The Socratic Method

Shila Mortazavi Pharm.D.
PGY1 Pharmacy Resident
Howard County General Hospital

As its name suggests, the Socratic method is an approach to teaching that originated from the renowned Athenian philosopher Socrates and is based upon engaged dialogue. According to Delić and Bećirović this method consists of five distinct stages starting with wonder and the postulation of questions by the student.1 In the subsequent stage, the teacher would then look to the student to form a hypothesis to the initial wonder. In response to the student’s primary hypothesis, the next stage would involve the teacher performing a cross-examination of the primary hypothesis by providing counterexamples to prove or refute the hypothesis. The following stage is the acceptance or rejection of the hypothesis in which the student can accept or reject the counterexamples. In the final stage, the student can act upon the discoveries from the dialogue between the teacher and student.1 Traditionally in this method, the teacher serves as a mere guide that incorrectly reasons with the student throughout the discussion to allow them to draw their own conclusions and develop a higher level of critical thinking.

In the writings of Socrates’s students such as Plato, most emphasize the cross examinations performed by Socrates as the critical point where the truth-value of a statement is discovered, which was a point referred to as the elenchus.4 While the origins of these lessons were intended initially to challenge philosophers on topics that related to their morals and ethics, these same methods can also be used to guide active classroom discussion in higher education. One structured application of this method is called the Socratic seminar, and much like the fishbowl approach employs a design where students are arranged in two rows of concentric circles.2 In this method, the students are provided reading materials to review, then asked to participate in one of two ways: the outside row of students observe while the inside row of students engages in a dialogue with the instructor. In this model, the students are not necessarily debating each other on the text that they have read but are instead working together to develop a more critical understanding of the text. The teacher is an expert in the subject matter and guides the discussion by posing questions and mediating the discussion. When the discussion of the inner circle concludes, the outer circle, who has thus far been exclusively observing the conversation, provides relevant feedback to the inner circle on their discussion.2,3 Similar to other models of instructional system design, there is a strong emphasis on students closely analyzing and gathering information before the discussion. This method also encourages students to discuss and develop critical knowledge on the topic through discussion and requires that they reflect and evaluate their discussion with appropriate feedback.

In terms of instructional design, the Socratic seminar could prove valuable in many ways. A study was conducted where middle school students took part in a Socratic seminar after reading a text on their own.3 Surprisingly, 80% of the student sample had shown evidence of performing metacognitive activity or higher-order formal operation. This meant that students focused on forming abstract thoughts to create a hypothesis which they then systematically tested. Polite et al. also found that middle school students who were involved in the Socratic seminars were largely comfortable with utilizing different degrees of conflict resolution skills. About 80% of the students had at least some conflict resolution skills and that about 66% of these students were able to utilize elaborate resolution skills such as the agreeing-to-disagree outcome.3 In the realm of higher education, it is not uncommon for students to have to digest primary literature. The Socratic seminar model could be applied and promote a more abstract discussion rather than stressing specific data points and trends. These discussions could also help students hoping to become future practitioners more critically assess what research and clinical guidelines they chose to implement in their personal practice. For instance, the ACC/AHA guidelines for hypertension management promote the use of thiazides, calcium channel blockers, angiotensin-converting-enzyme inhibitors, or angiotensin II receptor blockers as first line agents. A further discussion into different aspects of the evidence behind these recommendations such as the studies’ inclusion or exclusion criteria, their demographic representation, or follow-up time all could challenge upcoming health care practitioners to consider commonly applied therapeutic generalizations more carefully. Ethically speaking, such discussions could help develop providers that are higher level critical thinkers that take the extra steps to ensure that their interventions for patient research they are utilizing to treat their patients would serve a purpose in their patient on a case-by-case basis.

While the Socratic seminar could prove incredibly useful in higher education, there are several limitations one must consider before employing the model. This model is not ideal for every type of lesson, such as lessons that require the instructor to provide facts and. This type of teaching approach should rather be left to courses where material is more sensitive to interpretation and students have a wider breadth of foundational knowledge. This model also heavily relies on student participation and interest, and without these key elements, the model’s effectiveness would be diminished. However, despite its weaknesses, in terms of crafting professionals through higher education, the Socratic seminar utility is clear. This method of teaching would encourage abstract thought, empower critical thinking, and in the case of pharmacy students, help develop pharmacists who are better prepared to face scrutiny or cross-examination when it comes to making clinical decisions.

References:

1. Delić H, Bećirović S. Socratic Method as an Approach to Teaching. European Researcher, vol. 111, no. 10, 2016, doi:10.13187/er.2016.111.511.

2. Griswold J, Shaw L, Munn M. Socratic Seminar with Data: A Strategy to Support Student Discourse and Understanding. Am Biol Teach. 2017 Aug;79(6):492-495. doi: 10.1525/abt.2017.79.6.492. Epub 2017 Aug 8.

3. Chowning JT. Socratic Seminars in Science Class: Providing a structured format to promote dialogue and understanding. Sci Teach. 2009 Oct;76(7):36-41.

4. Richard Robinson, Plato's Earlier Dialectic, 2nd edition (Clarendon Press, Oxford, 1953). Reprinted in Gregory Vlastos (ed.), The Philosophy of Socrates (Anchor, 1971). Edited in hypertext by Andrew Chrucky, June 2, 2005.

“See many, Do many, Teach many”

Paige Ruffier, PharmD
PGY1 Pharmacy Resident
Children’s National Hospital

In 1890, William Halsted became the first Chief of Surgery at John Hopkins Hospital. At the time, surgical residents were either self-taught or underwent an apprenticeship1. Halsted’s model of “see one, do one, teach one” is a procedural training methodology that seeks to promote progressive skill development while prioritizing adequate supervision and patient safety2. It is important to note that Halsted was not only interested in developing a methodology to train surgeons, but also interested in developing teachers and role models1. The “see one, do one, teach one” approach has now expanded far greater than just the setting of aspiring surgeons. Before we dive into how “see one, do one, teach one” can be extrapolated into settings outside of the medical field, let’s first further explore each aspect of it.

