Case-Based Learning: The Adult Way to Eat

By Sarah Luttrell, PGY2 Psychiatric Pharmacy Resident, University of Maryland

          How best to teach a subject changes continuously, and is never unanimous among professionals. An article by Anello suggests that for students to be successful, they must “eat”¹. Eat doesn’t refer to food, but to an instructional design: Experience, Apply and Theory.¹ The application of “eat” boils down to experiencing a theory firsthand, applying the experience, and then learning the underlying theory. The example from Anello involves free trade. First, high-school students engaged in a game based on free trade concepts. Afterwards, they answered questions about their experiences, which framed the game in terms of the theory. After discussing, the didactic information was taught. The benefits to this altered classroom is that students have hands-on experience with the concept before having to comprehend a bulky abstract theory.¹

          The above shows how a classroom can be changed to fit the learners’ needs. The rationale behind this is not only to shake up the traditional student mindset, but also to learn how to apply general theories to clinical practice. Wrenn and Wrenn discuss how to ensure students aren’t simply regurgitating information, but retaining and learning how to critically apply it as practitioners.² They state the keys to ensuring success with this transition from student to clinician are active learning and constructivism.² Active learning facilitates engagement and information retention, while constructivism helps students internalize the subject by rebuilding current understanding using new concepts.² This was demonstrated in Anello’s article, as the students had to be actively engaged during the game and assessment, and then use constructivism during the didactic section to comprehend the theory. 

           

          While games are useful active learning tools during K-12 education, they’re less practical in professional education. Instead, there have been several publications in the last year regarding effectiveness of utilizing case-based learning (CBL) over lectures, requiring critical application of clinical concepts, and teamwork during team-based cases. Overall, the results have been positive. In an E.R. in Spain, medical residents who participated in case-based sessions demonstrated significantly better knowledge retention 50 days later when compared with traditional didactic techniques.³  In addition, Hong and Yu found that adding more advanced cases resulted in improved critical thinking based on higher scores on several critical thinking measurement tools.⁴ In this example, multiple ‘episodes’ of each case were used to show progression of a patient along a disease state, which better simulates a real-world scenario.⁴ This study showed that CBL developed critical thinking skills, which many students lack after graduation.² In both of the above studies, students came out with significantly better outcomes due to increased student expectations and involvement within the classroom. For the pharmacy curriculum, CBL could be incorporated for various large disease states, such as COPD, and require the use of guidelines to complete the case. This builds critical thinking skills and the ability to analyze relevant resources, which are both skills students need to master to become excellent practitioners. 

         

          One benefit of “problem-posing education,” like CBL, is that the “teacher is no longer one who only teaches, but also learns through dialogue with students.”² Each student learns differently and has his or her own way of processing, constructing and rebuilding information. Active learning sessions with engaged students lead to thorough discussions that may result in points the instructor never thought of. This leads back to Wrenn and Wrenn’s assertion that “students are also co-teachers,”² and that learning can be a two-way road rather than hierarchical.  The students learn individually, from one another, and from the professor.

          However, the ‘experience’ gained through CBL is not enough. The students in Anello’s article not only participated in the free trade simulation game, but also discussed the experience, the concepts and, eventually, the underlying theory behind the game.¹ In other words, students need to have “guided reflection and analysis.”² There must be an internal process to link past learning with new concepts, and help construct a new framework the student can continue to build upon. One way to assist students in their reflection is to have questions at the end of each module, or rotation, regarding the most challenging, rewarding, or surprising situation. In addition, less formal methods of reflection can be done after any encounter, such as asking how as student came to an answer, or what could have been done differently after a patient interaction.

Case-based learning has shown to improve knowledge retention, and to build critical thinking skills necessary for medical professionals. The material become more relevant, and, as Wrenn said, “students are more enthusiastic learners when they see firsthand that what they’re learning translates into benefits for those they serve.”² However, this method is time-consuming, and must be undertaken with the understanding that large amounts of prep work are required of both the students and the teacher. In my opinion, complex CBL should be incorporated into curriculum starting first year, but should be balanced with classical didactic teaching. If every class has intensive in-classroom work, the students will not have time to adequately prepare, and knowledge retention will suffer.  In addition, guided sessions to help frame the experiences with an adequate understanding of the concepts at hand is imperative.

