Using Videos to Enchance Education

Brittany Vogel, PharmD, MBA, PGY1 Managed Care Resident at Kaiser of the Mid-Atlantic States

I have always been a fan of Ted Talks and when I came across this one, I thought it was so relevant to how we teach and learn today! Sal Khan presents a Ted Talk on using video to reinvent education. Khan is the creator of Khan Academy, an online collection of educational videos in subjects from history to calculus.

Khan starts off his talk by speaking about the feedback he received from his cousins after posting instructional videos online. He used to tutor his cousins in person and simply posted these videos online for their supplemental use. The first thing his cousins told him was that they preferred him online in the videos rather than in person. I, along with Khan, first found this funny but then realized how true this is nowadays.

Videos online allow the learner to pause, rewind and repeat something the learner might have missed or misunderstand the first time. Allowing the learning to pause also gives the learner more time to process what was just taught on the screen, or to simply use the bathroom without missing any important information. Being taught online really allows the student to go at their own pace and on their own time.

Other benefits of learning online can also include saving the student from embarrassment. I know I am one of those students that hates to ask questions in class because I think maybe I just missed what was said or I didn’t understand it, and I just need to review it. What if I ask a stupid question and everyone laughs or rolls their eyes at me? I also hate to waste people’s time, whether it be my fellow peers or my teacher. I also hate when teachers ask questions, expecting a response- what if I get called on and I don’t know the answer? I think many students can relate and have these same thoughts!

Khan continues to point out yet another benefit of online learning that may be overlooked- the opportunity to make the teaching experience more individualized rather than the one-size-fits-all lecture from the classroom. Teachers were starting to incorporate his videos into their lessons; they were “flipping” the classroom to have the students watch the videos as homework outside of class and do the typical homework assignments in class. This allowed for a more collaborative classroom. Instead of the students quietly sitting there trying to absorb the material and not talk to each other, they are allowed to interact and learn from each other.

Another interesting concept Khan discusses is testing the information the students are learning. This is usually done with a quiz or exam, in which the student will get a percent grade and move on to the next topic. But this does not necessarily mean that if they got a 100% on that particular exam they know everything or that they will remember it all. This happens frequently with students- they don’t learn the topic, but rather memorize or learn just enough to be able to pass the test. This prevents students from building on concepts and expanding their knowledge. Being able to build on concepts is important in all areas, but I especially see the value for pharmacists. Typically, we learn the basics during our first year- pharmacology, side effects, brand/generic drug names, patient counseling. If we don’t retain these basics onto our second year, where we learn about specific disease states and complex cases, it becomes more difficult to process. Khan says rather than being tested to a percentage, it is best for the student to keep practicing that concept until it is mastered. In order to get a concept mastered though, it involves failing and experimenting- something the learner should not be punished for.

Khan Academy allows student-specific data and class dashboards to be obtained by the teachers. For example, teachers are able to see what videos have been watched, how many times the videos were paused, what exercises they used, and even what or how many problems the students are getting right or wrong. This essentially allows the teacher to be able to focus in on specific areas that the class, or student, may be struggling with during the face-to-face teaching time. Khan states that the Academy has noticed that students may be slow in the beginning, but they use the resources they feel will help them the most and are able to move forward and get faster as they master the concept.

I think the use of video and other online resources to supplement the classroom teaching is exactly what is needed in schools, no matter the age of the learners or the difficulty of the subject. Society is continually developing and we, as educators, would be silly to not use the advances in technology to our benefit. Technology is how students are learning- it is what they are becoming used to. It is important to adapt our ways of teaching to be able to relate and communicate with the students in a way they are familiar with and that is most beneficial to them.

The use of these type of video and online resources to supplement in-person teaching in the classroom would especially be ideal if incorporated into pharmacy school curriculums, for many reasons. One reason to start with is that a large portion of pharmacy students these days are second career students, or students that may have a family. Having an opportunity to review videos outside of the classroom may make it more convenient for these types of students if for some reason they have something come up during class times. It would also be beneficial to these type of students because it may have been a while since they sat in classes, and they may learn better watching videos outside of class where they can take their time and process the information, rather than potentially having to ask questions and get embarrassed during class. Another scenario that this type of teaching would be beneficial for is the other end of the pharmacy student spectrum- those that are fresh out of undergrad or just got their prerequisites. These students may need more structure and providing that both outside of the classroom and during class would be beneficial.

Ideally, the incorporation of video usage and student-specific data in pharmacy education should be used whenever possible.  I don’t think this tactic should be limited to any one particular class. I would recommend this tactic be started in the first year of pharmacy school, slowly getting the students adjusted to this type of education and the tools available to them. This would also be a good time frame for the educators to learn about their students as well to see how they are impacted. By the second year, not only will students have discovered how they learn best and what approach is most beneficial in their learning experience, but the teachers will also have a good working knowledge of how their students learn. This would especially be valuable during second year when pharmacotherapy topics are started, topics that often build upon previously learned material. I think the repetitiveness and individualized learning experiences via instructional videos and materials online will only help developing pharmacy professionals throughout their pharmacy career.