The first component, “see one”, represents the learner’s direct observation of the skill. In addition to strictly observing the skill completed with expert technique, this is when the learner can take advantage of asking the expert any clarifying questions. The next component, “do one”, represents the learner’s completion of the skill independently. It is here when the expert may chime in with feedback that will be crucial to the learner’s continued success. The last component, “teach one”, represents the learner teaching the skill to a new learner. At this point the learner has essentially transitioned from the learner to the expert, as they begin to instruct a new learner. The “see one, do one, teach one” approach is a cycle that continues to pay it forward to each future generation of learners.

“See one, do one, teach one” can be attractive to many. The process not only has educators instructing students initially, but also encourages students to be autonomous with their own learning early on3. Additionally, the “see one, do one, teach one” approach is simple and relatively easy to follow. However, as with any instructional design model, it poses challenges. For example, what if you have a learner that is able to complete the skill independently, but has many errors? Do we want that learner teaching a new learner when they haven’t yet mastered the skill themselves? There are no guardrails in place.

In today’s times, the phrase “see one, do one, teach one” has transitioned to “see many, do many, teach many4.” We know that not all people learn the same way or at the same speed. By changing one to many, this considers the differences in rates that learners learn, as well variation in complexity of the skill (as we would suspect that more challenging skills will need more repetition). Furthermore, when we bring this methodology back to its original audience of surgeons-in-training, the adaptation to “see many, do many, teach many” is preferred in terms of patient safety and ensuring patients are provided the utmost level of care.

Outside of the medical field, we can find the “see many, do many, teach many” practice applied in a variety of learning environments. For example, learning to drive a car. You first need to observe an expert (someone with an active driver’s license) driving on many occasions. It is typical for a teenager (who is the learner), to observe a parent (the expert). The next component, “do many”, is typically when the teenager will practice under supervision of the parent. The teenager will then obtain a driver’s license and be able to drive oneself independently. The last component, the “teach many”, is demonstrated when the teenager is then comfortable to drive other’s around (thus serving as the expert). We can also apply this to pharmacy education. Whether a pharmacy student is learning to administer immunizations, provide medication counseling, or even perform patient chart review, the “see many, do many, teach many” method can be applicable to various aspects within pharmacy school curriculums.

The “see many, do many, teach many” instructional process really can be appropriate in almost all settings in which a learner is learning any sort of new skill.

References:

1. Kotsis SV, Chung KC. Application of the "see one, do one, teach one" concept in surgical training. Plast Reconstr Surg. 2013;131(5):1194-1201. doi:10.1097/PRS.0b013e318287a0b3

2. Heath JK. See One, Do One, Teach One, Tell All. Chest. 2020;158(5):1820-1821. doi:10.1016/j.chest.2020.05.566

3. Cooksey A. See One, Do One, Teach One. Knowledge Quest: Journal of the American Association of School Librarians. September 11, 2017. Accessed September 25, 2021. https://knowledgequest.aasl.org/see-one-one-teach-one/

4. Rohrich RJ. "See one, do one, teach one": an old adage with a new twist. Plast Reconstr Surg. 2006;118(1):257-258. doi:10.1097/01.prs.0000233177.97881.85

The Use of Rubrics in the Pharmacy Curriculum

Allison Loi, PharmD
PGY1 Pharmacy Resident
Safeway Pharmacy Mid-Atlantic Division

Throughout pharmacy school, student pharmacists encounter various evaluation methods that assess their knowledge acquisition, problem-solving capability, application of skills, and critical-thinking ability. With new learning experiences, questions related to grading and assessment always seems to be topic of interest among student learners such as "exactly where did I lose points?" and "what could I have done to get a better grade?" To help facilitate student learners from novice to competent, rubrics are incorporated into various learning experiences throughout the pharmacy school curricula, such as patient counseling activities and assessment and plan development.

O'Donnell et al., defined a rubric as a scaled tool with levels of achievement and descriptions of each criterion for each level of performance.1 Essentially a rubric is a document that defines what is expected from the student and what will be assessed for a particular project, presentation, or evaluation. Typically, rubrics are designed as a grid-type structure consisting of evaluative criteria, scoring strategy, and quality statements.2 The evaluative criteria describe the critical elements of a student's work related to the learning outcomes being assessed. The evaluative criteria are skills, knowledge, and behavior that the learner must demonstrate. For example, as part of a new prescription medication patient counseling activity, the evaluative criteria might include an introduction and patient history, basic counseling points, patient education, organization and succinctness, verbal, and nonverbal communication.3 The next component of a rubric is a scoring strategy to rate each criterion which is often combined with levels of performance such as "not meeting," "meeting," or "exceeding" expectations. Although the scoring scale can be either numerical or descriptive, the important aspect is that the different levels reflect variance in quality and not a shift in importance. The last component of a rubric is the quality statements that describe each level of performance.

According to Heidi Andrade, a rubric expert, an effective rubric goes beyond a grading/answer key.4 An effective rubric serves as a teaching and learning tool. For the instructor, a rubric for a learning activity helps clarify the learning goals, promotes objectivity and consistency in grading, and is a tool for providing timely, useful, and focused feedback.1,2,4 In a review paper by Cockett and Jackson on rubrics in higher education, students identified that they used the rubric as a guide to prepare for the learning activity, better understand what is expected of them, and what to do to be successful.2 Also, the review paper noted that students used rubrics to assess their progress and reflect on their competency in completing work.2 Overall, the review paper by Cockett and Jackson on rubrics in higher education concluded that student self-assessment, self-regulation, and understanding of assessment criteria were enhanced using rubrics.2

Rubrics are embedded in the pharmacy curriculum for various learning activities to communicate teaching and learning expectations and provide informative feedback, so students are "practice-ready" upon graduation. For example, a SOAP note rubric may be integrated with the various pharmacotherapy courses as it is required for students to document patient care activities accurately and concisely.3 The SOAP note serves as a learning tool to provide clear assessment criteria and a resource for students to self-assess progress toward competence.

