Atypical Awareness - Responding to the Educational Needs of Patients with Autism Spectrum Disorder

by Elizabeth Yett, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Mississippi School of Pharmacy

In 2018, 1 in 59 children had a diagnosis of autism spectrum disorder (ASD) by the age of 8 in the United States, based on the DSM-5 criteria.¹ However, we are unable to determine a reliable estimate of the prevalence of ASD among adults. Given that there is a spectrum of characteristics that a patient with autism might display, healthcare practitioners have an obligation to identify patients who may have ASD and adapt patient education strategies to meet their needs. As a resident, I have had the pleasure of interacting with 2 pediatric patients (to my knowledge) with autism. They are quite different in their ability to receive information and respond to questions. One patient is completely non-verbal, while the other prefers to play games on his phone rather than engage in a conversation — just like a typical teenager. Reflecting on my own experiences, it is no wonder that people with disabilities, including patients with autism, face significant health challenges and health care inequities. Patients with disabilities report lower satisfaction with health care, lower health self-efficacy when navigating the healthcare system, and lower use of recommended preventative care services.²

Effective patient-provider communication is essential in improving health outcomes. Yet if we do not know (or understand) the patient’s specific educational needs, how can we be certain we are meeting them? Luckily, the Academic-Autistic Spectrum Partnership in Research and Education (AASPIRE) has created the Autism Healthcare Accommodations Tool (AHAT) to assist us in understanding the needs and preferences of people with ASD.³ Reflecting on the ADDIE model of instructional design assists with the analysis of each patient’s individual needs and how best to communicate and interact with the patient. Patients and/or their caregivers can create a personalized accommodations report that includes information to assist with the patient’s preferred communication style, tips to help patients answer questions, and how to approach physical exams. The AASPIRE website also includes great information for healthcare providers regarding the diagnosis of ASD as well as legal and ethical considerations in caring for patients on the autism spectrum.

Finding the most effective communication mode for a patient with ASD can be challenging, especially if it involves changing your usual communication style. Although patients with autism have unique educational needs – indeed, all patients do for that matter – it can be beneficial to understand a few ASD-related characteristics that often impact communication and learning. This recognition, along with a few recommended strategies to accommodate the patient with ASD, can facilitate a more effective patient interaction (Table 1). Along the same lines, this can help you implement ADDIE with an effective design and development of instructional materials that are most appropriate for the patient.

Table 1

ASD-Related Characteristic	Instructional strategies/tips
Tendency to take language literally and a need for precise language Tendency to be visual thinkers	Avoid figures of speech, broad questions, and vague statements Be concrete and specific with questions Show patients lists of symptoms or visual scales to assist with the assessment Create a visual schedule for the patient for when to take his or her medications
Difficulty understanding and carrying out nonverbal communication	Recognize that patients may struggle to understand your body language or tone of voice Respect a patient’s methods of nonverbal communication
Repetitive behaviors (self-stimulatory behaviors or “stimming”) - including hand-flapping, rocking, jumping, squealing, pacing, echoing, and obsessing	Recognize these behaviors as outlets for anxiety and energy Aim to thoughtfully provide an environment to minimize potential stressors Play soothing music during encounters, teach mindful breathing, reinforce appropriate behavior
Need for consistency Limited awareness of time Difficulties organizing	Help patients set up an alarm for when to take medication Link the act of taking medications to specific parts of their daily routine Help patient or caregiver set up pillbox or organize medications Provide worksheets or handouts that can be used to keep track of symptoms or concerns between visits
Adapted from: AASPIRE Healthcare Toolkit. Available at: http://autismandhealth.org/.

