How Millennial Learners are Making Educators “Flip-Out”

Sarah Fillman, PharmD, Sinai Hospital of Baltimore PGY1 Resident

Generational diversity is a hot-button issue that has gained increased attention in recent years particularly when discussing the millennial generation. For some, this topic is nothing more than entertaining internet banter, but truly understanding this concept is vital for the successful education of this cohort. Differences between generational cohorts can be applied to help educators understand how their students will learn best. A significant amount of research in this area has been published over the years focusing on the millennial generation. One particularly interesting concept is the application of an instructional model called the “flipped classroom” and the success it has had for educating millennial students.

So what exactly is a “flipped classroom”?

The concept of the flipped classroom has been around for many years, with some of the earliest work starting in the 1990s. Its development was influenced by the desire for educators to move away from the traditional lecture and to incorporate teaching styles that would accommodate students with all types of learning styles. To do this, educators would need significantly more contact time with students, which has been made possible with advances in multimedia and internet-based resources. The flipped classroom ultimately works by taking the lecture activities normally done inside the classroom and swapping them with the conceptual practice typically done outside of the classroom. Students are expected to come to class prepared with content knowledge they obtain through materials viewed outside of class, including pre-recorded lectures, PowerPoints, textbook readings and a variety of other modalities. Once in class, they are engaged through a multitude of different educational techniques to help them apply the concepts with the help of the instructors and classmates.¹

What do millennials have to do with this?

          The flipped classroom instructional model may be used in many settings and can be adapted to all types of learners. In fact, one the key benefits of the flipped classroom is the ability to engage people with all types of learning styles by allowing them to use whatever method works best for them to obtain content knowledge via self-directed efforts.¹ The millennial generation, identified as individuals born between 1983 and 2002, has been characterized by some as tech-savvy individuals who may prefer team projects and could potentially have difficulty thinking individually.² Roberts et al. have provided tips to teach these students, which include a focus on team dynamics and encouraging collaboration.³ However, there is not complete agreement on this characterization of millennials, nor on the use of one particular teaching style. DiLullo et al. have stated that this singular view of millennial learners is not supported by current evidence. Instead, they found that the statistics show considerable diversity in the millennial cohort that ultimately results in a variety of preferred learning styles.⁴ Regardless of this incongruence in defining the millennial learner, the flipped classroom is an adaptive instructional model that has been proven efficacious in these learners, with a significant volume of research focusing on its use in the instruction of healthcare professionals.

How does this apply to healthcare education?

At this point in time, almost all millennials have completed high school and many are currently enrolled in higher educational programs at all levels. The flipped classroom model has been studied in a variety of educational settings, with researchers finding that it resonates well with millennial students. Lucardie et al. described the implementation of this instructional model in the training of millennial-aged medical residents, concluding that the high level of interaction and collaboration is advantageous for this cohort of students.⁵ Numerous studies have documented the effectiveness of the flipped classroom in healthcare professionals in terms of improved grades and student perception of the educational experience. Examples of this include how Galway et al. demonstrated a significant improvement in mean examination scores between public health students enrolled in a flipped classroom course compared to the previous year’s students who learned via traditional lecture.⁶ McLaughlin et al. evaluated pharmacy student perceptions of the instructional modal, finding that 89.5% of students said they preferred the instructional format after completing the course.⁷ McLean et al. went on to show that the flipped classroom is not only efficacious in these surface level evaluations, but that medical science students reported improved development of their own independent learning style and enhanced deep or active learning engagement.⁸ This multitude of evidence supporting the use of the flipped classroom model in the instruction of millennial healthcare professionals is compelling enough for many educators to want to jump right in to this instructional model, however, there are several caveats to its real-world implementation.

What are the practical implications of implementing the flipped classroom model?

          Before jumping in to designing a flipped classroom, there are a multitude of limitations to consider. This instructional model requires a significant amount of contact time between instructors and students, making it much harder to implement with particularly large classroom sizes. While millennial students are of the Internet generation, being significantly more tech-savvy than their predecessors, there are limitations to the use of technology for dissemination of learning materials. Advances in technology are costly and not every student will have equal access, nor the experience to manage them effectively. Additionally, there is a significant time-investment for educators in developing a multitude of educational materials ahead of time.¹ Finally, it is important to understand that generational diversity is only one type of diversity that will influence the classroom. For instance, Moraros et al. found that international students were more likely to rate the flipped classroom model as being effective than American students.⁹ With these considerations in mind, educators can begin to assess the practicality and net benefits of implementing a flipped classroom instructional model based on the type of students they will be instructing and the ultimate goals of their educational experience.