Although evidence suggests that rubrics are most effective when co-created with students and other faculty members, this is not always feasible due to time constraints and the availability of resources.1,2,4 However, it is still important to seek feedback from students and evaluators to revise the rubric as needed to make it as effective a tool as possible. Other challenges of using rubrics as part of the assessment process include reduced creativity, can cause performance anxiety and inter-rater reliability issues. 1,2,4

In summary, effective rubrics can serve the purposes of teaching and learning as well as evaluation. For instructors, a rubric is a tool to establish clear rules for evaluation and to define criteria for performance to meet learning goals. In contrast, rubrics provide students with clear expectations of performance, an opportunity to self-assess progress and receive timely, detailed feedback.

References:

1. O'Donnell, Jean A et al. “Rubrics 101: a primer for rubric development in dental education.” Journal of dental education vol. 75,9 (2011): 1163-75.

2. Cockett, Andrea, and Carole Jackson. “The use of assessment rubrics to enhance feedback in higher education: An integrative literature review.” Nurse education today vol. 69 (2018): 8-13. doi:10.1016/j.nedt.2018.06.022

3. Sherman, Justin J, and Christa D Johnson. “Assessment of pharmacy students' patient care skills using case scenarios with a SOAP note grading rubric and standardized patient feedback.” Currents in pharmacy teaching & learning vol. 11,5 (2019): 513-521. doi:10.1016/j.cptl.2019.02.012

4. Andrade HG. Teaching with rubrics: the good, the bad, and the ugly. College Teaching. 2005;53(1):27-31.

Neurodiversity: Importance of Inclusive Classrooms

Sara Hall, PharmD
PGY-1 Resident, Sinai Hospital of Baltimore

Neurodiversity is a term used to describe a variety of cognitive and neurological diagnoses including attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), epilepsy, dyslexia, Tourette’s syndrome, etc1. This term has become increasingly popular as a movement focused on neurodiversity has grown to produce social change. This movement is led by neurodivergent advocates who work to shift attitudes about neuro-atypicality.

According to the US Department of Education, neurological conditions can affect school performance for a variety of students. For example, students with ADHD had lower average marks, more failed grades, more expulsions, higher rates of dropping out, and lower rate of undergraduate completion2. Neurodiverse students have a variety of challenges that neurotypical students may not face, as public education was designed for neurotypical students. Many neurodiverse students have difficulty with executive function, which can cause difficulty with time management. Some may take longer to process information that they read3. Educators must be conscious of these differences to ensure student success. Conscious educators could provide accommodations, or alternatively can work with students to improve time management and provide coping strategies to address executive dysfunction.

A major concept that is generally encouraged in the neurodiversity movement is an inclusive classroom. When looking at a neurological condition as just a difference instead of a deficit, taking the steps to inclusion can be beneficial for a student’s social and educational development. An inclusive classroom integrates both general education students and students eligible for special education services. In an inclusive classroom, teachers work together to meet the needs of all students regardless of if they are neurodiverse or neurotypical. This involves systemic reform and can include modifications of content, alterations of teaching methods, and integrating strategies that can overcome potential barriers to provide equitable education for all students. This inclusive style of classroom benefits the neurodiverse students as well as neurotypical students and helps create welcoming communities while combating discriminatory attitudes4.

With the idea of inclusive classrooms in mind, understanding neurodiversity and destigmatizing it is necessary to become the best educator possible. When developing a learning experience, it is already standard practice to perform a preliminary analysis where the audience is identified, and an education plan is developed based on the results of the preliminary analysis. To benefit all students, this analysis must be conducted with neurodiversity in mind. A neurodiverse mind may require different teaching styles. For example, some neurodiverse students may find it beneficial to physically move or “fidget” during class so they may be able to better focus if the lesson plan includes movement. A study revealed that fidgeting showed higher performance on focused related tasks specifically when comparing students with ADHD to those without5. Other neurodiverse brains may require alternative methods to help improve focus. It is important to identify the needs of each student and attempt to develop a plan that has aspects which are beneficial to all learning styles.

Currently, research surrounding neurodiverse students in graduate level health profession programs is scarce. Though specific data is lacking, that does not mean that neurodiverse students are not still present in these programs. One study showed that among students in US allopathic medical schools surveyed, students with self-disclosed disabilities represented 2.7% of total enrollment. Of those students identified, the most common disabilities were ADHD (33.7%), learning disabilities (21.5%) and psychological disabilities (20.0%). This same study showed that 97.7% of students with self-reported disabilities received some level of accommodations ranging from testing, assistive technology, clinical assistance, and facilitated learning6. These accommodations allow neurodiverse students to be successful in their programs and does not directly impact their neurotypical peers.

As a neurodiverse student myself who struggled as a child to find teachers who were willing to accommodate my learning style, I can personally speak to the importance of inclusive learning. Punishing students for their perceived flaws associated with their neurodiversity does nothing but discourage students from learning. Teachers who recognize a neurodiverse student’s strengths and adjusts their teaching style to be fully inclusive can truly change the lives of their students and encourage them to be interested in their education.

References

1. Tougaw, J. (2020, April 18). Neurodiversity: The Movement. Psychology Today. Retrieved September 18, 2021, from https://www.psychologytoday.com/us/blog/the-elusive-brain/202004/neurodiversity-the-movement.

2. US Department of Education. (2021, March 30). Identifying and treating attention deficit hyperactivity disorder: A resource for school and home.-- PG 4. Identifying and Treating Attention Deficit Hyperactivity Disorder: A Resource for School and Home. Retrieved September 18, 2021, from https://www2.ed.gov/rschstat/research/pubs/adhd/adhd-identifying_pg4.html.

3. O'Donnell, Z. (2020, March 10). Challenges for neurodiverse students. Ranger Review. Retrieved September 18, 2021, from https://www.rangerreviewonline.org/features/2020/12/07/challenges-for-neurodiverse-students/.

4. Hehir, T. (2016, August 15). A Summary of the Evidence on Inclusive Education. Abt Associates. Retrieved September 18, 2021, from https://www.abtassociates.com/insights/publications/report/summary-of-the-evidence-on-inclusive-education.