 

It is important to evaluate current practices in place in order to make positive improvements. In England, the perspectives of 40 families of children with ASD were gathered through a survey to gain a better understanding of their healthcare experiences.⁴ Families noted the need for healthcare providers to be more knowledgeable and trained about the heterogeneity of ASD, and to view families as allies in facilitating during patient encounters. Earlier this year, Children’s Hospital and Medical Center of Omaha launched a new program called PATCH (Patient Assistance Team at Children’s Hospital & Medical Center) that intends to do just that. PATCH creates a pathway that facilitates communication between parents of ASD-impacted patients and hospital staff. This helps ensure patient needs are clearly and efficiently identified and necessary modifications can be made to the care plan. Wouldn’t it be amazing if a similar program could be implemented at all medical centers!

When working with an unfamiliar patient population, we have an obligation to educate ourselves to best serve their needs. This can include finding appropriate resources (listed below), seeking opportunities to work with or volunteer with patients with ASD, and demonstrating an interest in developing the diversity of our patient care skills. In this way, we can take steps to minimize disparities experienced by patients with autism by improving their satisfaction with healthcare and increasing their self-efficacy.

The main character in the television program The Good Doctor is a physician with autism. One of the other characters on the show, fighting to save the main character’s job, wisely states, “Aren’t we judged by how we treat people? I don’t mean as doctors, I mean as people. Especially those who don’t have the same advantages that we have.” I think we can all agree that it is impossible for us to always understand how to best interact with patients, especially those with ASD. There are always opportunities for improving communication with the patient, family, and other providers to create environments that address their needs. While we shouldn’t treat patients differently based on their disease states or disabilities, we should adjust to their needs. It might not always be easy to interact with patients with autism, but as educators, we need to do our part to achieve the most positive experiences for our patients.

Select readings and resources about Autism Spectrum Disorder:

• Straus J, Coburn S, Maskell S, Pappagianopoulos J, Cantrell K. Medical Encounters for Youth With Autism Spectrum Disorder: A Comprehensive Review of Environmental Considerations and Interventions. Clin Med Insights Pediatr. 2019;13.
• “Autism related guidelines for healthcare providers.” Autism Speaks. Accessed 24 March 2020. https://www.autismspeaks.org/science-news/autism-related-guidelines-healthcare-providers
• “What is autism and how to get involved.” Autism Society. Accessed 22 March 2020. https://www.autism-society.org/
• “Autism news and resources: from autistic people, professionals, and parents.” Thinking person’s guide to autism. Accessed 24 March 2020. http://www.thinkingautismguide.com/
• “Caring for Children with Special Health Care Needs.” National Resource Center of Health and Safety in Child Care and Early Education. Accessed 24 March 2020. https://nrckids.org/CFOC/Special_Needs

References:

1. Autism spectrum disorder (ASD) Surveillance Summaries. Centers for Disease Control and Prevention. 2018; 67(6):1–23.
2. Nicolaidis C, Kripke CC, Raymaker D. Primary care for adults on the autism spectrum. Med Clin North Am 2014; 98(5): 1169–1191.
3. AASPIRE Healthcare Toolkit. AASPIRE. Accessed 23 March 2020. https://autismandhealth.org/
4. Kouo J. Seeking Patient-and Family-Centered Care: The Experiences of Families of Children with an Autism Spectrum Disorder. Autism Open Access 2020; 10: Article 247.

Developing Residents into Preceptors Using the Layered Learning Practice Model

by Brianna F. Waller, PharmD, PGY-1 Pharmacy Practice Resident, Baptist Memorial Hospital – North Mississippi

During their year-long commitment toward becoming a competent practitioner, many pharmacy residents (and other post-graduate trainees) will suddenly find themselves partially or fully responsible for someone else’s learning as a “preceptor." Although assuming this role may make some residents uneasy, the positive benefits of “near-peer” teachers and layered learning have been repeatedly discussed in secondary and higher education literature. Indeed, medical school students report they value and respond well to learning from near-peers due to their recent experience and relatability.  Near-peer teachers are not too far removed from the students’ “struggles” and experiences.¹ Let’s take a closer look at how this can be applied within pharmacy education.