 

References:

1. Khan, Sal. “Let’s use video to reinvent education.” TED. Mar 2011. Lecture. Available at: https://www.ted.com/talks/salman_khan_let_s_use_video_to_reinvent_education?utm_source=tedcomshare&utm_medium=referral&utm_campaign=tedspread

Teaching Students to Think - Focusing Beyond the Grade

By Chih-Wei Hsu, PGY-1 Pharmacy Practice Resident, MedStar Union Memorial Hospital

With grades being one of the criteria for admission to most colleges and graduate schools, getting student loans, and applying for scholarship, it is hard for students to not to put their attention to grades. For instructors, grading is a pretty straightforward measure to evaluate how well the students are learning and how much they understand the materials delivered in the class. However, this distracts instructors from providing a more positive and effective classroom environment for learning and it also distracts students from focusing on learning and lead them to more studying just to pass the class. But we can’t really blame students on being too focus on getting good grades at school. The reason being although most of the time when you get into real-world work environment, no one cares about the grades, but before getting to that stage grades sometimes matter depending on which career pathway you choose. For instance, if pharmacy students are thinking about getting into residency after graduation, all the programs have minimum GPA requirements!

Grading is definitely still one of the essential tools used for providing feedbacks regarding one’s performance. First. let’s take a step back and look at how grade system developed in the past. The first official record of a grading system was back in 1785 in Yale and it was graded into four categories: Optimi, second Optimi, Inferiores, and Perjores.¹ At some point in the early 1900s, 100-point scale was very commonly used with the purpose of providing a more uniform measure in grading, but it was found that 100-point scale was actually not that reliable and different teachers teaching different subjects assigned grades very inconsistently. That lead us to the A-F grading system that we currently use the majority of the time because researchers thought this provided more reliable communication of the evaluation between institutions and from teacher to teacher. Of note, neither the 100-point scale or A-F grading system were designed to motivate students to learn. With that being said, it is quite concerning when seeing one of the studies found that faculty members who were classified as “easy graders” were given better evaluations by students instead of evaluating from the viewpoint of how much knowledge they learned from the faulty members.²

The A-F grading system instructors currently use to evaluate students’ performance will probably not change in the near future, but what can instructors do to achieve the balance and make students’ pay attention not just to their grades but also why and what they learn?

1.   Come up with their own goals and objectives: This helps students to conceptualize the purpose of their learning and can motivate students to think about the things they are learning or what they want to learn, not just studying for good grades.

2.   Think about how the knowledge will be used before the class starts: An author from one of the articles provided a very good example. There was an instructor asked his students to think about their professional destination, what skills and knowledge they are going to need in a real work environment, and do they have enough of those skills or knowledge? Give students some time to do self-reflection prompts them to examine what knowledge or skills they need to acquire in order to be successful for their future careers and be more responsible for their own learning experience.

3.   Present the topics they are interested in: When people are doing things they like and are interested, it increases their engagement in process. “If you can teach it you know it.” By letting learners prepare their own teaching materials, they would at least master part of the course content.

However, it would be hard to implement these activities if class size is large and could potentially make teaching less effective. Take therapeutics courses in pharmacy school for example, those are required courses that every pharmacy student has to take. This tells you that you are going to have a lot of audiences at baseline, so this is probably the time that traditional teaching strategy and A-F grading system are preferred. On the other hand, for some of the elective classes for specialized pharmacotherapy (e.g., oncology, geriatric, infectious disease, … etc.), the activities listed above could be feasible and more applicable since the class size is usually smaller and most of the students already have baseline interests to those topics when they enroll in these classes. Let’s change the setting a little bit. Preceptors of IPPE/APPE rotations may consider to have students complete activities 1 and 2 prior to their rotations and activity 3 during rotations. This way not only it helps preceptors to know what the students want to get out of that rotation, but it also gives students opportunities to reflect on themselves to see if they achieve their goals at the end of the rotations. Keeping the balance being between evaluation-oriented and learning-oriented is hard. Therefore, when appropriate, use the three activities suggested above to engage learners more and have them take control in their learning process and to shape the learners’ mindset more towards learn to think, not just learn to get good grades.

References:

1.   Schinske J, Tanner K. Teaching More by Grading Less (or Differently). CBE Life Sci Educ. 2014 Summer; 13(2): 159–166.

2.    Kidd RS, Latif DA. Student Evaluations: Are They Valid Measures of Course Effectiveness? Am J Pharm Educ. 2003;68(3): Article 61.

3.   Farias, G., Farias, C. M., and Fairfield, K. D. Teacher as judge or partner: The dilemma of grades versus learning. Journal of Education for Business. 2014; 85: 336-342.

To Grade or Not to Grade?

By Deanna Bauerlein, PGY-1 Pharmacy Practice Resident, VA Maryland Health Care System

In traditional education, students are evaluated using number or letter grading systems. Grading in various forms have been used since the 1600s¹. The first letter grading system used was in 1984 by Mount Holyoke College in Massachusetts¹. Their grading system originally used letters A through E, but in 1898 they switched E to F to signify failure¹. As the number of schools grew there became a need to have uniform grading across universities², creating the grading culture we know today. However, there is much debate on whether this system is beneficial to the learner. There are numerous thoughts that make one question the use of grading systems. First, do grades motivate or punish students? Second, how well do grades translate to a level of understanding of the material? Such questions allow one to explore that pros and cons of grading systems.

The first question is whether grading helps or harms the learner. Grades can motivate the learner to do well in hopes of getting a good grade. This positive reinforcement however, may encourage the student to only study for a test to get a good grade, rather than to understand the material. Students may become competitive against one another to get the best grades. This can be good as it pushes and challenges students, however some personality types can take this to an extreme and obsess unhealthily over grades. For students who obsess and/or have a family culture that highly values grades, grades may act as negative reinforcement if students fear bad grades which can cause stress, anxiety, and shame¹. This can lead to a negative feedback loop, that for some students, can be hard to break. Additionally, do low grades motivate students who are doing poorly to work harder - or to give up²? This likely differs from person to person as everyone has varying levels of resilience. All things considered, grades may do more harm than good for students where psychological benefits are concerned.