References:

1.    TES [Internet]. San Francisco: TES Global Limited; c2017. “Swap the structure of traditional lessons to boost learning; 2017 Jan 20 [cited 2017 Mar 9]; [about 3 screens]. Available from: https://www.tes.com/us/news/breaking-views/swap-structure-traditional-lessons-boost-learning

2.    Wrenn J and Wrenn B. Enhancing learning by integrating theory and practice. Int J Teach Learn High Educ [Internet]. 2009;21(2):258-65 Available from: http://www.sciencedirect.com.proxy-hs.researchport.umd.edu/science/article/pii/S1471595305000405

3.    Muñoz DR, Salinas GA, Díez EF, et al. Training in management of arrhythmias for medical residents: A case-based learning strategy. Int J Med Ed. 2016; 7:322-3. Available from: https://www-ncbi-nlm-nih-gov.proxy-hs.researchport.umd.edu/pmc/articles/PMC5056024/  

4.    Hong S and Yu P. Comparison of the effectiveness of two styles of case-based learning implemented in lectures for developing nursing students’ critical thinking ability: A randomized controlled trial. International Journal of Nursing Studies. 2017; 68:16-24. Available from: http://www.sciencedirect.com.proxy-hs.researchport.umd.edu/science/article/pii/S0020748916302449

Out With the Old, in With the New: Transitioning to a Flipped Classroom in Pharmacy Schools

by Ciera Patzke, PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

In 2015, the American Association of Colleges of Pharmacy reported that 47.7% of the pharmacy school applicants had a baccalaureate degree or higher (Taylor et al. 2016). This is markedly increased from the 40.7% reported in 2008 (Taylor et al. 2009). As the classrooms of our pharmacy schools consist of more mature students, the student body becomes more self-directed in their learning. This additionally occurs as students progress through the pharmacy curriculum. It is therefore important that instructional strategies transition toward andragogic approaches to meet the learning needs of this maturing student body (Peeters 2011). One such approach is the “flipped classroom,” one that transitions toward a learner-centered, learner-responsible approach to education.

What is the “flipped classroom”?

The “flipped classroom” model flips the learning activities that occur during class with those that occur outside of class (University of Texas 2016). It encourages a more active approach to learning, rather than the passive approach that is typical in lecture settings. It also transitions much of the learning responsibility onto the learner. Traditionally, learners are expected to review materials prior to class, listen to a lecture during class, and then apply concepts learned through homework after class. Conversely, the flipped classroom moves a majority of the didactic teaching to outside (prior to) the classroom and utilizes class time for application of concepts. Learners review interactive lectures and materials prior to class and utilize in class time to work through higher cognitive processes with the direct guidance of the instructor (Armstrong 2017).

Does the “flipped classroom” work?

In a study that compared before and after results of the implementation of a flipped classroom in a second-year pharmacotherapy course, final grades of an A or B were much higher after the implementation as compared to before (88% vs. 67%, p=0.005) (Koo et al. 2016). Similar results were seen by Prescott and colleagues after implementing the flipped classroom in their first-year, 2-semester patient assessment sequence (2016). Higher course grades were seen with the flipped classroom model as compared to the traditional classroom setting in both semesters (Fall: 92.2% vs. 90.0%, Spring: 90.3% vs. 85.8%, p<0.001).

Conversely, negative results were seen by Bossaer and colleagues after flipping their third-year oncology pharmacotherapy course, with numerically lower examination scores after implementation of the flipped classroom (2016). These negative results were attributed to the lack of student accountability for completing pre-class assignments. These results are therefore not surprising: not only are the students evading the higher levels of learning during class from inadequate preparation, but they are also eliminating the lower levels of learning that they minimally would have achieved in the traditional classroom setting.

What are some of the drawbacks of a “flipped classroom”?