Layered-Learning Practice Model
Senior educators work with advanced learners to teach junior leaners

A survey sent to all residency program directors (RPDs) of ASHP-accredited programs determined precepting opportunities for residents, identified barriers to developing precepting skills, and discovered opportunities to optimize programming. Among the 538 responses, the researcher found that 71% of residency programs did not offer a formal precepting rotation despite the fact that 59% of RPDs admitted their graduates frequently accepted positions that involved teaching / precepting.² Just as importantly, there is a serious shortage of pharmacy preceptors!  In another survey (n= 4,396) of pharmacists, 73% accepted an invitation to precept two or more students in the past year but almost half turned students away.³ This gap is a glaring opportunity for the layered learning practice model.  One of the benefits of this model is the fact that it increases the amount of time that attending pharmacists (aka senior preceptors) can spend focusing on their practice while allowing the resident to spend the most time supervising students and thereby gaining valuable precepting experience. Engaging residents in this role increases the number of people available to precept the growing number of student pharmacists without causing the workflow to suffer. Providing structured experiences for residents to precept students not only helps fill the gap, but they get feedback about their precepting skills before accepting post-residency positions that require them to teaching/precepting.

The layered learning practice model (LLPM) is a teaching strategy designed to train residents to precept students and, in some cases, more junior residents with oversight from a more experienced pharmacist. The four recommended steps to help all parties get the most out of the LLPM are orientation, pre-experience planning, implementation, and post-experience evaluation.⁴ I will use my own experiences with the Teaching & Learning Program during my PGY-1 program through the University of Mississippi School of Pharmacy (UMSOP) to illustrate concepts of the LLPM.

Let’s start by breaking down each component of the LLPM. Orientation to the LLPM is vital not only for the resident but also for the attending pharmacist. This helps outline goals, expectations, and responsibilities for each party, thus reducing the potential for overlap and confusion.⁴ In my own experience, this was extremely beneficial given the chaotic effect that COVID-19 seemed to have on nearly everything at the School of Pharmacy and the Medical Center. I had several meetings with faculty and staff regarding my role, a list of things I needed to accomplish, and, most importantly, how to use the tools to host virtual seminar meetings and IPPE rotation experiences. Typically, during the orientation the resident gets some feedback regarding his/her performance which can help build their confidence and independence.

Table 1: Typical Roles and Responsibilities in the LLPM

Primary Preceptor	Orient resident & student to layered learning practice model, practice site, and staff Create or obtain resident and student syllabus Outline trainee responsibilities Define the expectations of all learners Assist resident performance for clinical and teaching activities Evaluate resident performance for clinical and teaching activities Oversee all patient care activities and pharmacy education
Resident Preceptor	Discuss learning experience with preceptor prior to the first day Assist in the development of student calendar and rotation activities Orient student to practice site and establish goals Integrate student into patient care activities Supervise student during patient care activities Obtain any resources students need to perform required activities Provide regular feedback to students Lead topic discussions and other educational activities Evaluate the performance of the student and provide regular feedback
Student Learner	Report directly to the resident preceptor Actively participate in patient care and rotation activities Provide feedback on the layered learning practice model and resident performance as an experiential educator

Once everyone's roles (see Table 1) are established, pre-experience planning begins. The resident is involved by developing activities and materials for students to uses. Examples include developing calendars, rubrics, and activity descriptions.⁴ For me, I develop presentations and getting a once-in-a-lifetime opportunity to create a 4-hour IPPE experience on chart review & labs.  Because students were no longer allowed at our practice site due to the risk of COVID-19 exposure, I had to deliver this instruction using a videoconference tool. The LLPM process allowed enough structure for me to develop these activities independently, while also having the support of my preceptor when needed.

The implementation stage is relatively self-explanatory. The material prepared by the resident is delivered. The resident is considered the primary preceptor for the student(s), and depending on the activity, they are responsible for assigning them specific patient care duties, evaluating student performance, or providing feedback. The senior preceptor continues to be available and provides guidance to the resident. In longitudinal settings, such as precepting over the course of the month, the preceptor directly observes the resident periodically in order to assess progression.⁴ In situations such as delivering a presentation, it is important that the senior preceptor observe the session in order to provide constructive feedback to the resident, as was done in my case.