The next thing to consider about grading systems is the actual value grades have. Tests can either be free-response or multiple choice. Free response questions are great because the teacher can really get a sense of the understanding of the student. However, grading of these types of questions is very subjective; different teachers may grade the same answer differently, and one teacher might grade the same answer differently from one day to the next. Multiple-choice questions are more objective however, they limit the student’s ability to think critically and can underestimate how much a student truly understands if they just happened to guess correctly. 

Furthermore, the use of curves when a class does poorly should be considered. It is assumed that a class is a sample of the population, and thus grades should be normally distributed¹. When the grades do not come out as such, teachers can adjust the grades to represent a bell-shaped curve. This causes two problems. First, grades become based on the test taking abilities of each specific class. If the class average is below what the population average should be, those students are rewarded with an improved grade because the class was not a true sample of the population. In addition, if a class as a whole does poorly, it may not be entirely the fault of the students. Perhaps the test was too challenging or poorly written, or the teacher did not prepare the class well - or a combination of such factors. The second problem curving creates is that classes from one year to the next cannot be compared to each other, as some grades may have been inflated with curving. Therefore, it goes back to the issue of whether grades can be translatable to different students and classes. This was shown in a study done by Rojstaczer, et al. (2012) that showed grading standards have lowered and that A was the most common grade given in 135 colleges across America³. 

The bottom line is there is no perfect way to grade, and with that grades need to be taken with a grain of salt. Even if one can get past how we grade, the specific student needs to be accounted for. There are many bright people who are poor test takers and there are many people who test well, but may not be able to retain or apply the knowledge. Therefore, grades do no correlate to future success. Yet grades are so highly valued, and sometimes students are not even considered for a job or residency because their GPA is too low. Meanwhile, maybe a student’s GPA is low because they were very active in extra-curriculars or had a full-time job. Thus, it is not fair to define the value of an employee based on one number. However, I do not see this changing because it is easy to use this objective information to compare students and to weed out job applicants. If I am ever in the position to hire employees I will not be using GPA as my sole criteria on evaluating candidates. If I did, I would be doing my institution a disservice by potentially missing out on excellent candidates. Especially in health care, subjective information is more important because to me it does not matter if you can take care of a paper patient on a test. I want to know how you take care of real patients in real life settings that are not as black as white as tests. Meeting candidates and asking them about certain situations and how they handled them, in addition to references from previous preceptors and supervisors would be more useful information. Although this may be true in some cases, I do not think a pharmacist who did poorly in school would make a bad pharmacist. I personally feel I have learned and retained more on APPE rotations and residency than I learned in school. So even if a student genuinely did not understand certain topics in school does not mean they will never understand. Maybe they just needed to be exposed to the topic a few more times or have it explained in a different way. Although it is great when someone has a high GPA, it should not be the only thing that matters as this number tells so little about the specific student.

As one can see, there are many flaws with grading systems. However, they are used by most schools since there is no better method for tracking a student’s progress and making a determination if the student understands the material enough to progress. This does not mean that modifications are not needed. One way to take the pressure off both students and teachers would be to have some assignments assessed just for effort and participation alone¹. This can encourage students to try their best for the sake of learning rather than just to achieve a good grade. Another method would be to have students correct their own assignment or have peer reviews. These grades do not have to be recorded, but giving the student a chance to recognize his/her own mistakes has additional learning benefits. Peer reviews allow for students to learn from each other and not from the teacher alone.  Two other strategies for grading is to use rubrics to limit subjectivity of grading and to avoid curving test grades. If a class does poorly on a test, extra credit can be assigned such as students correcting their tests. This allows students to earn an improved grade and encourages the student to rectify what they misunderstood before¹. In conclusion, grading systems will always be used as a way to evaluate students, but it is up to the teacher to use a grading system that motivates students and measures understanding as accurately as possible.

References

1.   Schinske J, Tanner K. Teaching more by grading less (or differently). Life Sciences Education [Internet]. 2014 [cited 2017 May 7];13(2):159-66. Available from: https://www.researchgate.net/publication/274836095_Teaching_More_by_Grading_Less_or_Differently

2.   Grant D, Green WB. Grades as incentives. Emprical Econom [Internet]. 2013 [cited 2017 May 7];44(21):1563-92. Available from: http://www.shsu.edu/dpg006/gincentives2.pdf

3.   Rojstaczer S, Healy C. Where A is ordinary: The evolution of American college and university grading. Teachers College Rec [Internet]. 2012 [cited 2017 May 7];114(7);1-23. Available from: http://www.gradeinflation.com/tcr2012grading.pdf

Cultural Competency and Teaching

By Sinead Cooper, PGY-1 Pharmacy Practice Resident, Western Maryland Regional Medical Center

To be a competent and successful teacher, it is vital to be aware of different cultures to appropriately teach all of your students.  One seemingly innocuous comment can offend a student and can alter their whole perception of you as well as the class.  Being culturally competent is an essential tool in the teacher’s arsenal to have an effective and thought-provoking class.  When teaching a technical class, such as a pharmacy or science course, it may appear to be cut and dry and unsusceptible to unintentional offense, but this is not the case.    