Time allocation, from both the learner’s and the teacher’s perspective, seems to be the biggest barrier to implementing the flipped classroom model (Rotellar et al. 2016). From the student’s perspective, should in-class time be removed to account for (some of) the increased time spent outside the classroom learning? Or should the number of credit hours received for a course be increased to account for this added time? Koo and colleagues opted to decrease in-class time by 30-60% (and keep earned credit hours the same), yet students still perceived the amount of workload to be much greater than prior to the flipped classroom setting (2016). From a teacher’s perspective, the time (and subsequent cost) allocation is large both upfront (during course development) and throughout (as evidence and guidelines change, and as feedback is received year to year) (Spangler 2014). This time and cost problem can additionally be exacerbated if more than one course (or all courses) in a program is/are flipped.

How do I implement the “flipped classroom”?

There are 9 major principles for design acknowledged by Rotellar and colleagues (2016):

1.    Provide student exposure to content before class

Pre-course activities should comprise of multiple short activities (ex. 6 5-minute videos, each focusing on a different topic) that cover primary learning points and are not excessive in detail. This makes pre-class work more manageable for the learner, and allows for modification of the activities more manageable for the teacher.

2.    Provide an incentive for students to complete the pre-class work

This often is incorporated into a quiz, which a successful grade can only be achieved by completing the required pre-class work.

3.    Provide a mechanism by which to assess students’ understanding of pre-class work

This often includes a quiz at the beginning of class, that also helps increase accountability of students to complete the pre-class work.

4.    During in-class activities, link material back to pre-class material learned

Various activities can be used for the in-class time, and should be tailored to both the material learned, as well as the level of learning the instructor would like the students to achieve. Examples of activities that can be used include (but are not limited to): simulated patients, case discussions, and group learning activities.

5.    Clearly define expectations and provide well-structured guidance

This becomes important particularly for students unfamiliar with the flipped classroom setting. For the past 15+ years, students have been accustomed to (and successful with) learning in the traditional classroom setting, a setting that is much more regimented.  Conversely, the in-class portion of the flipped classroom can be viewed as chaotic and unorganized if well-structured guidance is not provided.

6.    Ensure students have enough time to complete required activities

Timing of when materials will be available or due must be flexible and allow adequate time for the students to complete. Providing materials far enough in advance is crucial for achievability.

7.    Facilitate the construction of a learning community

In-class activities often thrive on group learning, so fostering an environment of collaboration is necessary.

8.    Feedback should be prompt and adaptive

This should occur both within the classroom (during active learning) and after.

9.    Technologies used should be familiar to the learners, and easy to use

This is crucial for the success of pre-class work, which is a prerequisite for success during the in-class work.

References:

Bossaer JB, Panus P, Stewart DW, Hagemeier NE, George J. Student Performance in a Pharmacotherapy Oncology Module Before and After Flipping the Classroom. Am J Pharm Educ. 2016 Mar 25; 80(2): 31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827582

Armstrong P. Bloom’s Taxonomy [Internet]. Nashville (TN): Vanderbilt University – The Center for Teaching; 2017 [cited 2017 Mar 17]. Available from: https://cft.vanderbilt.edu/guides-sub-pages/blooms-taxonomy/

“Flipping” a class [Internet]. Austin (TX): University of Texas at Austin Faculty Innovation Center; 2016 [cited 2017 Mar 16]. Available from: https://facultyinnovate.utexas.edu/teaching/strategies/flipping

Koo CL, Demps EL, Farris C, Bowman JD, Panahi L, Boyle P. Impact of Flipped Classroom Design on Student Performance and Perceptions in a Pharmacotherapy Course. Am J Pharm Educ. 2016 Mar 25; 80(2): 33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827584

Peeters MJ. Cognitive development of learners in pharmacy education. Curr Pharm Teach Learn 2011;3(3):224-9. www.sciencedirect.com/science/article/pii/S1877129711000396

Prescott WA, Woodruff A, Prescott GM, Albanese N, Bernhardi C, Doloresco F. Introduction and Assessment of a Blended-Learning Model to Teach Patient Assessment in a Doctor of Pharmacy Program. Am J Pharm Educ. 2016 Dec 25;80(10):176. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5289732

Rotellar C, Cain J. Research, Perspectives, and Recommendations on Implementing the Flipped Classroom. Am J Pharm Educ 2016; 80(2): 34. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4827585