Finally, post-experience evaluation occurs whereby the primary preceptor solicits and provides feedback to resident(s) and student(s).⁴ An additional benefit is the identification of potential improvements that can be made within the LLPM at the institution, as well as the opportunity to solicit feedback from both layers of learners regarding their experiences and suggestions for improvement. One of the most helpful ways this was achieved in my own experience was by surveying the students in an effort to measure the effectiveness of my presentation, as well as obtain recommendations for improvement.  Afterward, I discussed this feedback in great detail with my preceptor.

More residency programs should adopt the layered learning practice model, as it appears to not only address the need for more preceptors but also affords the resident meaningful teaching experiences, and provides a more relatable role model for students. 

References

1. Lockspeiser T, O’Sullivan P, Teherani A, and Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ 2006;13(3):361-372.
2. Dipaula BA, Mohammad RA, Ayers P, et al. Residents as preceptors and educators: What we can learn from a national survey to improve our residency programs. Curr Pharm Teach Learn 2018;10(1):21–7.
3. Skrabal MZ, Jones RM, Nemire RE, et al. National Survey of Volunteer Pharmacy Preceptors. Am J Pharm Educ 2008;72(5): Article 112.
4. Loy BM, Yang S, Moss JM et al. Application of the Layered Learning Practice Model in an Academic Medical Center. Hospital Pharm 2017; 52 (4): 266-272.

Advancing Community Pharmacy Practice Through Integrated Course Design

by Joseph Nosser, Pharm.D., PGY-1 Community Pharmacy Resident, University of Mississippi School of Pharmacy and Tyson Drug Company

A wise person once told me, “everyone wants progress, but no one likes change.” In recent years, pharmacy benefit managers (PBMs) have repeatedly reduced reimbursement rates to pharmacies.  For many independent community pharmacies, the traditional dispensing-prescriptions-only service model is no longer viable. Clinical services, such as medication therapy management (MTM), chronic care management (CCM), wellness visits, and immunizations can be (and successfully have been) implemented in community pharmacies to diversify revenue streams. Pharmacy students learn about community pharmacy practice through introductory and advanced practice experiences, as required in the 2016 ACPE educational standards.⁴

A wealth of research supports the effectiveness of experiential learning. However, a call to action has been issued to increase community pharmacy practice exposure in the didactic classroom. A 2011 study found that less than 40% of pharmacy students strongly agreed that they received the necessary education to provide clinical services and only 35% felt strongly confident in their abilities to provide these services in a community pharmacy.⁵ While many community pharmacy advanced pharmacy practice experiences expose students to the delivery of quality clinical service, these results suggest that pharmacy students would benefit from additional didactic instruction through an integrated-curricular design.

James Beane, the author of Towards a Coherent Curriculum, compared a traditional curriculum-based education to a jigsaw puzzle.^1,2 Students have traditionally learned in “disciplinary silos”, moving “from one classroom to another, one time-block to another, one textbook to another, and one teacher to another”.^1,2 Like puzzle pieces, each foundational knowledge course and each practical skill that is learned in a practice lab or experiential course contributes, only partially, to the final outcome. No single learning outcome or “puzzle piece” creates the entire picture needed to become an effective health professional. However, when those “puzzle pieces” in a curriculum are connected-together (in a thoughtful way), it can produce the picturesque mosaic that can truly impact real-world practice. Unfortunately, in most curricula, students gather the pieces of knowledge and skills in a “disconnected, fragmented” manner, and often have difficulty connecting those pieces.^1,2 Moreover, learning in this manner can be like assembling an intricate, 1,000-piece puzzle without the container’s display image.^1,2