5. Sarver DE, Rapport MD, Kofler MJ, Raiker JS, Friedman LM. Hyperactivity in Attention-Deficit/Hyperactivity Disorder (ADHD): Impairing Deficit or Compensatory Behavior?. J Abnorm Child Psychol. 2015;43(7):1219-1232. doi:10.1007/s10802-015-0011-1

6. Meeks LM, Herzer KR. Prevalence of Self-disclosed Disability Among Medical Students in US Allopathic Medical Schools. JAMA. 2016;316(21):2271-2272. doi:10.1001/jama.2016.10544

The Utility of Simulation Based Learning within Pharmacy School Curriculums

Reid LaPlante, PharmD
PGY1 Pharmacy Resident
University of Maryland Medical Center

         Throughout pharmacy school curricula, the use of simulation-based learning is incorporated into many aspects of the instructional design of each college of pharmacy within the United States, as required to maintain the Accreditation Council for Pharmacy Education (ACPE) Standards.¹ Simulation learning has been utilized for patient-pharmacist, pharmacist-provider, and pharmacist-interprofessional team interactions for abilities labs, integrative problem solving courses, therapeutic modules, and IPPE/APPE simulations. The theory behind using these practices is to develop a more confident, well communicated, and independent pharmacist upon graduation from an ACPE accredited pharmacy school, but the question is does this truly occur due to these simulations or do they just cause extra stress for pharmacy students and extra work for pharmacy school instructors.

        The use of simulation-based learning is a common method utilized by pharmacy schools that allows students to practice their skills by mimicking real-life scenarios, but in a clinical risk-free setting.² To the contrary, during pharmacy school, anecdotally, simulation-based learning made a majority of pharmacy students very nervous and potentially could impact both their performance in the simulation, as well as their confidence as a student pharmacist. Furthermore, many students failed to see the utility of their participation within simulations, and how it would truly benefit them as a practicing pharmacist. Therefore, the benefit of this needs to be elucidated to outweigh weigh this potential risk imposed on pharmacist students. Fortunately, this has been evaluated and studied by various professors of pharmacy and in many different aspects of pharmacy school curricula.

        The most prominent use of simulation-based learning in pharmacy school curricula is within various types of pharmacy abilities/skills labs for objective structured clinical evaluations (OSCE).³ OSCE can utilize many different types of simulation-based learning including high fidelity manikins, medium fidelity manikins, standardized patients, role playing, and computer-based simulations. Furthermore, many different pharmaceutical tasks have been integrated into OSCE through simulation-based learning including physical assessment, medication reconciliation, code response, and provider and patient interactions. When surveyed more than 60% of pharmacy students feel more confident in their communication abilities with patients and making pharmaceutical recommendations after participation within simulation-based learning with standardized patients.⁴ This data comes from Cho et al, where they furthermore demonstrated that more than 60% of pharmacy students felt less anxious after these simulations. This cross-sectional study also surveyed pharmacy practice faculty, where greater than 70% of faculty members found that working with standardized patients was not difficult, and greater than 90% of faculty members would agree to continue to use standardize patients in the future for more simulation-based learning. Another outlook on the use of simulation-based learning within pharmacy labs was by Fidler et al.² In this survey-based study, Fidler utilized virtual patient simulations as part of a required pharmacy course to assess students’ readiness for IPPEs. Fidler found many benefits in various outcomes to using virtual simulations from comparing scores from the beginning of the semester to the end of the semester. All subjective and objective data collected during these assessments showed a statistical significance from the beginning of the semester to the end of the semester, signifying more prepared pharmacy students for IPPE rotations. Furthermore, like Cho et al, Fidler also found a significance in an increase in pharmacy student confidence after the use of simulation-based learning, even with use of a virtually based platform, with an increase from 53% feeling confident pre-simulation to 83% feeling confident post-simulation. All in all, more studies beyond Cho et al and Fidler et al, continued to find these benefits of increased pharmacist student confidence, as well as pharmacy student clinical improvement post-simulation-based learning within OSCE or abilities/skills labs.

        Another major area of use of simulation-based learning is within IPPE and APPE clinical rotations. Similarly, to lab-based simulations, there have been benefits seen of utilizing simulation-based learning during IPPE and APPE clinical rotations.⁵ Clinard et al found using post survey data that full environment simulations utilizing a high-fidelity mannequin with high acuity poisoning scenarios and an antidote tasting sessions that greater than 90% of pharmacy students found value in these simulations.⁵ These sessions were also incorporated with other medical professionals including medical students, emergency medicine residents, and pediatric physician residents that also continued to help pharmacy students to develop their closed-loop communication skills. Furthermore, this led to more than a 50% increase in pharmacy students understanding the term of closed-loop communication. In the end, these simulations enforced interprofessional teamwork, especially in with improved communication skills, with an overwhelming positive experience seen by majority of pharmacy student participating.

The utilization of simulation-based learning has been integrated and thoroughly studied in various settings throughout pharmacy student education. This research overwhelmingly demonstrates a positive utility for producing more prepared, better communicated, and increasingly more independent pharmacists at the end of pharmacy school curricula with incorporated simulation-based learning. Pharmacy educators should advocate for more use of simulation-based learning opportunities for their students, so they can gain more exposure and be better prepared for the workforce upon graduation.