References

1.    Lage M, Platt G, Treglia M. Inverting the Classroom: A Gateway to Creating an Inclusive Learning Environment. J Econ Edu. 2000;31(1)30-43.

2.    Johnson SA, Romanello ML. Generational diversity: teaching and learning approaches. Nurse Educ [Internet]. 2005 Sep-Oct [cited 2017 Sep 9];30(5):212-6. Available from: https://www.chw.org/~/media/Files/Medical%20Professionals/Nursing%20Students/Preceptors/generational%20diversity%20teaching%20and%20learning%20approaches.pdf

3.    Roberts DH, Newman LR, Schwartzstein RM. Twelve tips for facilitating Millennials' learning. Med Teach [Internet]. 2012 [cited 2017 Sep 9];34(4):274-8. Available from: http://www.xyoaa.org/sites/all/modules/ckeditor/ckfinder/ckfinder/userfiles/files/education_materials/Millennials%27%20Learning%20Tips.pdf  doi: 10.3109/0142159X.2011.613498

4.    DiLullo C, McGee P, Kriebel RM. Demystifying the Millennial student: a reassessment in measures of character and engagement in professional education. Anat Sci Educ [Internet]. 2011 Jul-Aug [cited 2017 Sep 9];4(4):214-26. Available from: https://www.ncbi.nlm.nih.gov/pubmed/?term=10.1002%2Fase.240 doi: 10.1002/ase.240

5.    Lucardie AT, Berkenbosch L, van den Berg J, et al. Flipping the classroom to teach Millennial residents medical leadership: a proof of concept. Adv Med Educ Pract [Internet]. 2017 Jan 13 [cited 2017 Sep 9];8:57-61. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5245808/ doi: 10.2147/AMEP.S123215

6.    Galway LP, Corbett KK, Takaro TK, et al. A novel integration of online and flipped classroom instructional models in public health higher education. BMC Med Educ [Internet]. 2014 Aug 29 [cited 2017 Sep 9];14:181. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167261/ doi: 10.1186/1472-6920-14-181

7.    McLaughlin JE, Griffin LM, Esserman DA, et al. Pharmacy student engagement, performance, and perception in a flipped satellite classroom. Am J Pharm Educ [Internet]. 2013 Nov 12 [cited 2017 Sep 9];77(9):196. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3831407/ doi: 10.5688/ajpe779196

8.    McLean S, Attardi SM, Faden L, et al. Flipped classrooms and student learning: not just surface gains. Adv Physiol Educ [Internet]. 2016 Mar [cited 2017 Sep 9];40(1):47-55. Available from: http://advan.physiology.org/content/40/1/47.long doi: 10.1152/advan.00098.2015

9.    Moraros J, Islam A, Yu S, et al. Flipping for success: evaluating the effectiveness of a novel teaching approach in a graduate level setting. BMC Med Educ [Internet]. 2015 Feb 28 [cited 2017 Sep 9];15:27. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363198/ doi: 10.1186/s12909-015-0317-2

Learning From the Best

By Rafah Saad, PGY-2 Geriatric Pharmacy Resident, 

University of Maryland School of Pharmacy

‘Teaching occurs only when learning takes place.'

Being part of a large academic center, I knew teaching was a major component of my residency program. Not having much teaching experience in the past in addition to not being a student for over ten years, I began looking for ways to learn how to teach. In my search for means to build upon my teaching skills, I came across this book ‘What the Best College Teachers Do' by Ken Bain for some insight. This book is based on extensive research on teaching. In his pursuit to find out what the best college teachers do, he conducted a study of 63 of the best college professors from 40 different disciplines to see what they do. His research lasted about 15 years. Most of the teachers he interviewed mainly taught undergraduate students with a few graduate professors.  He chose the teachers to be included in the study by interviewing students that were highly satisfied with their teachers. He also searched for teaching award winners. He sought out professors with exceptional reputations who were recommended by other professors. He questioned what they understood about learning, how they prepared for classes, how they evaluated themselves and their relationship with their students, and many other aspects of teaching and learning. In this post I chose a few of his findings that resonated with me.