In recent years, pharmacy schools have worked toward creating integrated learning experiences and facilitating their students’ assembly of the “puzzle pieces”.¹ Pharmacy education has experienced a paradigm shift to this integrated curricular model away from the traditional disciplinary model where each student was responsible for correlating classroom learning with pharmacy practice.¹ For example, pharmacy students are trained to administer immunizations in their first or second year, while learning about the pathophysiology and pharmacotherapy of diabetes mellitus in their second or third year. However, do students connect their knowledge about immunizations and diabetes mellitus when conducting MTM visits at a community pharmacy? An integrated curriculum intentionally creates a learning environment for students to make meaningful connections between their foundational knowledge and real-world practice.¹

Integrated course design generally includes a careful examination of learning goals, learning activities, and assessment/feedback methods. ³ Instructors for an integrated course must account for situational factors, such as class size, students’ knowledge level, and available resources, which can influence each component. Initially, the team of instructors must develop learning goals that define what students should be able to do in order to achieve success. The instructors use the course goals and resources to create activities and learning experiences that correlate with real-world pharmacy practice. Active learning strategies should be emphasized, which may include facilitated group discussions, group projects, and case-based simulations. Instructors use authentic assessments to measure and evaluate student performance, while also allowing students to provide course feedback for continuous improvement.³

A great example of an integrated course was implemented at the University of North Texas College of Pharmacy.  The goal of the course was to improve second and third-year pharmacy students’ knowledge about clinical and business management skills related to community pharmacy practice. This elective course was created by community pharmacy-trained faculty in collaboration with the university’s Center for Innovative Learning, which supports integrated course design in the classroom. The instructors created course learning goals based on the 2012 NACDS and NCPA competencies for community pharmacists.⁴ Moreover, feedback from community pharmacy residency programs guided their focus to emphasize certain clinical services (i.e., MTMs, CCM, immunizations, wellness visits) in the course content.^4,6 Instructors accounted for situational factors (i.e., class size, student’s prior knowledge) to create meaningful learning experiences. This course was offered to students who had previously completed training in point-of-care testing, patient assessment, and counseling during their first-year. The small class-size enabled student engagement and facilitated discussion.⁴ The course activities included a behavioral change assignment, topic discussions with guest lecturers, quizzes, and a group-based business plan proposal.⁴ The instructors used a pre/post survey to measure changes in the students’ knowledge and confidence. There were statistically significant improvements in student knowledge related to the course learning goals.  Moreover, there was a significant improvement in student confidence to perform these clinical services.⁴ Student feedback identified the guest-lecturing community pharmacists as one of the most valuable components of the course, as they shared real-world experiences that connected clinical knowledge and skills with the clinical services provided in their practices. Students also believed that the business plan proposal and behavioral change assignment helped them to develop the skills needed to implement clinical services and motivate patients towards behavioral change.⁴

The integrated course design model is an intentional process that promotes active learning, connecting students’ foundational knowledge from various disciplines with real-life applications.¹ Instructors should assess students’ abilities to connect and use clinical knowledge and skills across disciplinary boundaries, while also using previous knowledge to make new associations.¹ For example, an assessment could include a case-based, simulated MTM activity with a standardized patient.

While integrated course design has many advantages, several limitations for implementing this model have been identified, including the lack of research evidence regarding its effectiveness and the amount of time and resources required to create course content.¹ However, this model offers a promising alternative method bridging foundation knowledge acquisition to real-world applications.  This form of instruction may be especially when teaching students about community-pharmacy-based clinical services. As the scope of community pharmacy practice evolves, pharmacy programs should use integrated course design to prepare students to effectively implement and perform clinical services in the communities they will serve.