References:

1.   Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree (“Standards 2016”), Accreditation Council for Pharmacy Education (2015) https://www.acpe-accredit.org/pdf/Standards2016FINAL.pdf

2.   Fidler BD. Use of a virtual patient simulation program to enhance the physical assessment and medical history taking skills of doctor of pharmacy students. Curr Pharm Teach Learn. 2020 Jul;12(7):810-816. doi: 10.1016/j.cptl.2020.02.008. Epub 2020 Mar 18. PMID: 32540042. https://www-sciencedirect-com.proxy-hs.researchport.umd.edu/science/article/pii/S1877129720300836?via%3Dihub#bb0025

3.   Vyas D, Bray BS, Wilson MN. Use of simulation-based teaching methodologies in US colleges and schools of pharmacy. Am J Pharm Educ. 2013 Apr 12;77(3):53. doi: 10.5688/ajpe77353. PMID: 23610471; PMCID: PMC3631728. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3631728/pdf/ajpe77353.pdf

4.   Cho JC, Wallace TD, Yu FS. Pharmacy faculty and students' perceptions of standardized patients for objective structured clinical examinations. Curr Pharm Teach Learn. 2019 Dec;11(12):1281-1286. doi: 10.1016/j.cptl.2019.09.006. Epub 2019 Oct 25. PMID: 31836154. https://www-sciencedirect-com.proxy-hs.researchport.umd.edu/science/article/pii/S1877129718304544?via%3Dihub

5.   Clinard VB, Kearney TE, Repplinger DJ, Smollin CG, Youmans SL. An interprofessional clinical toxicology advanced pharmacy practice experience. Curr Pharm Teach Learn. 2019 May;11(5):505-512. doi: 10.1016/j.cptl.2019.02.002. Epub 2019 May 3. PMID: 31171253. https://www-sciencedirect-com.proxy-hs.researchport.umd.edu/science/article/pii/S1877129718302041?via%3Dihub

 

Multiple Problems with Multiple Choice Exams

Daniel Cericola, PharmD
PGY-1 Pharmacy Resident
University of Maryland Baltimore Washington Medical Center

During a pharmacist’s first year of pharmacy education there are a plethora of classes embedded into the curriculum to prepare students for the vast amount of clinical information that is to be mastered in the proceeding semesters. One such class at the University of Maryland School of Pharmacy is “Professional Foundations of Pharmacy”. While attending one of the first lectures of this course a clinical faculty member ended his lecture by imploring to the students this message: “The information that you learn over the next four years is going to prepare you for the rest of your life, please don’t make the mistake of cramming and dumping information to get good grades on exams. Good grades are not going to benefit you while you’re out in clinical practice, but truly understanding and learning the material as you progress over the next few years will make you a strong and independent pharmacist.” Although this message was given to me during one of my very first lectures of pharmacy school it resonates with me to this day because it was genuine, truthful, and encapsulates the meaning of pharmacy school, to become a strong and independent thinking pharmacist. I pose a question to you: If the goal of pharmacy school is to become a strong and independent thinker shouldn’t assessments during pharmacy school facilitate this goal? 

Historically both teaching and assessment in pharmacy education comes in the context of limited resources. As a consequence assessments are typically in the format of multiple choice (MC) exams because they can be graded using a key which allows for rapid grading. However, there are many short comings in assessing a student’s mastery of material using this testing style.1 First, MC exams are prone to test taking strategies such as option elimination. Therefore students who develop good testing strategies may simply be narrowing down what they believe is the most correct answer by eliminating answers they know are wrong. While this is beneficial for licensure exams this is not going to be useful in clinical practice when as a pharmacist they need to make a therapy management decision based on recall. Second, the format of MC exams creates a learning environment where a student must be able to simply identify a correct answer rather than be able to justify answers and demonstrate a complex understanding of a topic. This type of environment facilitates learning that revolves around studying for a test rather than studying to understand. Third, MC exams do not assess a student’s complete understanding of a topic.1 This phenomenon is demonstrated in a study completed by couch et al.1 where they assessed student knowledge of chemical reaction dynamics using both MC and multiple-true-false (MTF) questions. When using a MC exam 95% of students demonstrated mastery of the concept, however, when assessed using MTF format only 49% of students demonstrated complete mastery of the concept. This finding shows that MC exams overestimate student comprehension because when asked about the same topic with a different question format only half of the students were able to fully answer the question. 

To better facilitate learning in pharmacy education I propose using MTF exams.1 There are multiple benefits of a MTF assessment. First, this style of still allows for effortless rapid grading which is the main appeal of MC exams. Second, MTF assessments promote appropriate studying habits.2 MTF assessments require more than simply identifying one single correct answer on an exam. Therefore, in order to do well on the exam students will require a complex understanding of information which facilitates robust study habits. Third, MTF assessments are shown to benefit lower performing students at risk for failing a course. MTF exams benefit lower performing students by using a partial credit scoring system. On a traditional MC exam questions are graded in absolutes where the student either gets full points or gets no points. However, MTF assessments allow for a partial credit scoring system where students can still gain points even if the topic is not completely mastered. Lastly, MTF exams are better able to depict a student’s partial understanding of a topic. Each question on a MTF exam can specifically be linked to a course learning objective and provide diagnostic information on a learner’s understanding as well as the lecturers ability to portray information in a way that ensures students are reaching learning outcomes.  

Due to the diagnostic capabilities of a MTF exam format the implementation into practice is not only beneficial to the student, but also the lecturer. Through analysis of the classes’ performance on individual questions and then subsections of each question the lecturer will have precise data on exactly where student comprehension is lacking. This information in beneficial in two separate ways. First, this information can be used to provide feedback or fill in knowledge gaps after exams. This is extremely important in pharmacy education because ultimately the goal of pharmacy education should be to produce strong independent thinking pharmacists. Therefore, MTF exams provide lecturers a unique opportunity to continue strengthening a student’s knowledge even after the exam has been taken or in some cases after a course has ended. Additionally, the diagnostic information supplied from student performance on exams can serve as a tool to guide the instructor on how to improve their lecture for the upcoming year. 

In summary, there are systemic flaws in the use of MC exams in pharmacy education. The MTF assessment style addresses the shortcomings of MC exams while providing benefits to both learners and lecturers. 

References:

1. Brian A Couch, Joanna K Hubbard, Chad E Brassil, Multiple–True–False Questions Reveal the Limits of the Multiple–Choice Format for Detecting Students with Incomplete Understandings, BioScience, Volume 68, Issue 6, June 2018, Pages 455–463, https://doi.org/10.1093/biosci/biy037

2. Dyson B. Study Hacks: How to Ace Multiple Choice Exams. Pharmacy Times. https://www.pharmacytimes.com/view/study-hacks-how-to-ace-multiple-choice-exams. Published 2017. Accessed September 11, 2021.