Bain found that the best college professors are truly passionate about their work, they are enthusiastic, and want to share their knowledge with their students. They try to instill their passion into the classroom since they believe that students learn best when they are also passionate and curious about the subject matter. They also know their subject matter extremely well and know how to explain it in a way that is more conversational than a typical lecture. I have had teachers in the past that just do the bare minimum, have no motivation and just lecture for an hour and leave. This teaching style had left me feeling just as unmotivated and that I was learning the material just to pass the exam. I have also had teachers who loved what they were teaching and wanted every student to be just as passionate as they were. These were the teachers and the subjects that I remember.

The way most successful teachers plan their teaching sessions plays a significant role in teaching and learning. It is imperative for the teachers to know their students and build strong, trusting relationships. To become a great teacher, one must understand what motivates their students to learn, what helps them learn better, and which teaching style to use. They design their classes by focusing on the students and what they need to learn. In teaching complex subjects, they start with simple concepts and move towards the more complicated. They concentrate on the teaching objectives and then plan backward starting with the desired results and assess the students’ comprehension based on those learning objectives. They also modify the lesson plan to fit the needs of the students better and are not held to a set lesson plan. Most of my education occurred in a lecture-based classes where the teachers had their established lesson plans and just explained the subject matter without considering the needs of the students. I felt most of my learning was self-directed, attempting to understand the subject matter on my own. I would like to develop a more facilitative role as teacher to help students to take responsibility for their learning. 

  In his research, Bain found that great teachers provide a safe non-judgmental environment where questions are welcome. I am not usually comfortable asking questions and speaking my mind in large classrooms, so I learn best in a classroom that feels open and safe from criticism. 

Finally, they are always striving to better themselves. They are continuously evaluating themselves and making appropriate changes accordingly. I still remember my biochemistry professor that had taught me almost fifteen years ago; I went to his office to ask a question and saw a book on his desk that he was reading on how to be a better teacher. He was in his seventies and had been teaching for decades. I asked him why he was reading that book and he said he would never stop learning and will never stop trying to be a more effective teacher.

Conclusion:

I know these professors are the exceptions and not the rule.  I am still in the process of finding my teaching style and trying to learn as much as I can from teachers that motivate. But what I do know is that I strive to be a teacher that inspires students to learn.

References:

Bain, Ken. What the Best College Teacher Do. Harvard University Press, 2004.

Testing as a Form of Learning in the Classroom

by Alison Blackman, PGY-1 Pharmacy Practice Resident, University of Maryland Medical Center

       

        Testing and assessing student knowledge appropriately in the classroom is an area of education that I feel is often subjective and left up to the opinion of the educator. Having completed my higher education, I have seen a multitude of different testing strategies – some that I felt were successful, while others I did not view as effective. Testing is inevitable in the classroom. However, I believe it should be an extension of education rather than solely being viewed as a grade. Herein, I will be discussing various ways testing can be creatively integrated into the classroom as a learning tool.

Pre-Tests

        There are many techniques discussed for how testing can be incorporated in the classroom. One article discusses three ways to use testing as a learning tool.¹ Some of these strategies include handing out pre-tests, spacing out information/exams, and utilization of recitation activities such as “think pair share” and other activities outside of lecture. The strategy that I found most interesting revolved around the idea of pre-tests. The article highlights the following, “The mere act of guessing engages your mind in a different and more demanding way than straight memorization or being fed answers.” Another article hypothesizes further that pre-tests may enhance learning by acting as tools to prime the brain for what is important and providing multiple possible answers for the tester to second guess themselves in order to truly assess their knowlege.² Getting information wrong by guessing helps the brain recall information more rapidly. ² This particular article highlights that “failure” is a tool that aids the mind in memorization.

Exam Questions: Open-ended vs. closed-ended

Another area of contention that I found in my search was the utilization of open-ended exam questions versus close-ended questions. One study analyzed the use of open-ended questions in an engineering program.³ The authors of the study point out that closed-ended questions require only one correct answer, whereas open ended questions require critical thinking and an in-depth understanding of the subject. What was interesting to me is that the authors of the study suggested that open-ended questions should make up 10-20% of a final exam – recognizing this is not a well-studied suggestion. I pose a counter question as to why an educator should not make up an exam that is all open-ended questions. It was the open-ended exams during my pharmacy school education that I retained the most information and still recall that information today. However, it should be noted that this is an opinion of the writer and it is recognized that the logistics of this testing method may be difficult in a large classroom setting and opens the door for students to criticize that the teacher had biases while grading. On the other hand, the article by Carey suggests that exposing students to multiple-choice exams allows the student to question whether they truly know that answer by seeing other options.² Regarding final assessment, and in the context of pharmacy school, I disagree with the overuse of multiple-choice exam questions. I see where the author is coming from in that if I student confidently knew the answer, they would select it correctly; however, I think that multiple choice exams limit the amount of information to be tested and are not always an accurate measure of students’ knowledge on the subject.