Spangler J. Costs related to a flipped classroom. Acad Med. 2014 Nov; 89(11): 1429. https://www.ncbi.nlm.nih.gov/pubmed/25350324

Taylor DA, Patton JM. The Pharmacy Student Population: Applications Received 2007-08, Degrees Conferred 2007-08, Fall 2008 Enrollments. Am J Pharm Educ. 2009 Dec 17; 73(Suppl): S2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058400

Taylor JN, Taylor DA, Nguyen NT. The Pharmacy Student Population: Applications Received 2014-15, Degrees Conferred 2014-15, Fall 2015 Enrollments. Am J Pharm Educ. 2016 Aug 25; 80(6): S3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5023992

Motivating Adult Learners

by Jasmine Ebron, PharmD, Pharmacy Practice Resident at Kaiser Permanente

As an ambulatory care pharmacist, I am responsible for monitoring and optimizing drug therapy regimens in the clinic setting, while providing chronic disease state management. I also have the privilege of managing a pharmacist-led diabetes clinic, where I outreach to patients on a weekly basis to obtain blood glucose readings, assess the need for dosage adjustments, assess drug-related problems, and promote medication safety. Managing chronic diseases such as diabetes, hyperlipidemia, and hypertension require patient participation to improve patient outcomes. Part of soliciting patient participation includes motivating my patients, or my adult learner if you will, to take an active role in developing a care plan with me.

When a patient first learns they have diabetes, they often have a lot of anxiety and can feel overwhelmed by all of the lifestyle changes required to tightly control their diabetes. Motivating my patients to stay engage in the treatment plan, and empowering them to feel like they can be successful requires an understanding of how to motivate the adult learner. During diabetes education classes, it is essential to incorporate the ‘Principles of Adult Learning’ into the lesson plan, ensuring that information is delivered effectively.

Adult learners have many responsibilities and must balance the demands of life with the desired to participate in various learning activities. Barriers such as lack of time, money, and scheduling conflicts can lead to lack of participation in the care plan.¹ Having empathy for the adult learner when life does not work out as planned goes a long way to build rapport with patients. When the adult learner, or in my case my diabetic patient, feels that I care about them as a whole person versus just focusing on medication optimization, they typically are more likely to be engage in and adhere to the care plan.

When teaching the adult learner, it is important to present meaningful information in “bite-size chunks” rather than presenting a lot of information that the adult learner has no connection to.¹ I try to first draw the link between a high carbohydrate diet and poor glycemic control, before discussing dietary modifications. I use charts and visual reinforcements to explain these concepts before discussing better food choices that should be incorporated into their diet. It is important for adult learners to see the value in dietary modifications by understanding how it will aid in tighter glycemic control. This understanding will hopefully encourage them to follow their new diet.

Dietary changes can sometimes be very difficult for a patient to make and a patient may be a bit resistant. The way the concept of change is introduce is a critical element as to how well change will be received. If the adult learner feels that they can contribute to the way things are changing versus just being told what to change, the patient may perceive the plan to change as ours plan that we developed together versus having the perception that it is my plan that I told them to adapt. Planning between the instructor and the adult learner gives the adult learner more control of the learning and often leads to easier adaptation of the care plan.²

When a patient’s care plan includes adding insulin to their treatment regimen it is important to provide patients with the proper support and counseling instructions. This phase in diabetes management is even more involved and takes even more participation from the adult learner. Teaching concepts such as how to draw up and inject their insulin, when they should take their insulin, how to adjust their insulin, and what symptoms to monitor for are all important concepts that I review. During this review, I often encourage active participation to help them master these learning concepts. One adult learning principle is that adult learners need to learn by doing.¹ I apply this principle by first demonstrating how to properly draw up and inject their insulin during diabetes education class, then I give my patient an opportunity to use the demo vial and syringe and practice on their own. 

Adult learners learn better in an informal and personal environment,² which is why I offer diabetes training in either a one on one setting, or in a small group setting. When I host a group class I am mindful of the room/environment and seating arrangement. I try to stay away from teaching in a classroom for fear of it being an intimidating setting for some adult learners. Instead I prefer to use a small conference room where I can rearrange the chairs in a circle to create an informal and personal environment if possible. For my elderly patients, who have different learning needs, or for my patients with a lower health literacy level, I encourage a one on one training approach so that I can teach at a slower pace and provided step by step instructions.