          While different cultures stems from more than just different ethnicities, it is what one generally thinks of when different cultures are discussed.  Thirty percent of the US population is racial minorities, and by 2050, minorities are expected to become the majority¹.  Different cultural backgrounds can have different characteristics such as gender, ethnicity, sexual orientation, country of origin among other demographics.  Every individual has different cultural boundaries, and while it is not realistic to cater to every aspect of every individual, it is important to not isolate students.  A big issue is unintentional cultural blindness, where people are unaware that what they are doing is offending others.  To become culturally competent, you, as the teacher must develop interpersonal awareness as well as leaning specific bodies of cultural knowledge.  Gaining cultural intelligence is important to teaching everyone.  In teaching different cultures, you must have knowledge of different cultures, an awareness of how culture shapes individuals, an understanding of social context of different, and an ability to delineate information in a way your pupils can understand².  Additionally being flexible and adapting to new situations or responses from your students is key.  An interesting article by Tanner and Allen discussed how to gain cultural competence in the college biology classroom.  I found this to be very applicable to teaching in science courses in general as well as pharmacy courses³.  

          Studies have shown that some students of different cultural backgrounds are a driving force for course selection³.  Students may be unwilling to abandon their own cultural identities and assimilate to a different cultural identity; they may not identify with their peers in the science community and may feel like an outsider.  An issue that has been identified is teaching concepts without context to the real world.  Some people, particularly females of color found this narrow focus had a negative impact on their learning³.  An easy remedy is relating it to real world scenarios, to keep the audience engaged and motivated. 

          To become a culturally competent teacher one must not only be aware of cultures other than their own but a self-reflection on the role their culture played on their education.  Four main ways were identified in the above mentioned study to teach with cultural competence.  The first is monitoring and changing ordinary language in the classroom to avoid any assumptions and unintended exclusions.  Another way is to become aware of patterns of interaction with students. This includes who we call on typically, who we praise or scold; even who we say when referring to a group project.  You, as a teacher can work on this by seeing who you normally talk to, looking at demographics of students, and if a small classroom setting, trying to understand each students backgrounds.  A third tactic is to integrate cultural relevance and diverse role models into your curriculum.  Some of your students may not have any role models in science that they can feel they can really relate to, for whatever reason.  As a women growing up, I didn’t know of any female leaders in science, it was only until I got older and did more research I was able to find female role models.  Highlighting the backgrounds of some of the people mentioned in courses, I think, could play an important role in creating more role models.  Finally the last tactic is confronting and revising differing expectations and stereotypes of the students, and is perhaps the most difficult.  Confrontation is never easy, and when dealing with stereotypes it get particularly dicey.  Subconsciously some teachers may treat students differently or have different expectations for their students.  The teacher’s expectations for students, regardless of their accuracy can have an impactful effect on students; this phenomenon is known as the Pygmalion effect³.  When a teacher has high expectations, the student will do better academically, regardless of their abilities³.  Removing these unintentional stereotypes is the end goal to become a culturally competent teacher and require hard work and dedication.   

          Becoming a culturally competent teacher is an important aspect in being a well-rounded and impactful teacher.  Despite many people’s perceptions that science classes are removed from bias, studies have shown that is not the case.  Through work and dedication of others cultures and being open can help new teachers become culturally competent.     

References:

1.    Kripalani S, Bussey-Jones J, Katz MF, and Genao I.  A Prescription for Cultural Competence in Medical Education.  J Gen Intern Med 2006;21:1116-1120.  Accessed Apr 2017

2.    Seeleman C, Suurmond J, and Stronks K.  Cultural competence: a conceptual framework for teaching and learning.  Medical Education 2009;43: 229-237.  Accessed Apr 2017

3.    Tanner K and Allen D.  Cultural Competence in the College Biology Class Room.  Amer Soc Cell Bio.  2007;6:251-258.  Accessed Apr 2017

Incentives in Education

By Sheena Matthew, PGY-1 Pharmacy Practice Resident, Medstar Union Memorial Hospital

Many theories have been created, and presented within this class, to aid teachers in their quest to teach. Some theories outline various learning styles that students possess, while others describe different teaching methods that may be effective to convey knowledge. Although there is already much guidance that exists, one of the largest struggles that teachers still face is eliciting the attention of their students so that they are able to retain the information with which they are presented. However, a newly proposed solution for this problem has been gaining the attention of many teachers and students alike.

Researchers at Bentley University in Massachusetts recently conducted a study which evaluated the influence of a cash incentive on students’ standardized test scores. A randomized, controlled trial was done in which students from nine different middle and elementary schools in Chicago were offered a $90 reward for a passing test score. Students were given a small test, with a cash reward, within the same week as their standardized test, for which no reward was offered. While these students were already deemed to be at risk of not passing their state reading and math tests, they were found to score substantially better on their test when a cash reward was being offered. Additionally, students tended to score higher on easier questions, when offered a financial incentive, suggesting that better scores came from students trying harder and more carefully reviewing their work when they were offered an added benefit.

Although this study already affirms the notion that students who work harder are more inclined to perform better in school, it also suggests that nearly all students are equally capable of achieving such goals. While some argue that such incentives may undermine the actual ability of the teacher to guide their students, I believe that this method of offering an incentive for learning may actually emphasize the teacher’s ability to do so. For example, Gagne’s Nine Events of Instruction outlines that an effective learning process includes gaining attention, providing a learning objective, stimulating recall of prior knowledge, presenting material, providing guidance for learning, eliciting performance, providing feedback, assessing performance and enhancing retention and transfer. There are many ways in which this technique aligns with Gagne’s steps. By extending a performance based cash reward, the teacher will nearly always gain the attention of his/her students; the students will instantly become interested in the topic at hand because they see the instant benefit of learning the material in the form of cash. Additionally, the student will then be assessed on their performance, in the form of a test, in which those students who perform well will be rewarded.