References

1. Pearson ML, Hubball HT. Curricular integration in pharmacy education. Am J Pharm Educ. 2012; 76(10): Article 204. Accessed March 7, 2020.
2. Beane JA. Towards a Coherent Curriculum. Association for Supervision and Curriculum Development. 1995. Accessed March 7, 2020.
3. Mantell A, Moore CS, Barnett A, et al. Composing a course for significant learning. Temple University, Center for the Advancement of Teaching. Accessed March 7, 2020.
4. Bullock KC, Horne S. A didactic community pharmacy course to improve pharmacy students’ clinical skills and business management knowledge. Am J Pharm Educ. 2019; 83(3): 6581. Accessed March 7, 2020.
5. Maynard RA, Wagner ME, Winkler SR, et al. Assessment of student pharmacists’ perceptions on participating in clinical services in the community pharmacy setting. Curr Pharm Teach Learn. 2011; 3: 123–136. Accessed March 8, 2020.
6. Schommer JC, Owen JA, Scime GM, et al. Patient care services provided at primary community pharmacy residency sites J Am Pharm Assoc 2013;53:e125–e131. Accessed March 8, 2020.

Rethinking Assessment Strategies

by Ben Carroll, PharmD, PGY-1 Pharmacy Practice Resident, North Mississippi Medical Center

Since making the transition from a student pharmacist to pharmacy resident, I have contemplated my four years in pharmacy school and whether the assessment strategies the instructors used were ideal. I graduated with almost two-hundred classmates. With such a large class size, my pharmacy school’s ability to provide individually tailored and personalized learning was limited. I feel that not only the school I attended but likely most others across the country, commonly fall short when it comes to using assessment strategies that accurately reflect the extent of a student’s learning.

Recently, I read the book Grading Smarter, Not Harder: Assessment Strategies That Motivate Kids and Help Them Learn by Myron Dueck.¹ In the book, Dueck contends that many of the assessment strategies teachers implement are detrimental to student motivation and achievement. He discusses ways educators can tailor assessment practices that really determine what matters most: student understanding and application of content.

The book challenges the traditional use of the grading policies related to late assignments and awarding zeroes for assignments not submitted. Dueck argues that the use of a grading scale from one to one-hundred does not make sense mathematically. Ten points separate an A, B, C, and D. However, if a student fails to turn in an assignment and is given a zero then 60 points separate that student’s grade between a D and an F. This scale can make missing a single assignment the “academic death penalty” and is mathematically inaccurate. It might be a better strategy to grade all assignments on the GPA scale of zero through 4 in which A=4, B=3, C=2, D=1, and F=0.

Dueck argues that it is unfair to assign a grade of zero to an assignment that was never submitted because this does not accurately reflect how much the student learned. In the book, he proposes giving uncompleted assignments an incomplete and implementing an intervention rather than handing out zeroes. There is a stepwise approach to this tactic. In the first step, the educator sets a timespan when each assignment should be completed rather than a due date. By communicating to students, that they have a certain window of time to turn in their assignment, they are given more flexibility and choice. The actual due date would be the final day in the timespan, but by setting a window of time for work to be completed, students may be less likely to procrastinate. This technique also helps prevent a flood of assignments from being submitted on a single day – making it more difficult for the teacher to grade them all in a timely manner. In the second step to this approach, Dueck suggests using a late or incomplete assignment form. Using this form, the student has the opportunity to explain why his or her assignment was not turned in. The form could include a section in which the student is asked to select potential interventions that might help him or her to complete the assignment. Dueck described examples of how this approach improved student success in his classrooms. One student in particular completed a form explaining that she failed to complete an assignment because of recent bouts of anxiety and panic attacks. This student was introduced to counseling resources at the school that she was not aware were available. Subsequently, her grades steadily improved.

This strategy of using incompletes and interventions rather than zeroes argues against a one-size-fits-all approach to assessing students. Conversely, when using grading and assessment strategies that are individualized, some students may feel they aren’t being treated fairly and others might take advantage of these lenient grading policies. None-the-less, I believe the benefits outweigh the risks. A fellow classmate of mine in pharmacy school was the mother of a child with a chronic illness that required frequent hospital admissions. I know that our school tried to accommodate her in certain ways, but there were times in which more leniency should have been provided in terms of extending deadlines and excusing absences. I don’t believe anyone in my class would have taken issue with a more flexible approach given her situation.