Ultimately when addressing the adult learner it is important to understand the different principles that need to be used to reach this audience. Techniques such as providing information in “bite size chunks”, allowing the adult learner to feel that they are a part of the decision making, giving the adult learner an opportunity to actively participate in the learning process, and keeping the learning environment informal and personal are all important principles that will aid in teaching the adult learner.

References:

1. Thomas, KJ. They're Not Just Big Kids: Motivating Adult Learners. ERIC [Internet]. 2001 Apr 8 [cited 2017 March 14] IR012:139. Available from:  http://files.eric.ed.gov/fulltext/ED463720.pdf

2. Collins J. Education Techniques for Lifelong Learning: Principles of adult Learning. Lifelong Learning [Internet]. 2004 March 29 [cited 2017 March 14] 24:1483-1489. Available from:http://pubs.rsna.org/doi/pdf/10.1148/rg.245045020

Collaborative Teaching in the Classroom

by Sherin Pathickal, Pharmacy Practice Resident at Suburban Hospital 

Collaborative teaching is becoming a more prevalent technique in the classroom. It is defined as instructors who have “the joint responsibility to design, deliver, monitor, and evaluate instruction for a diverse group of learners in classes where both are present and engaged simultaneously.”¹ It began as a method to facilitate classroom activities with children with special education needs, but I see collaborative teaching in my own courses. Collaborative teaching in large groups allows smaller targeted group discussions and students spend less time waiting for teachers to help them. Smaller group activities also allows students the opportunity to express their own ideas. Additionally, students are exposed to various methods of thinking, problem solving, or perspectives on topics allowing them opportunities to develop their own thoughts and see collaborative relationships.²

Collaborative teaching allows one teacher to review the material with the students, while the second teacher focuses on helping students who are having trouble grasping the content within the same classroom, allowing instructors to identify students with learning difficulties immediately. Similarly, one teacher may teach while the other simply observes the class. One issue that may arise is that the collaborative aspect may be lost if both teachers continually stay in their respective positions for each class and may ultimately foster an unequal relationship of power. Teachers may also opt for ‘station teaching’. This allows them to divide the topic so that each teaches an area that is most comfortable to them. ‘Stations’ must be timed appropriately to allow an equal amount of time in each area, and also allows students to gain more perspective on different ways of approaching a topic. Parallel teaching allows students to be divided into 2 or more groups, allowing each teacher to approach the same material but in their own way. This allows smaller group discussions while fostering individualized interactions. However, if the instructors are not equally strong in the content or are not covering the same material, problems may arise. Perhaps the more conventional form of collaborative teaching is the ‘tag team’ approach where each teacher will equally cover the material allowing them to establish an equal relationship among themselves, while allowing them to blend their respective thoughts and perspectives on a specific topic. Extensive lesson planning is required to ensure that the topic is adequately covered. Problems with collaborative teaching methods may arise when teachers do not agree on what to teach, how to split the topics, or how to approach the material, leading to conflict. It is important that teachers be proactive and ensure that they have these discussions sooner rather than later.^1,2,3

Our initial live class allowed me to see collaborative teaching in practice. Each pair of residents approached their respective topic in a collaborative manner with virtually every group dividing the material into two equal subtopics while integrating them into one cohesive presentation. These last few months of completing a residency with my coresident has shown me the differences and similarities between us and I am excited to see how we approach the material together. I know that we will both have our own ideas on how to develop the presentation, but it will be fundamental to find a way to allow both of us to highlight our strengths, both creatively as well as professionally, while keeping the class engaged. We will most likely utilize the ‘tag team’ approach where we will divide the work equally and work together to present the material.

Collaborative teaching goes beyond the classroom and extends into the workplace as well. As an incoming resident, each pharmacist broke up the clinical training with each teaching an area that they were more experienced in (i.e. antibiotic consults vs anticoagulation vs parenteral nutrition). Each pharmacist observed the other while they taught us and chimed in when necessary, but for the most part, the most experienced pharmacist in their respective field took over the training for that component.