Another testing strategy that I found interesting, especially in the context of pharmacy school was an article that focused on a team, case-based examination in a patient safety and informatics course.⁴ Rather than the traditional test, professor developed higher level activities. Utilizing previous strategies discussed, the course also administered a pre- and post- survey for students to self-reflect upon their ability to perform what was taught in the class. Overall, the mean score on the exam was 93.6% and 81% of the students reflected that the exam was beneficial for their learning. It is recognized that this mode of testing is not feasible in the majority of subjects, but may be an option in lab or more “hands-on” courses.

       

Overall, there are many ways to test student knowledge. Some ways promote learning over others. When discussing teaching, educators being aware of various student learning styles is often a hot topic. It seems to me that testing is something that should fall under this category, however it is not often emphasized. I believe that educators should be aware of student assessment styles as well as strategically select appropriate testing strategies in order to enrich student learning. Optimal assessment of knowledge will always be an area that is debated as education evolves. As a future teacher, whether it is in the classroom or as a preceptor, I will try my best to incorporate creativity and be aware of testing options that promote learning rather than fear of a grade.

References

1. Pillars W. 3 ways to use testing as a learning tool. Education Week. 2015. Accessed September 2, 2017 <http://www.edweek.org/tm/articles/

2015/05/12/3-ways-to-use-testing-as-a.html>

2. Carey B. Why flunking exams is actually a good thing. The New York Times Magazine. 2014. Accessed September 2, 2017 < https://www.nyt

imes.com/2014/09/07/magazine/why-flunking-exams-is-actually-a-good-thing.html?_r=0>

3. Husain H, Bais B, Hussain A, et al. How to construct open ended questions. Social and Behavioral Sciences. 2012;60:456-462

4. Beckett RD, Etheridge K, DeLellis T. A team, case0based examination and its impact on student performance in a patient safety and informatics course. The American Journal of Pharmaceutical Education. 2017;81(6):Article 117 

To Blend or Not to Blend, That is the Question

         MacKenzie Crist, PGY1 Resident, University of Maryland Medical Center

         Blended learning has become a new “hot topic” in the academia world. Essentially, blended learning or flipped classroom includes mixing activities for students to individually complete at home with normal didactic lectures.¹ This teaching style has become increasingly prevalent with data supporting the role for blending learning in the classroom. Blended learning is taking center stage due to the ability of incorporating self-learning with typical didactic criteria in teaching students. This type of learning also allows students to review material outside of class multiple times to enforce mastery of the subject.

On the other hand, blended classrooms can be a burden on students with extra out-of-classroom material being included in an already overwhelming pharmacy curriculum. As more professors utilize flipped classrooms, students will have to complete more work at home. Sometimes, teachers from different courses don’t realize how much they are burdening the students with work because they fail to coordinate how much out of classroom work the students are overall receiving. Some students will go as far as skipping class if they have not reviewed the material required prior to class time due to spending time on other academic activities.

Guidelines and Best Practices

Kahanova and colleagues recognized a deficiency in guidelines for professors wishing to utilize flipped classrooms and attempted to create a resource for teachers.¹ This study looked at mid-point and final evaluations of 10 flipped courses over the span of two years.¹ Using a coding system, the researchers determined which factors were recurring throughout these evaluations.¹ The recurring themes that were brought up in student evaluations included: advantages of blended learning along with concerns about implementation, benefits of pre-class learning and factors that can negate the benefits, the role of the instructor for ensuring the flipped classroom activities are successful, and the need for assessments that coincide with what was taught during the blended lesson.¹ Overall, this study gives a good guideline of what professors should consider when including flipped classrooms in their curriculum and how to ensure this flipped classroom will be beneficial for everyone, teachers and learners, involved.