While this technique addresses some of the steps of Gagne’s Events of Instruction, it does not address how the material should be delivered or what methods may work best for ensuring students learn the material at hand. This will have to come from the experience within the classroom and what styles the students find most helpful to aid in their learning process.

Realistically, in terms of pharmacy school, students would benefit from a system like this; however, again, monetary rewards would not be feasible. Gaining the attention for these students would most likely be best achieved when concepts are taught and applied to real world situations, or simulated with actual patients. Additionally, it would be beneficial to provide incentives including less assignments or bonus points when a task is done well.

Although this unique idea of extra motivation for students poses a potential aid to the teaching environment, it of course, may not be feasible to offer all students cash rewards for every task at hand. Even if only offered as a way to assess some performances, this may hinder students’ performance on other tasks and make the student less motivated when a reward is not offered. While this may not be the best solution for both teachers and students, it does provide an interesting idea and helps show how some of the teaching strategies that have been presented within our class can be put into practice.

References:

Kamenetz A. Paying students may raise test scores, but the lesson is not over. NPRED. May 2016.

Khadjooi K, Rostami K, and Ishaq S. How to use Gagne’s model of instructional design in teaching psychomotor skills. Gastroenterol Hepato Bed Bench. 2011. 4(3):116-9. 

Teaching for Mastery – How Video-Learning is Changing the Face of Education

Ana Vega, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

In his 2011 TED Talk entitled “Let’s use videos to reinvent education” Salman Khan explores the idea of a global electronic classroom.¹ As an avid user of the Khan Academy videos myself, I was curious to discover the data that has grown to support this method in just a few short years. From a health education perspective, there are numerous examples in the literature regarding the use of video education to improve skills and understanding for both practitioners and patients.^{2, 3, 4} Nonetheless, uptake has lagged in the classroom. Khan has evolved his idea into a well thought-out method that is quite possibly the future of education. He details three main points in his talk related to educational theory and practice.

1.  Video-learning eliminates the one-size-fits-all classrooms.

One of the benefits of video-education, as discussed by Khan, is that learners can engage with material at a personal pace. Whereas the traditional classroom environment requires learners to sit and listen to their professor lecture for hours, videos allow the learner to choose when to pause, play, repeat, forward, speed, or slow down the lecture at their leisure. It provides the opportunity to have an animated, virtual professor that you can control to fit your needs. In the traditional setting, educators labor for hours creating fun and interactive lectures that often miss the mark, simply because all students are not created equal. For instance, take students A, B, and C. In a typical lecture hall, student A may miss a concept presented 30 minutes into the lecture, student B may have difficulty remaining attentive near the end of the lecture, while student C may not recall previous material adequately and be lost from the minute the lecture starts. The professor will inevitably move on to cover all topics that meet predetermined curriculum standards without the ability or time to confront the issues faced by student A, B, C individually. Video-learning eliminates these issues by allowing personalized learning in which a student can move at their own pace, return to previous modules when necessary, and test their knowledge until they master a concept.

One of my favorite quotes from the Khan’s talk is: “Our traditional model penalizes experimentation and failure but does not expect mastery.”¹ This is absolutely true in my experience. My public school education emphasized learning to achieve certain test scores (i.e. to pass state-administered standardized testing) more than learning for mastery. With this system, even high-achieving students suffer as all students become victims of resulting gaps in knowledge. For instance, even for those who consistently scored a 95 in mathematics throughout school, the current system is not designed to revisit the one or two concepts they may have not adequately grasped. The lesson plan must go on! On the other hand, the video-learning model includes interactive quizzes and games tied to every concept at the touch of a button. For this reason alone, whether used as a supplement to classroom education or as a stand-alone system, I believe video-learning will become the future of education.

2.  Video-learning allows for tracking of life-long learning.

A second benefit to video-learning is the ability to track life-long learning. In his TED Talk, Khan jokes that if Isaac Newton had recorded videos on calculus, the Khan Academy wouldn’t have to.¹ The Khan Academy has made an integrated electronic set of tools by which a student can be tracked continuously on material they have covered, mastered, or struggled with. This data goes into building broad “knowledge maps” which are essentially road maps of all things learned in the past (as well as concepts yet to be conquered). As concepts build on each other, the knowledge map gives way to more branches – representing new material that the learner is now ready to undertake. It is pretty revolutionary to think that a student’s learning can now be tracked over a lifetime of education and that one can revisit a concept learned in the past at any point in time.

3.  Video-learning increases access to education.

A final benefit of video-learning is the increased access to education that it creates. Videos uploaded online can be accessed from any computer around the world at any point in time. The Khan Academy provides the same quality of education to a child from the slums of India as to a child from an upper-middle class family in America. Communities in third-world countries that have limited resources to provide education can benefit indefinitely if provided a computer and access to the internet. Additionally, this “online-schooling” creates a global community of learners whereby anyone, anywhere in the world, can become a mentor or tutor to another person. If I want to become a Spanish tutor, for example, I can become a mentor through Khan Academy to a child from France and help him/her learn a new language.

So what does this mean for traditional classroom learning?