Teachers should strive to incorporate collaborative teaching in their curriculum. It not only fosters professional relationships, but also allows students to be exposed to a multitude of thoughts and ideas. There are multiple ways to incorporate collaborative teaching. Working closely with other colleagues allows fresh thoughts to be developed, and can allow each instructor a perspective into how the other teaches, while allowing them to refine their own teaching methods. Collaborative teaching takes commitment and proactivity. Meeting before the semester begins and explaining his or her teaching style, what material to present, and how it should be covered, will allow for easy communication and minimal surprises. Instructors should develop a learning plan together to determine how the class will run and how to account for any issues that may arise. Once each instructor agrees on a method of collaborative learning described above, they can test it on their first class with the understanding that they can change their method depending upon the class receptiveness (i.e. changing from station learning to teaching/observing). It is important that each instructor communicate with the other to ensure that they are on the same page and so that they can refine their teaching accordingly.³

Collaborative learning may not be completely integrated into each classroom yet, but it is easy to find small examples that begin to hint at its development. Collaborative learning has many struggles and challenges that come along with it, but also helps to facilitate new methods of learning and allows students to see professional relationships at work.

References:

1.     Building Teacher Partnerships to Support Student Learning [Internet]. New York (NY): United Federation of Teachers; 2010 [cited 2017 Mar 12]. Available from: http://www.ufttc.org/wp-content/uploads/2013/09/Centering_on_CTT_2010.pdf.

2.     Morin A. Collaborative Team Teaching: What You Need to Know [Internet]. USA: Understood; 2007 [cited 2017 Mar 12]. Available from: https://www.understood.org/en/learning-attention-issues/treatments-approaches/educational-strategies/collaborative-team-teaching-what-you-need-to-know.

3.     Keefe EB, Moore V. The challenges of co-teaching in inclusive classrooms at the high school level: what the teachers told us. American Secondary Education [Internet] 2004 [cited 2017 Mar 7];32(3):77-88. Available from: https://www.jstor.org/stable/41064524?seq=1#page_scan_tab_contents. 

The Goal of Education Is Learning, Not Teaching

By Soumil Sheth, Pharmacy Practice Resident, Howard County General Hospital 

Traditional education is defined as teacher-centered teaching to students who are the receivers of information⁵. It is pretty well known that traditional education emphasis more on teaching rather than learning (Bacon and Stewart, 2006). In most classes, memorization is thought to be the key to learning. Most of the information memorized is only remembered for a short period of time and then is forgotten. You can improve your students’ academic performance by incorporating concepts derived from research into how students gain, process, integrate, and apply information and skills. Research has shown that students who have inaccurate or incomplete assumptions and beliefs about a topic will have difficulty grasping new concepts and information (Bransford et al. 2000). Research has also shown that students can more easily recall what they already know and integrate new material when given a conceptual framework (Bransford et al. 2000). I strongly believe that in order to improve students’ academic performance, we will have to optimize student learning for long-term retention and retrieval, and application of information in a real-world setting.

One way we can optimize student learning is by promoting students’ intellectual development. Belenky and associates define students’ intellectual development in three different stages. The earliest stage is known as “received knowledge” where students believe that there is a single right answer. Students believe that knowledge is established facts and that education consists of a professor providing explanations. Students begin to realize, over time, that in many instances there is no perfect answer and learn to revise their thinking. Belenky et al. (1986) define this developmental stage as “subjective knowledge” where knowledge no longer consists of right and wrong answers; knowledge becomes a matter of educated opinion. In the final stages of cognitive development, students begin to have their own opinion on issues on the basis of their own analysis. Belenky et al. (1986) define this stage as “constructed knowledge” where students integrate knowledge from others with knowledge learned from self-experience.