          Another study from the University of Wisconsin-Madison School of Pharmacy, looked at blended learning in depth and recorded answers of student’s perception of flipped classrooms.² This study took a group of P1, P2, and P3 students who were to give feedback on blended learning.² The major findings of this study were the answers to what that professors should have in place if one desires to utilize a blended classroom. The study listed factors as best practices for those who may want to include blended classrooms in their curriculum. The best practices listed from this study were: setting the stage, consistency with team teaching, timeliness, time on task, structured active learning, faculty feedback on student preparation, incorporating student feedback, reviewing online material during the class, and utilizing technology.² These characteristics help a course coordinator set up a blended learning environment for success. As a recent pharmacy student, I agree with most these best practices. It is important to outline to students what is expected and how much time the activity will take. During pharmacy school, time management was difficult as many classes would pull you in opposite directions and rotations had many assignments in addition to didactic courses. Having these parameters in place will facilitate the best learning environment for student success in flipped classrooms.

          Overall, blended learning has revolutionized how material is delivered to learners. This type of classroom allows the learner to supplement didactic material with online modules. There are many advantages and disadvantages to blended classrooms. It is important for the professors to have these benefits and pitfalls in mind while designing a flipped classroom activity.

           

References:

1.    Khanova J, Roth MT, Rodgers JE, et al. Student experiences across multiple flipped courses in a single curriculum. Med Educ. 2015 Oct;49(10):1038-48. 

Available from: http://onlinelibrary.wiley.com.proxy-hs.researchport.umd.edu/doi/10.1111/medu.12807/abstract;jsessionid=B686165E3CF7BE8E19F9BBDD0267B880.f04t02

2.    Margolis AR, Porter AL, and Pitterle ME. Best Practices for Use of Blended Learning. Am J Pharm Educ. 2017;81(3):Article 49.

Available from: http://www.ajpe.org/doi/full/10.5688/ajpe81349

Engaging Kinesthetic Learners in Pharmacy Education

Mallory Mouradjian, PharmD, PGY1 Pharmacy Resident, UMMC

Within any given classroom, each student may have a different learning style in which they best gather and store information. Some learners understand information best by reading information or interpreting graphical information while others may prefer to listen to a podcast. One common method used to classify learning styles utilizes the VARK modalities, first described by Fleming and Mills in 1992. The postulated that there were four categories that learning modalities could fall under:

• Visual: learn best through visual depictions such as charts and graphs
• Aural/Auditory: learn best via listening and reciting back in their own words
• Read/Write: learn best via textual inputs/outputs, like to read and digest information on their own time
• Kinesthetic: Learn best through hands-on experiences

Given the variety of modalities that students utilize to understand information, it is in the best interest of an educator to attempt to incorporate diverse activities into the structure of their courses. Busan et al. conducted a survey of 230 medical students in 2014 in an effort to characterize the distribution of learning styles of learning in the medical field. They issued a questionnaire that placed students into 3 categories, visual, auditory, and kinesthetic. They found that 33% were visual learners, 26% auditory, and 14% kinesthetic. The remaining students were classified as multimodal, meaning that they preferred two or more of the learning styles, namely 12% visual and auditory styles, 6% visual and kinesthetic, 4% auditory and kinesthetic, and 5% utilized all three styles¹.

Busan et al.  demonstrated that there is a significant portion of learners that are classified as kinesthetic learners. Despite this information, some academics claim that kinesthetic learners may be the least engaged group in modern education.² This is not necessarily a surprise as It can be a challenge to incorporate activities for kinesthetic learners in the classroom, especially if the format is lecture-based.

Kinesthetic learners, as the name implies, understand information best when they can carry physical, hands-on activities. They “learn by doing,” not by listening or reading material. They benefit from learning experiences that incorporate case study and real-world scenarios in which that can role-play and use critical thinking. When looking at pharmacy school programs, kinesthetic learners benefit most from the last year of experiential education but may be poorly engaged prior to this last year of clinical rotations. Some pharmacy schools have begun implementing activities in order to reach this under-engaged group of learners. Below are some possible activities that may help to engage kinesthetic learners.