Video-learning through software like that developed by Khan Academy can integrate perfectly into the classroom and become a supplement to one-on-one live education. One way this can penetrate the classroom is through the flipped classroom technique. Teachers can assign Khan Academy lectures to their students for homework and students can come to class to work on assignments that would traditionally be considered “homework”. In this way, the passive learning is done at home while application of the material is done in school. This increases the “valuable-time-with-the-teacher-ratio” as teachers would now have more time to interact with students one-on-one, walking around the classroom to help them solve problems and foster their critical thinking skills. In this way, Gagne’s first four events of instruction take place at home and the teacher can focus on more important principles such as providing guidance, practice, and enhancing retention. Furthermore, this method facilitates the instructional system design process by allowing more in-depth analysis and evaluation of learning through the data-tracking tools provided for each individual student.

Video-learning for pharmacy education.

Video-learning can be a wonderful asset to traditional pharmacy education as well. Teachers can implement the flipped-classroom model and provide lectures for students to watch at home. These lectures do not have to be provided by Khan Academy, although they do offer a plethora of information of pharmacology that can be used as a supplement. When students come in to class, they can work on self-assessment questions or patient cases. This would foster independent, self-directed learning and allow time for fun activities to reinforce concepts learned. For instance, patient-care labs can be integrated into regular courses if teachers don’t have to spend time on lecturing. Alternatively, students can be chosen to examine primary literature related to the video modules they watched at home. The professor can then track learning via the Khan Academy software to make sure their students are adequately prepared for the board exam or otherwise individualize remediation.

References:

1.    Khan, S. Let’s use video to reinvent education [video file]; 2011. TED Conferences, LLC. Retrieved from https://www.ted.com/talks/salman_khan_let_s_use_video_to_reinvent_education

2.    Wang V, Cheng Y-T, Liu D. Improving education: just-in-time splinting video. Clin Teach. 2016 Jun;13(3):183–6.

3.    Wieland ML, Nelson J, Palmer T, O’Hara C, Weis JA, Nigon JA, et al. Evaluation of a tuberculosis education video among immigrants and refugees at an adult education center: a community-based participatory approach. J Health Commun. 2013;18(3):343–53. 

Evaluating Experiential Learning

Written by:

Lauren Grecheck, Pharm.D.

PGY-2 Ambulatory Care Pharmacy Resident

University of Maryland School of Pharmacy

Students graduating from Schools of Pharmacy will enter into the workforce at different perceived and actual readiness and competency levels.^1,2 It is our responsibility as educators to ensure students are provided with experiences to prepare them for pharmacy practice. We do this through didactic and experiential education. While the didactic learning is generally uniform from student to student, it is more challenging to achieve uniformity for experiential learning.

         

Lounsbery et al described a tracking tool for Ambulatory Care Advanced Pharmacy Practice Experiences (APPE) that aimed to determine the number of patient encounters needed for a specific medical condition and the number of times a clinical skill needs to be performed for the student to be considered competent in that area.³ This study of fourth year pharmacy students focused on ten medical conditions (anticoagulation, asthma, infectious disease, chronic obstructive pulmonary disease [COPD], diabetes, lipids, hypertension, mental health, smoking, and women’s health), as well as nine skills (asthma action plan, asthma education, diabetes education, pain assessment, primary literature search, drug consult/information, motivational interviewing, presentation to another healthcare provider, and care coordination).³ The preceptor evaluations employed the use of the Dreyfus Model, which breaks skill acquisition and learning into five stages: (1) novice, (2) advanced beginner, (3) competence, (4) proficiency, and (5) expertise.⁴ Using this model for the forty-six APPE students allowed the preceptors in the study to objectively grade the students’ competency levels. Students were considered competent if they were graded per the Dreyfus model as stage 3 or higher, and students were classified as not competent if graded as stages 1 or 2.³ Students ranked as competent had an overall higher mean number of patient encounters compared to students ranked as not competent (5.1 vs. 4.3, p=0.01).³ There was no statistically significant difference between the individual medical conditions and competency levels.³ Overall, the students who were ranked as competent in regards to skill performance had a higher mean number of times the skill was performed compared to students rated as not competent (3.8 vs. 2.7, p=0.0009).³ Asthma education was the only skill to show a statistically significant difference independently (4.5 vs. 2.6, p=0.05).³ Tracking of patient care experiences and skills will allow preceptors to quantitatively evaluate the experiences a student is offered. Using this information on rotations can serve as a method for tailoring experiences during the rotation, as well as to set up rotation experiences to meet objectives set forth by the Accreditation Council for Pharmacy Education (ACPE) for pharmacy education.⁵

          

Recognizing that not all ambulatory care rotations offer the same experiences, Schools of Pharmacy can still provide continuity of experiences by creating guidelines for expected experiences. For example, performing the asthma education skill 4.5 times facilitated competency compared to only performing the skill 2.6 times.³ This information can be used to create a suggested number of experiences the students should engage in. Currently, many evaluation methods or learning experiences do not state exact numbers of experiences; instead, learning descriptions usually loosely state that a student should be exposed to a particular experience. For preceptors who are not directly affiliated with the university, they may have trouble determining what a sufficient experience is for the student; therefore, creating guidelines with specific expectations of what should be achieved in a rotational experience will help these preceptors ensure they are providing an adequate learning experience for the student. These guidelines could be used by the preceptor when creating their syllabus or learning description for the rotation, which can then be directly referenced in the evaluation. Additionally, this guideline should serve as an extension of the guidance provided by ACPE by incorporating specific examples of skills, as well as quantitative set points for each skill that is expected to be performed.⁶ Furthermore, providing the preceptor with the Dreyfus model examples of how the student should be performing for each stage of learning will allow the preceptor to demonstrate concrete behaviors that the student should be able to replicate to achieve the goals of the rotation. This is important to ensure continuity of experiences in preparing the next generation of pharmacy professionals.