One way to optimize students learning is by helping them retain, retrieve, and apply information. One of the most important concepts is to emphasize the value of the review, reviewing important concepts every few days or weeks. Research suggest that more than half of the new material is forgotten within a matter of days or weeks if they do not continue to review that material as needed based on a student. Strategies such as developing mnemonics, charts, tables and visual images tend to help students retain key concepts. Reiteration of key concepts throughout the semester also help students retain information (Bransford et al. 2000)

In addition, providing opportunities for active learning will also help students grasp important concepts. Students learn by doing, writing, and discussing. Such activities allows them to test what they have learned and how thoroughly they understand the material. The more opportunities students have to restate or apply key concepts, the better they will be able to remember those concepts. Furthermore, creating opportunities for students to learn in the context of real-world challenges will enhance these concepts. Real-world challenges reflect how knowledge is obtained and applied in everyday situations, also known as situation learning. Examples of situation learning include asking students to research literature in order to provide optimal care for their patients, giving a presentation on a disease state, or developing a treatment plan for a patient based on patient related factors and evidence based medicine (Anderson et al. 1996)

Lastly, design tests that emphasize what you want students to learn. Studies show that studying for frequent quizzes enhances students’ long-term retention. What students remember is also influenced by the kind of material that appears on the tests. Cumulative tests are extremely effective because they require students to continually review and integrate the course material.  (Bacon and Stewart, 2006)

Overall, improving students’ academic performance is a multi-factorial approach. The process initiates with optimizing students’ learning to providing opportunities to help them retain, retrieve, and apply information.

References

1)      Anderson, J. R., et al. “Situated Learning and Education.” Educational Researcher, 1996, 25(4), 5-11.

2)      Bacon, D. R., and Stewart, K. A. “How Fast Do Students Forget What They Learn in Consumer Behabior> A Longitudinal Study. Journal of Marketing Education, 2006, 28(3), 181-192.

3)      Belenky, M. F., et al. Women’s Way of Knowing: The Development of Self, Body, and Mind. New York: Basic Books, 1986.

4)      Bransford J. D., et al. How People Learn: Brain, Mind, Experience, and School. Washington DC: National Academy Press 2000.

5)      Hearst Newspaper. The Advantages of Traditional Schools.http://education.seattlepi.com/advantages-traditional-schools-2140.html. Published 2016. Accessed March 16, 2017.

Thinking About Thinking – How can we facilitate metacognition?

by Diana Berescu, Pharmacy Practice Resident, Howard County General Hospital

 

As part of this teaching course, I have worked with students in various settings either through facilitating a case discussion or precepting. I found myself wondering about the differences in self-learning and critical thinking between students. From my experience, those who possess these skills appear to perform at or exceed expectations and I came across a research paper by Schneider and colleagues that supports this observation. Specifically, the paper looked at the impact of metacognition, also known as “thinking about thinking,” on test performance. But I was left with the question: how do we as teachers/preceptors/facilitators help students develop these skills?

 

Critical thinking and self-learning are challenging to teach and require some innate motivation from the student. We know that these skills are important for life-long learning after graduation and they are even stressed by the Accreditation Council for Pharmacy Education (ACPE). Self-learning skills that are addressed in a pharmacy curriculum include reflection, planning, learning, evaluation and recording. These skills are necessary for promoting critical thinking in both students and post-graduate pharmacists (Janke et al. 2012). Metacognition is a skill that is necessary to empower self-learning and understanding of one’s knowledge gaps. A study of 107 pharmacy students assessed the correlation between their metacognitive skills and summative exam performance (Schneider et al. 2014). Students were asked to predict their performance and the authors reported that higher performing students were better at accurately identifying incorrect answers more than lower performing students. This study supports the development of metacognitive skills in pharmacy students.

 

There are different strategies for developing metacognitive skills, but in this essay I focus on reflection and questioning. Self-reflection was assessed among 94 pharmacy students who divided into two groups (Austin et al. 2008). Group 1 completed a standardized test consisting of 24 questions without interference. Group 2 completed the same test but there were two additional questions. The first prompt on the test asked students to rate their own confidence on a scale from 1-10 for question 13. The second prompt occurred at question 18 and utilized “reflection in action” by asking students to provide a brief written explanation and justification of why they selected the answer. The authors reported that for the first 12 questions performance did not differ between the two groups. Following the first prompted question, group 2 had improved performance which persisted for the remainder of the test. While there are some limitations due to design, small sample size and lack of validation of the whole instrument, this study suggests that incorporating questions that require the student to self-assess and self-reflect may improve performance. The findings of these results can be applied to pharmacy courses by inserting similar questions prompting reflection throughout assessments. These answers can be free-text and would not be graded but may support developing metacognitive skills.