Innovative Teaching Roles for Pharmacy Students

Paige Gilk, PharmD

PGY1 Pharmacy Resident, Safeway Mid-Atlantic Division

Interprofessional education allows health professional students to gain a better understanding of their colleagues’ roles which leads to them providing more effective team-based care. However, collaborating with other health care professionals without adequate practice can be difficult. A successful team requires everyone to understand one another's perspectives and approaches to care. A 2020 study published in the American Journal of Pharmaceutical Education focused on a required workshop where fourth-year pharmacy students taught second-year medical students the basics of prescription writing1. The pharmacy students also led a case-based discussion on nonprescription drug use for third-year medical students on their family medicine rotation. Final survey results demonstrated at the end of the workshop, second-year medical students were more confident in their abilities to write prescriptions and fourth-year pharmacy students were more confident in their ability to teach prescription writing. Also, third-year medical students were more confident in their ability to access resources, make recommendations, and counsel patients regarding nonprescription drug use.

Various methods of teaching can be used for interprofessional education. The primary methods include small-group activities, simulation-based learning, games, role play, and case-based discussions. Currently, interprofessional education activities involving pharmacy students center on models where a faculty member or clinician serves as the teacher1. Next, pharmacy students usually work together with students from different disciplines, often medicine, to solve a clinical patient case. Overall, the current methods provide benefits to all students and do allow pharmacy students to act as the medication experts on the care team. However, pharmacy students are not acting as teachers to their peers in medicine or other disciplines during the activities1. This educational gap is something that can easily be closed. The 2020 study published in the American Journal of Pharmaceutical Education, mentioned above, is the first study to use a unique method of teaching to provide interprofessional education1. The specific method allows pharmacy students to serve as the primary teacher within an interprofessional education activity. The Educational Theory and Practice course focuses on many aspects of education including different learning strategies. A pharmacy student leading an interprofessional activity is using the social learning strategy, which is an informal but effective approach2. As demonstrated in the 2020 study, medical students were able to learn in new environments and gain innovative approaches to practice by actively participating in small group and case-based discussions with pharmacy students1. The activity allowed both medical and pharmacy students to gain a deeper understating of their colleagues' roles and responsibilities and as a result team-based care should be a more positive experience in their future practices.

Furthermore, the 2020 study published in the American Journal of Pharmaceutical Education has shown that fourth-year pharmacy students serving as teachers within interprofessional activities has a favorable impact on students’ confidence in their abilities and their perception of their role within the healthcare team1. Educators can use this information to improve interprofessional activities and implement diverse teaching roles. Part of the development stage for developing an activity is pilot testing2. Allowing pharmacy students to lead an interprofessional activity proved to be an effective pilot that will aid educators when fully implementing this model in the future. An additional 2020 study conducted in Korea demonstrated that role-play and small-group activities were popular and proved to be effective because of the interactive component3. Educators can create activities that consist of more interactive learning and less lecture-based learning for interprofessional education. Moreover, improvement can be made in the development of didactic sessions. A limitation in the 2020 study published in the American Journal of Pharmaceutical Education was that the didactic session was taught by a college of pharmacy faculty member rather than a student1. Future activities could allow fourth-year pharmacy students to lead all teaching aspects with support from a college of pharmacy faculty member.

References:

1. Allen SM, Kachlic MD, Parent-Stevens L. Pharmacy Students Teaching Prescription Writing and Nonprescription Product Selection to Medical Students. Am J Pharm Educ. 2020;84(3):6972. doi:10.5688/ajpe6972. ajpe6972.pdf (nih.gov)

2. Hodell C. ISD from the Ground up: A No-Nonsense Approach to Instructional Design. Alexandria, VA.: ATD Press; 2016.

3. Jung H, Park KH, Min YH, Ji E. The effectiveness of interprofessional education programs for medical, nursing, and pharmacy students. Korean J Med Educ. 2020;32(2):131-142. doi:10.3946/kjme.2020.161. kjme 32-2 수정(0526).hwp (nih.gov)

Flipped Classroom Model: What, Why, and How

 

Natalie So, PharmD
PGY1 Pharmacy Resident
MedStar Montgomery Medical Center

What is a flipped classroom? Are you saying we are not going to be lectured? Are we going to have to learn pathophysiology and all the medications that involve the heart by ourselves? There are many cardiology disease states, how are we going to do that? These were the thoughts I had when my classmates and I were told that our cardiology therapeutics unit was going to be implemented via a flipped classroom format during our third year in pharmacy school. I was skeptical about flipped classrooms at first, but after experiencing it, I could see why it has become a popular instructional model. 

 

What is flipped classroom? 

According to the Derek Bok Center for Teaching and Learning at Harvard University, flipped classroom has become interchangeable with active learning, but it is one of the instructional active learning methods¹. In the flipped classroom model, students learn class material before class by accessing instructor-created videos and lessons or other resources. Class time is used for “working through problems, advancing concepts, and engaging in collaborative learning” instead of delivering lectures or transmitting knowledge^2,3. In this approach, students are responsible for their own learning and for applying the concepts learned in class. Speaking from experience, professors divided up the whole cardiology unit into different disease states, such as hypertension, heart failure, arrhythmias, etc. Before each active learning session, we were expected to complete assigned readings, such as guidelines and journal articles, and to answer pre-class questions to prepare for in-class activities. During class time, we were challenged to apply what we had learned at home by working through patient cases, assessing relevant information, and making drug therapy recommendations. Professors also took the time to answer any questions we had and clarify difficult concepts. 

 

Advantages of flipped classroom 

A review by Akcayir points out that the flipped classroom approach improves learning performances, increases student satisfaction, and enhances their level of engagement in the classroom³. Other advantages include flexibility of learning anytime and anywhere and individualized learning³. Personally, the flipped classroom instructional model allowed me to take charge of my own learning and challenged me to think critically. Before each session, I had to set aside time to complete assigned pre-class activities and attempt to digest and understand the material thoroughly to prepare for the in-class activities. Most of the time I found myself seeking additional resources, such as online videos, to enhance my understanding of some difficult concepts. When I encountered something, I truly could not grasp, I would make sure to raise questions during the active learning sessions. I also found that the flipped classroom model helped with information retention. Compared to the previous courses taught in the first and second year of pharmacy school, I found that the concepts I learned in the cardiology therapeutics course stick with me for a longer term. Lastly, the instructional model also taught me to be resourceful. I now know where to look for evidence-based information and society-recommended guidelines, which had set me up for clinical rotations during my fourth year in pharmacy school and now in residency.   