In the book, Dueck also argues that teachers should be more focused on finding ways to promote learning through creativity. In my opinion, pharmacy schools do not emphasize the importance of creativity enough. We take case-based multiple-choice exams with clear-cut, one correct answers. However, when we practice pharmacy in the real-world, we are frequently called to think creativity to solve complex patient issues. I spent countless hours in pharmacy school using notecards, highlighters, and acronyms attempting to memorize every detail about a medication in order to be prepared for tests. While I believe that a certain amount of this type of learning is necessary, I do think we should spend more time practicing “how to think” rather than memorizing. This can be done by setting up more project-based activities which require students to integrate knowledge across a range of disciplines. Perhaps students should not be assessed on their performance during these activities. Removing assessments for these activities may alleviate some stress and students may feel more freedom to think outside the box. They may also be more inclined to ask questions knowing every word isn’t being critiqued. Creativity promotes curiosity and requires students to think on a deeper level about concepts and ideas.

When thinking back on some of my best teachers, I realize that they all shared one common attribute: the ability to motivate. In the book, Dueck states, the best teachers are “often better coaches than teachers” and highlights the value of applying coaching skills learned on the playing field in the classroom. I believe that, in general, coaches are more likely to develop personal relationships with their players than teachers are with their students. Coaches often share personal stories about how they overcame adversity to improve to motivate their players. I feel many students would benefit from their teacher adopting this approach. Coaches also promote the importance of team unity whereas in the classroom it sometimes feels like every-man-for-himself. Teachers can promote more unity in the classroom by not grading on a curve. Grading on a curve encourages students to constantly think about how their grade compares to their classmates. Studies have shown that students in competitive class environments do not learn or retain information as well as students in more cooperative class environments.² Also, the use of a curve is based on the idea that the aptitudes of a single class represent a sample of the general population which is rarely the case.

I think we should rethink the assessment strategies commonly used in pharmacy and other health professional schools.  By adopting coaching techniques and giving students more flexible opportunities to demonstrate what they have learned, they will be more motivated to achieve success, and would, in turn, begin their careers as better clinicians.

References

1. Dueck M. Grading Smarter, Not Harder. Assessment Strategies That Motivate Kids and Help Them Learn.  ASCD; Alexandria, VA., 2014,
2. Humphreys B, Johnson RT, Johnson DW. Effects of cooperative, competitive, and individualistic learning on students’ achievement in science class. Journal of Research in Science Teaching. 1982;19:351–356.

Using Mnemonics and Spatial Visualization to Retain Critical Knowledge

by Robbie Ross, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

A student ruffles through his notes, textbook, and lectures for several hours trying to cram every last bit of information before the upcoming pharmacology exam. He arrives on test day, reads the first question, and his heart sinks; he knows he read about it, but just can’t remember the answer. Memory is an important part of teaching/learning and involves more than just recollection. Memory involves the learning, understanding, and the ability to link information together whether it was taught or experienced/researched on one’s own. When a teacher evaluates a student’s memory through tests, they are assessing more than just recall, but rather a deeper understanding of the information.

Students today live in an age of technology where information is always available at their fingertips and many students come to believe that recalling information really isn’t as important as it used to be. For example, how many of us can recall a friend’s phone number any more? Moreover, we are more likely to remember things we find interesting, which can pose a challenge in some classes. Students are more likely to achieve higher marks in courses related to their major or in electives, and more likely to struggle in general education classes.¹

The responsibility for remembering and retaining information is mutual — both the student and the teacher need to do their part. Educators need to pay attention to the “learning” aspect of “teaching/learning” and help students develop strategies to retain and understand the information. When a student is presented with new information, it is first held in short-term (aka working) memory while it is processed. Short-term memory is limited in capacity and duration — only five to nine items can be held in short-term memory for about ten to twenty seconds.²

This is where memory aids can come in handy. Several strategies have proven effective to facilitate memorization and long-term retention including mnemonics and spatial visualization.

• Mnemonics are strategies for associating words or phrases with a list of facts or principles.
• Spatial visualization involves assigning pieces of information with everyday actions and objects. Then when it is time to recall the information, imagining those actions and objects associated with the information.