         

 To further tailor the rotation experience for the student based on his or her stage of learning, a baseline competency for each individual student should be obtained. One limitation of the Lounsbery et al study was that baseline competencies were not completed; therefore, achievement of competency cannot be directly linked to that particular rotation experience and/or the number of patient encounters from that rotation. To bridge the gap from the start of the rotation to the end of the rotation, another goal for rotations should be to show individual progression. To accomplish this, baseline competency is essential. Creating mock ambulatory cases for the students to complete that combine interview skills, counseling, drug information, and SOAP note writing on the disease states that will be seen in that clinic will allow the preceptor to target student-specific areas for improvement. A strong correlation between low performers on an Objective Structured Clinical Examination and low performance on an APPE rotations has been demonstrated.⁷ Unfortunately, most preceptors do not have data about a student’s performance in pharmacy years one through three; therefore, they are unable to tailor the complexity of their rotation to that student’s ability level. The baseline competency allows each preceptor to learn about the student as an individual and ensure the learning environment they create fosters the skill level the student presents with, thus enabling focused rotation experiences to address the student’s deficiencies.

         

 Continuity of rotation experiences is essential for preparing pharmacy students to become effective practitioners. One way to ensure competencies are met is to provide further guidance to preceptors regarding specific examples of what activities a student should be able to perform, as well as how much the student has advanced throughout the rotation. To achieve this goal during short APPE rotations, students must perform baseline competencies, so their experiences can be tailored to where they would benefit the most.

References:

1.    Truong et al. Factors Impacting Self-Perceived Readiness for Residency Training: Results of a National Survey of Postgraduate Year I Residents. Journal of Pharmacy Practice. 2015;28(1):112-118.

2.    National Association of Boards of Pharmacy. North American Pharmacist Licensure Examination®: Passing Rates for 2014-2016 Graduates Per Pharmacy School. Published February 15, 2017. Website: https://nabp.pharmacy/wp-content/uploads/2017/02/2016-NAPLEX-Pass-Rates.pdf. Accessed on May 1, 2017.

3.    Lounsbery JL et al. Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences. Am J Pharm Educ. 2016;80(1):Article 14.

4.    Dreyfus SE. A Five-Stage Model of Adult Skill Acquisition. Bulletin of Science, Technology & Society. 2004;24(3):177-181.

5.    Accreditation Council for Pharmacy Education. Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (“Standards 2016”). Website: https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf. Accessed March 16, 2016.

6.    Accreditation Council for Pharmacy Education. Guidance for the accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree (“Guidance for Standards 2016”). Website: https://www.acpe-accredit.org/pdf/GuidanceforStandards2016FINAL.pdf. Accessed March 16, 2016.

7.    McLauglin JE, Khanova J, Scolaro K, Rodgers PT, Cox WC. Limited Predictive Utility of Admissions Scores and Objective Structured Clinical Examinations for APPE Performance. Am J Pharm Educ. 2015;79(6):Article 84.

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The Socratic Method in Experiential Medical Education

By Miguel Franquiz, PharmD, PGY-1 Pharmacy Practice Resident, University of Maryland 

The delivery of medical care in the modern era is increasingly specialized¹, involving numerous, numerous systematic approaches have been developed to aid the already overburdened clinician in fostering clinical reasoning among medical learners.² One of the oldest and most prevalent is the Socratic method.

professionals working collaboratively within their respective skillsets to achieve optimal outcomes. Physicians, nurses, pharmacists, dieticians, respiratory therapists, physical therapists, occupational therapists; all of these disciplines make medical decisions which are informed by a vast body of clinical evidence and an understanding of physiology.  Years of experience impart critical thinking skills at the apex between evidence-informed and intuition-based medical decisions, which results in care delivery that cannot be found in a textbook, yet at the same time is based in objectivity. The task of building such clinical intuition for oneself alone is daunting, and even seasoned clinicians will struggle periodically with patients who defy both objective and intuitive convention. But because consistent clinical practice is the only way to truly develop this skillset, the clinician is additionally responsible for imparting critical reasoning to junior trainees within their discipline.  This is assuredly a monumental task, and because of this

Baseline knowledge is often insufficient to provide excellent care in medicine. Instead, baseline knowledge applied within a framework of understanding that recognizes key patient specific factors will optimize medical decision making.³ The Socratic method is centered around a philosophy that assumes medical learners have the baseline knowledge required to approach therapeutic decision making, but lack sufficient experience to apply such knowledge appropriately. The Socratic method is then achieved by sequential, probing questions which allow the learner to critically appraise the validity of the assumptions they used when making a decision. In this manner, they will arrive at an optimal therapeutic plan on their own, using their own baseline knowledge, and simply guided by questioning from a more senior clinician. The aim of Socratic questioning should be clear, and focused on having learners examine the validity or fallacy of the assumptions they used in arriving at a treatment plan.

Unfortunately, this method is plagued by inherent disadvantage and often poor execution. To start, many learners perceive the repeated, probing questions used by this method as hostility. Coupled with the fact that this method is often carried out in the presence of other medical learners, the pupil may become quickly discouraged. Failure of the Socratic method in the learner may manifest with apathy in one extreme (“I don’t know, what’s the answer”) or over-analysis in another (learners who inappropriately second guess content they were previously confident to be true). Social dynamics no doubt play a role. Most learners will be uncomfortable “being wrong” in front of others. However, it should be noted that the complexity of medicine as a discipline demands humility, and even the most experienced clinician will encounter puzzling patients in whom they diagnose or treat incorrectly. Perhaps the Socratic method is helpful then in fostering some of this healthy anticipation of failure.