 

Disadvantages of flipped classroom 

Some disadvantages of the flipped classroom approach are limited student preparation before class, time consuming and increased workload, reported by both instructors and students³. Personally, I found myself spending more time outside of the allotted class time to prepare for the active learning sessions and to really digest the material. On average, I would say I spent twice as much time learning in the flipped classroom approach than in the traditional format. Moreover, given the limited time of the active learning sessions for solving problems and discussing patient cases, some students just perform better when information is presented in class and when higher levels of thinking are performed without time constraints. 

 

How to implement flipped classroom 

To implement this instructional method, instructors should first decide what is the best use of class time before searching for or creating learning materials for students to use before class, because most of the benefits of the approach depends on how the active learning sessions are planned and executed¹. Furthermore, instructors should find or create relevant learning resources that will prepare the students for in-class activities and allow them to see the advantages of spending that extra time before class to learn the materials by themselves¹. Lastly, because unlike traditional lectures, students are not able to ask questions at home as they learn. Instructors should make sure to spend some time during each session to answer questions and to clarify concepts. 

 

References: 

1.    Flipped Classrooms. Harvard University the Derek Bok Center for Teaching and Learning. https://bokcenter.harvard.edu/flipped-classrooms. Accessed September 11, 2021. 

2.    Tucker, B. The Flipped Classroom - online instruction at home frees class time for learning. Education Next. https://www.educationnext.org/the-flipped-classroom. Published October 4, 2011. Accessed September 11, 2021. 

3.    Akcayir G, Akcayir M. The flipped classroom: a review of its advantages and challenges. Computers & Education. 2018; 126,334-345. https://doi.org/10.1016/j.compedu.2018.07.021

 

Interprofessional Experiential Education in the Hospital

Elizabeth You, PharmD

PGY1 Non-traditional Pharmacy Resident

Children’s National Hospital

“Learning is the process whereby knowledge is created through the transformation of experience.”

- David Kolb

Working in the healthcare setting requires health professionals to work collaboratively to provide high quality patient care. Several accrediting institutions for healthcare education have required the incorporation of interprofessional education (IPE) and in 2007, the Accreditation Council for Pharmacy Education issued the incorporation of direct patient care into the Doctor of Pharmacy program¹. Students are now exposed to working cooperatively within a group of pharmacy, medical, nursing, and physical therapy students, among other practicing professionals. Together, they practice and demonstrate proficiency in providing patient care as part of a multi-disciplinary healthcare team.

As part of the Doctor of Pharmacy experiential curriculum, pharmacy students are required to practice in patient care during clinical rotations and are incorporated into the medical team. Students conduct medication reconciliation, refer complicated cases to clinical specialists, answer drug information questions, and perform discharge counseling¹. Along with a preceptor, students also evaluate patients’ medical charts and make interventions on medication therapy. For example, a patient with stage 3 chronic kidney disease with a creatinine clearance of 10mL/min developed an infectious disease. The physician on the primary team consulted the infectious disease fellow, who asked the pharmacy student on his infectious disease rotation to provide renal dosing information for an antibiotic he recommended. The student came up with the renal dosing of the antibiotic, then contacted the physician on the primary team to inform him of the dose. The pharmacy student also informed the nurse that the oral antibiotic should be taken with food. Patient care activities such as these enhance the student’s proficiency in managing drug therapy problems and ability to effectively communicate and work through the problems with other health professionals.

Embedded in interprofessional education is the constructivism learning theory that David Kolb alluded to in his introduction of the experiential learning cycle². His theory postulates that people learn by integrating their concrete emotional experiences with reflection. A learner goes through four stages that occur in a cycle, where new knowledge and skills are achieved through concrete experience, reflective observation, abstract conceptualization, and subsequent active experimentation². In the healthcare profession, this process can be observed in active learning through role playing, such as when a pharmacy student fulfills his or her role as the clinical pharmacist within a multi-disciplinary healthcare team.

An article by Coppock demonstrated the benefits of an interprofessional program in which pharmacy and optometry students participated in the presentation of topic discussions, examination of over-the-counter ophthalmic products, and discussion of the clinical implications of medications in patient cases³. In the post-activity survey, pharmacy students said that they gained a deeper understanding of ophthalmic conditions, and optometry students learned more about the usage of ophthalmic medications³. In a meta-analysis conducted by Guraya et al., the analysis of 12 articles showed that multidisciplinary health professional students experienced statistically significant improvement in objective knowledge, understanding the role of other disciplines, and attitudes toward health care teams⁴.

Kolb and other theorists of constructivism maintain that experience alone does not teach a person. To acquire a new skill, the student must reflect on his or her experiences, and process internally about how they will make sense of their experience. The student then shapes or changes his or her previous understanding, which will enable the student to test out their ideas actively⁵. Application of this theory will catalyze the beginning of a new experiential learning cycle, where the learner can reinforce or re-shape the idea depending on what happens during the experimentation. Lifelong learning defines a healthcare professional’s career, especially while he or she directly cares for patients in a clinical setting. Interprofessional experiential education should be introduced early in a health professional student’s career, as it will be instrumental in preparing the student to become a successful clinical pharmacist. 

References:

1.    Rathbun RC, Hester EK, Arnold LM, et al. Importance of Direct Patient Care in Advanced Pharmacy Practice Experiences. Pharmacotherapy. 2012;32(4):e88-e97.

2.    Kolb, D. A. Experiential Learning: Experience as the Source of Learning and Development. Englewood Cliffs, NJ: Prentice Hall; 1984.