 

Reflection and questioning can also be used by students in experiential settings. Problem-based learning involves students learning through problem solving and reflecting on experiences. Metacognitive questioning has also been described to support the development of metacognitive skills in students (Hmelo-Silver et al. 2006). Preceptors facilitate learning and help students develop application of theory and critical thinking. There is evidence to suggest that lower level questions (defined by Bloom’s taxonomy as “knowledge” questions) do not encourage critical thinking. A survey consisting of acute care clinical scenarios was administered to 126 nursing facilitators. The authors found that most questions were knowledge questions (59%) (Philips et al. 2017). In addition, the authors reported that nursing facilitators with teaching education or qualifications asked more high-level questions which were defined as application, analysis, synthesis and evaluation. Best strategies for effective questioning for pharmacy students were outlined by Tofade and colleagues. Outside of Bloom’s taxonomy, they outlined three different strategies for formulating questions: two methods described instructor-generated questions and the third described student-generated questions. This third strategy required students to create their own questions and may lead to deep learning and greater understanding of the course material. Questioning defined as “thinking out loud” also supports metacognition. Questions that may help students include: “what are my goals for learning?” and “does this material make sense to me?” (Tofade et al. 2013). This combination of reflection and questioning can help students learn metacognition. Teachers can challenge students by asking high-level questions and using other questioning strategies.

 

There are several ways reflection and questioning can be applied to facilitate metacognition. The first may be to have students develop their own learning plan or objectives prior to a rotation or even a lecture: “what are my goals for this learning activity?” They can use Bloom’s taxonomy to identify both lower and higher level learning objectives. In addition, facilitators can provide prompts that at different intervals to self-assess or reflect. For example, one could provide students with a list of questions for self-assessment. Questions can include: “Does the disease and treatment make sense to me?” or “why were other treatment options not used?” To take this a step further, the student can then present this information to the facilitator and explain his or her thought process (thinking out loud). The facilitator can ask questions that would deepen the student’s learning and continue to develop metacognition.

 

The strategies of reflection and questioning have been shown to improve metacognition in pharmacy students and can be applied in both classroom and clinical practice settings.

 

References

Armstrong P. Bloom’s Taxonomy. Center for Teaching. Vanderbilt University. Link: https://cft.vanderbilt.edu/guides-sub-pages/blooms-taxonomy/

Austin Z, Gregory PA, Chiu S. Use of reflection-in-action and self-assessment to promote critical thinking among pharmacy students. Am J Pharm Educ. 2008;72(3):48. Link: https://www.ncbi.nlm.nih.gov/pubmed/18698383/

Hmelo-Silver, C. E. , & Barrows, H. S. (2006). Goals and Strategies of a Problem-based Learning Facilitator. Interdisciplinary Journal of Problem-Based Learning, 1(1). Link: http://docs.lib.purdue.edu/ijpbl/vol1/iss1/4/

Janke KK, Tofade T. Making a Curricular Commitment to Continuing Professional Development in Doctor of Pharmacy Programs. Am J Pharm Educ. 2015;79(8):112. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678737/

Mitchell R, Regan-smith M, Fisher MA, Knox I, Lambert DR. A new measure of the cognitive, metacognitive, and experiential aspects of residents' learning. Acad Med. 2009;84(7):918-26. Link: https://www.ncbi.nlm.nih.gov/pubmed/19550190

Phillips NM, Duke MM, Weerasuriya R. Questioning skills of clinical facilitators supporting undergraduate nursing students. J Clin Nurs. 2017. Link: http://onlinelibrary.wiley.com.ezp.welch.jhmi.edu/doi/10.1111/jocn.13761/epdf

Schneider EF, Castleberry AN, Vuk J, Stowe CD. Pharmacy students' ability to think about thinking. Am J Pharm Educ. 2014;78(8):148. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4226285/

Tofade T, Elsner J, Haines ST. Best practice strategies for effective use of questions as a teaching tool. Am J Pharm Educ. 2013;77(7):155. Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776909/