Additionally, delivering excellent patient care does not impart the clinician with excellent teaching skills. Many clinicians mistake the Socratic method for “pimping”, or simply asking repeated questions solely based in the regurgitation of rote memorization. Such questioning is not useful in fostering critical thinking skills and instead focuses on simple recall of prior knowledge, rather the building on the process of therapeutic decision making. Also, the clinician may fail to structure Socratic questioning in a way that helps the learner examine the assumptions of their reasoning. This most often manifests in a “guess what I’m thinking” approach, where the clinician produces a line of questioning that does not flow logically towards the desired conclusion.

Some strategies for appropriately executing the Socratic method include assessing the learners baseline knowledge, providing the rationale or goal of one’s questions, and linking the clinical context to the line of questioning in a way that allows the learner to understand the steps that were taken to reach the desired conclusion.⁴ By first understanding a learner’s baseline knowledge the clinician can assess whether or not the Socratic method should even be attempted, or the learner should be referenced to resources that will allow them to engage in critical thinking exercises in the future. Proceeding to the structuring of Socratic questioning, the clinician must themselves understand the assumptions made the learner in reaching a conclusion, and sequentially question the assumptions which lead to the improper conclusion (or key assumptions that lead them to the appropriate conclusion). The rationale for questioning should be briefly stated, so the learner does not immediately perceive their conclusions as incorrect, and so the learner perceives the questioning as comfortable academic dialogue. Next, the learner will arrive at the appropriate conclusion through Socratic questioning, or the clinician should explain incorrect assumptions and their own clinical rationale if the learner does not reach the desired conclusion. This description of this process is quite qualitative, so let’s finish by examining two examples.

Example 1: Poor execution of the Socratic method

Clinician: “Why do you want to give this patient with liver disease and an INR of 2.1 (without anticoagulation) Vitamin K?”

Learner: “To lower the INR and reduce bleeding risk”

Clinician: “How much Vitamin K will they need to reduce their INR and bleeding risk”

Learner: “I was going to give 10 mg”

Clinician: “What literature are you using to support this”

Learner: “I’m not sure my senior told me to do this”

Clinician: “How do you know this will lower bleeding risk”

Learner: “Ok, I’ll discontinue the order”

Notice how the clinician commits several mistakes in the execution of the Socratic method here. The level of baseline knowledge is not assessed. The line of questioning does not examine the learners understanding of the pathophysiology of coagulopathy in liver disease, which is key to reaching the desired conclusion. The questions are probing but do not flow logically together, and the learner quickly withdraws from the dialogue, assuming they are wrong. Let’s look at how this could be done better.

Example 2: Appropriate execution of the Socratic method

Clinician: “Why do you want to give this patient with liver disease and an INR of 2.1 (without anticoagulation) Vitamin K?”

Learner: “To lower the INR and reduce bleeding risk”

Clinician: “I’d like to discuss this decision, and understand your rationale. Do you feel comfortable in your understanding of the pathophysiology of liver disease, and specifically; coagulopathy?”

Learner: “Yes, patients with liver disease do not synthesize clotting factors appropriately due to destruction of their liver cells, which normally synthesize these factors. As related, the INR creeps up”

Clinician: “You are correct. Do you have an understanding of how Vitamin K might intervene on this pathophysiology?”

Learner: “Well I know we use Vitamin K to correct high INR’s in patients on warfarin, so I was applying the same principle.”

Clinician: “You are right about Vitamin K for correcting INR in patients on warfarin, but how is that different than patients with liver disease?”

Learner: “I think we use it in patients on warfarin because warfarin blocks enzymes which use Vitamin K, so we give Vitamin K to overcome the blockade.

Clinician: “And how might the situation be different in someone with liver disease?”

Learner: “I can see your reasoning now; for a patient with liver disease they just have cellular destruction and low synthesis of clotting factors as related. There’s no enzyme blockade, so using Vitamin K to correct blockade that is not there does not make sense.”

Clinician: “Excellent, so now you can see why correction of the INR with Vitamin K in someone on warfarin is much different than in a patient with liver disease.”

Notice how in this scenario the clinician assessed baseline knowledge, and questions appropriately, knowing that an understanding of the pathophysiology is key to reaching the desired conclusion.

Closing thoughts

Imparting critical thinking skills is undoubtedly one of the most difficult pedagogical exercises for the instructor, particularly because prior experience (which learners lack) is so essential in addition to prior knowledge. The Socratic method is a simple and systematic manner for teaching critical thinking, and with practice and appropriate structuring, effective for the busy clinician. Clinicians should be wary to avoid “Guess what I’m thinking” questions and “pimping”, which are often mistakenly implemented in an attempt to conduct Socratic questioning. The clinician should also be aware that their attempts at using the Socratic method will likely be rocky in the beginning, but with practice, eventually effective.

References

1. Goldbloom RB. Increasing specialization in medicine. CMAJ 1978; 118(11): 1347–1348.

2. Ker J. Teaching on a ward round. BMJ 2008; 337: a1930.

3. Oh RC. The socratic method in medicine- the labor of delivering medical truths. Fam Med. 2005;37(8): 537-8.

4. Carlson ER. Medical pimping versus the socratic method of teaching. J Oral Maxillofac Surg. 2017;75: 3-5.

5. Oh RC and Reamy BV. The socratic method and pimping: optimizing the use of stress and fear in instruction. Am Med Assoc J of Ethics. 2014;16(3): 182-6.