performance during a series of tests of varying levels of difficulty.³ The study found that although highly anxious students tended to do poorly on examinations, students who were prone to anxiety who received positive feedback from their examinations tended to have big gains in their performance, especially on exams of low difficulty (“easy”). The authors highlighted how items or questions of optimal difficulty on an examination often induced anxiety.  But that’s a Catch-22.  Students can only perform at their optimum when their anxiety is reasonably low.  The take-home message from this study is that students can show improvement in their test performance when anxiety is not highly apparent. Therefore, a testing approach that reduces the risk of selecting a wrong answer and utilizes immediate feedback can be expected to reduce anxiety.  This, in turn, allows learns to perform at their best.

Now that we have covered how the AUC method works and its potential benefits, one may be curious as to when and where it can be applied. Health professionals must be able to perform well on a test, but also be able to apply that knowledge to patient care or in the work environment. A good application of the AUC method would be a pharmacy law course. Pharmacy law, not unlike many topics in a pharmacy school curriculum, is important because every pharmacist must understand and adhere to the laws and regulations that govern pharmacy practice and the sale of medications. Traditional testing methods often require long periods of time to score or grade them.  Thus, students won’t know what answers they got wrong until they get their exam back some days or even weeks later.¹ Thus, students are forced to progress to the next topic in the course without having mastered the previous material and don’t have the opportunity to learn from their mistakes. Thus, educators can apply the AUC method by having students take law exams and answer each question until they reach the correct response. This not only teaches them what the correct answers are, but perhaps more importantly, students begin to learn why the other answers are not correct.

Students and educators will benefit from using the AUC method. This assessment technique has been shown to improve academic performance, alleviate anxiety that can hinder students from learning and test-taking, and addresses some of the limitations inherent in more traditional multiple choice exam formats.

References

1. Persky A, Pollack G. Using Answer-Until-Correct examinations to provide immediate feedback to students in a pharmacokinetics course. Am J Pharm Educ. 2008; 72(4): Article 83.

2. Epstein M, Epstein B, Brosvic G. Immediate feedback during academic testing. Psychological Reports. 2001; 88: 889-94.

3. Rocklin T, Thompson J. Interactive effects of test anxiety, test difficulty, and feedback. Journal Of Educational Psychology. 1985; 77(3): 368-72.  [accessed April 21, 2015]