3.    Coppock, K. Interprofessional Education Programs Focus on Pharmacists as Patient Care Providers. Pharmacy Careers. 2019;13(2). November 5, 2019. Accessed August 29, 2021. https://www.pharmacytimes.com/view/interprofessional-education-programs-focus-on-pharmacists-as-patient-care-providers

4.    Guraya SY, Barr H. The Effectiveness of Interprofessional Education in Healthcare: A Systematic Review and Meta-analysis. Kaohsiung J Med Sciences. 2018;34:160-165.

5.    Fenwick TJ. Experiential Learning: A Theoretical Critique from Five Perspectives. Information Series 385. Columbus, OH: ERIC Clearinghouse; 2001.

Closing the Classroom Theory to Practice Gap

 

Chelsey Axelrod, PharmD

PGY2 Psychiatric Pharmacy Resident

University of Maryland School of Pharmacy

Education of several healthcare professionals requires both didactic training achieved in the classroom, as well as clinical experience through rotations or “clinicals.” Arguably the most vital step in professional education is the ability to transfer the information learned in the classroom into clinical practice. Having experienced four years of pharmacy school, and now being in my second year of residency, I can certainly speak to whether I felt I was adequately prepared through didactic training to enter APPE rotations and clinical practice. Everyone’s educational experience is different, depending on the pharmacy school attended, types/difficulty level of clinical rotations, and mentorship; however, I personally believe that the gap between classroom theory to APPE rotations is quite large, and perhaps even larger between student rotations and residency. During my first clinical APPE rotation, I remember feeling so lost and not knowing where and what to look for when collecting patient information in preparation for rounds. Developing treatment plans and making recommendations to physicians seemed close to impossible, when I really had no idea how to apply the knowledge used in school to actual patients. 

For this blog post, I looked for articles that addressed this classroom theory to practice gap and attempted to reduce it through an instructional activity. As I am the PGY2 in psychiatric pharmacy this year, I decided to choose an article that addressed the gap by simulating a psychiatric pharmacy practice experience during a P3 elective class. The writers of this article, similar to myself, believe that real-life scenarios/patients present challenges that pharmacy students are not necessarily prepared for when entering APPE rotations. They discuss the essential role reflective learning plays in the development of essential clinical skills necessary to bridge the classroom to practice gap.¹ Reflective practice includes analyzing past experiences to improve future performance and form deeper learning. According to Tsingos and colleagues, reflective practice “helps develop critical-thinking, problem-solving, and self-directed and lifelong learning skills through gaining new understandings, new perspectives, and new alternatives for future experiences.”² In an effort to guide reflective learning and bridge the gap between didactic learning and APPEs, Pittenger and colleagues, developed an educational design project and evaluation.¹

The educational design project implemented was a 15-week advanced psychiatric pharmacotherapy elective that was peer-led and team-based. The writers had a great understanding of what an instructional design project should entail. An instructional design project should create learning experiences that result in the acquisition and application of knowledge and skills. They should include assessing the needs of the audience, designing a process, developing the materials necessary for implementation, and evaluating the effectiveness of the design.³ In this article, the 4C/ID instructional design model was used to create the course, which includes the four components of learning tasks, supportive information, just-in-time (JIT) information, and part-task practice.

The learning tasks component of the 4C/ID model includes whole-task experiences which are organized from simple to complex with more support given to the learners at the beginning, and less as the course progresses. The learning tasks form the backbone of the course.³ The authors of this article incorporated learning tasks by including complex psychiatric cases that were given to the students each week that had intentional, but real-world clinical guideline conflicts and insufficient evidence that made decision-making difficult. The first case was completed together as a class with facilitation from the course instructors to make expectations clear. Future cases were worked up and presented by either of the two teams that students were divided into.¹

The other 3 components of the educational design support the learning task or case. Supportive information bridges the learner’s prior knowledge with the current learning task.³ The supportive information in the course included content previously learned from the students’ psychiatric pharmacotherapy course, and suggested readings, guidance from fellow teammates, and a patient case work-up template provided by the instructors that was to be complete prior to the class where they were presenting the case.¹

The just-in-time information component of the instructional design typically includes demonstration and corrective feedback.³ This aspect was implemented by including visiting psychiatric pharmacists who attended each case discussion, either in person or virtually through video chat. They provided feedback on the patient case work-up following students’ patient case presentation. Additionally, students completed reflective assignments where they would write pre and post-class personal learning objectives.¹ Part-task practice gives learners the opportunity to have additional practice on completing tasks in order to achieve the learning objectives.³  The instructional design project in the article included part-task practice by having the non-presenting students write comments and questions on a projected shared google doc in real time during the case presentation. All students would have guidance from the visiting experts each class session for the case. Evaluation of the course was provided through post-course conversations with visiting experts and an open-ended course evaluation for students to complete.¹

This article is a great representation of how an educational design project can be created and implemented to help close the gap between classroom theory and clinical practice. In fact, feedback from student’s post-course revealed they felt their previous classroom experiences were much simpler and falsely represented what it meant to practice pharmacy. After the course they felt more excited to begin APPEs and expressed interest in having a similar course design with complex patient cases in future courses. This article did not follow students and evaluate their performance in APPEs after having completed the course, but feedback from visiting experts did show belief that students had improved in their clinical skills and ability to make clinical decisions.¹ Although there may be other possible solutions to bridging theory with practice, I believe this instructional design project represents a feasible example that can be utilized by other educators, especially healthcare educators, to foster deeper learning and prepare students for clinical practice.

 References:

1.   Pittenger A, Dimitropoulos E, Foag J et al. Closing the Classroom Theory to Practice Gap by Simulating a Psychiatric Pharmacy Practice Experience. American Journal of Pharmaceutical Education. 2019;83(10):2102-2110.

2.   Tsingos C, Bosnic-Anticevich S, and Smith L. Reflective Practice and Its Implications for Pharmacy Education. American Journal of Pharmaceutical Education. 2014;78(1):1-10.

3.   Khalil M and Elhider I. Applying Learning Theories and Instructional Design Models for Effective Instruction. Adv Physiol Edu. 2016;40(2): 147-156.