Another technique this is often used to memorize information is repeating.  Repeating is simply that, repeating the information to keep it in short-term memory. Unfortunately, repeating doesn’t move the information into long-term memory. Moreover, short-term memory has a limited capacity, so it’s difficult to retain large amounts of information when we rely on repeating. Cramming for an exam is a common example where students often use the repeating method to pass a test but fail to recall the information days or week later.²

Many of us first learned about mnemonics in childhood. For example, “Every Good Boy Does Fine” was a useful way to remember the major musical notes and “Please Excuse My Dear Aunt Sally” was a mnemonic I learned to remember the order of operations in middle school math class. Other methods used in our early schooling included rhymes to remember what year “Columbus sailed the ocean blue” and the months that have 30 days. While mnemonics were useful for retaining these “elementary school” concepts, can these principles be applied to college-level courses where the content is much more detailed and sophisticated? In short, yes! One study tested the use of mnemonics in college students who were required to match a portrait to the name of its artist. Students who used mnemonics to recall the information significantly outperformed those who did not.³ The technique has been used to teach engineering students.  Eighty percent of the students reporting they benefited from the use of mnemonics and believe it help improved their exam scores.³

Mnemonics are rarely used in pharmacy school and vast amounts of information are presented to students from PowerPoint slides. From my experience, cramming for tests is common and most student use the repeating method, reading and re-reading handouts and notes as many times as possible shortly before an exam. This works well for some types of information and for a short period of time (long enough to remember it for the exam), but it is soon forgotten. A few instructors (but not many) still include memory aids in their presentations.  I still remember “Please Let Grandma Brown Bring Peaches To Your Wedding” as a way of remembering the colors of warfarin tablets (pink/ lavender/ green/ brown/ blue/ peach/ teal/ yellow/ white). However, mnemonics are used far less often in college than in elementary school.

Another memory aid that health professional students could use is SketchyPharm and SketchyMedical.com which uses spatial visualization to help learners understand complex topics. This is a subscription-based service first developed for medical students but has one section specifically related to pharmacy topics. A picture is presented and each item in the picture is associated with a more complex piece of information, and essentially helps the student visualize what they are learning through storytelling. This gives the phrase “a picture is worth a thousand words” a whole new meaning.⁴ While there are no peer reviewed research articles (yet) to support its effectiveness, medical students from the University of North Carolina rated the use SketchyPharm higher than many other common exam prep techniques (like flash cards) and 83% of students claimed they used it to study for their Step 1 medical licensure exam.⁵

The use of memory aids diminishes as a student progress from elementary school, to high school, to college, and beyond. Why?  Memory aids work and instructors should be using mnemonics and encouraging students to use spatial visualization to not only recall information but move important facts out of short-term memory. There are lots of websites to help create mnemonics; so, there no excuse not to incorporate them into lectures in combination with active learning activities. Encouraging students to use SketchyPharm or spatial visualization strategies during and after a lecture can really solidify the information being taught.

References

1. Comtois T. Using Memory to Become a more Effective Advisor [Internet]. Manhattan (KS): NACADA Clearinghouse of Academic Advising Resources; 2006 Nov [cited 2020 Feb 22].
2. Banikowski AK, Mehring TA. Strategies to enhance memory based on brain-research. Focus on Exceptional Children [Internet]. 1999 Oct [cited 2020 Feb 22];32(2).
3. Dave H, Awasthi S. An Investigation of the Role of Mnemonics in Higher Education. Proceedings of International Conference on Digital Pedagogies (ICDP) 2019 [Internet]. 2019 Apr 21 [cited 2020 Feb 22].
4. SketchyMedical [Internet]. Sketchy Group, LLC; 2018 [cited 2020 Feb 22]
5. Keepers B, Oh L. Step 1 Preparation: 2020 Hindsight. University of North Carolina [Internet]. 2018 May [cited 2020 Feb 2022].