Real-world Simulation with a Virtual Patient

A group of educators at MCPHS University incorporated a virtual patient software program into the curriculum of their pharmacotherapuetics course. The software allowed students the opportunity to interview a patient, perform a physical exam, and provide medication counseling to digital standardized patient. This was intended to supplement the therapeutics course as it focused on disease states that were being covered in the course. The students were evaluated on their ability to conduct a mock clinic visit. They found that students that utilized the software conducted more thorough patient interviews during their mock clinic visits and students felt that this experience had been helpful in their understanding of the material.³

Case-based Learning

Another strategy that can be utilized to engage kinesthetic learners is to complement traditional learning methods with case-based learning to encourage higher order thinking. Case-based learning generally involves the distribution of a realistic patient case, complete with all of the pertinent laboratory data and patient history, and students are required to work through the case, develop a care plan, and provide supporting literature. The case is then discussed in small groups of 6 to 10 students to encourage collaborative thinking and problem-solving. Jesus et al. found that students that participated in the case-based learning had improved clinical decision-making and learning motivation as well as higher post-exam scores.

Gamification

Gamification is the practice of adapting a game for a purpose of education. This method can reach kinesthetic learners because it allows them to learn while physically participating in an interactive activity rather than simply listening to a lecture. Educational games can range from Jeopardy-type games that facilitate memorization of drug names, indications, and adverse effects, to games that require students to apply information learned in lectures in realistic scenarios. In a systematic review from 2105 that reviewed the use of games in pharmacy education found that educational games may help “complement and reinforce taught material by promoting students’ participation and engagement in an interactive, enjoyable, and motivational learning environment”.⁵

Kinesthetic learners are an under-engaged group in the medical educations. It can be a challenge to incorporate activities that involve hands-on activities in a lecture-based course, however there are potential benefits from encouraging hands-on and critical thinking activities as a supplement to the class.

References:

[1] Busan A. Learning styles of medical students. Curr Health Sci J. 2014;40(2):104-110. Full Text

[2] Wood N, Sereni-Massinger C. Engaging online kinesthetic learners in active learning. Proceedings of IMCIC – JCSIT 2016:116-119. Full Text

[3] Taglieri CA, Crosby SJ, Zimmerman K, Schneider T, Patel DK. Evaluation of the use of a virtual patient on student competence and confidence in performing simulated clinic visits. Am J Pharm Educ. 2017;81(5):1-9. Full Text

[4] Jesus A, Gomes MJ, Cruz A. A case based learning model in therapeutics. Inov Pharm. 2012;3(4):1-12. Full Text

[5] Aburahma MH, Mohammed HM. Educational games as a teaching tool in pharmacy curriculum. Am J Pharm Educ. 2015;79(4):1-9. Full Text

Cultural Sensitivity in Shaping Education

By Mari Cid, PharmD, PGY1 Community Pharmacy Resident

University of Maryland, School of Pharmacy

According to a paper published by the American Medical Association, cultural competency, or cultural awareness and sensitivity, is defined as, "the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own. It involves an awareness and acceptance of cultural differences, self awareness, knowledge of a patient's culture, and adaptation of skills".¹ The foundation of our American culture is in our cultural diversity as the melting pot of the world. Though there is beauty in our differences, diversity is not without its challenges. It is important to grow as a society as we grow in our diversity and one of the ways that begins is within our education system. Implementing cultural sensitivity and awareness into our education system will shape new ways of learning and is important to the success of future generations.

Historically, the most vulnerable students come from low income background and are people of color who are usually at the bottom of achieve gap with the lowest graduation rates. It is naive to think that one perfect system will work for every student. Across the United States, difference cultural values and economics play a vital role in the curriculum at different schools. As a Pilipino-American who grew up in Southern California, I was fortunate to grow up with many people who shared my similar background of immigrant parents. This identity in our community shaped curriculum in our school districts. With a significant number of us growing up Asian-American, I was able to take a Filipino class and learn about the culture of the Philippines through language, food, and dance in a classroom and never had to struggle with feeling a connection to classmates and teachers. I excelled in school, eventually earning my Doctorate in Pharmacy. Unfortunately that is not always the case.

In his TED talk, Manuel Hernandez, an educator, author, ESL (english second language) teacher in New York City describes seeing a lack of connection to curriculum as a challenge in his classroom. ² He saw that multicultural students wanted to learn, but classroom materials, such as Shakespeare, weren’t relatable to their own cultural experience. To meet this challenge, he introduced Latino/a literature and noticed a significant difference in the classroom when culturally relevant materials were introduced into the learning experience.² He noticed students began to participate and were more engaged in the class.² Through his efforts, he was able to bridge the gap of communication to help teach his students to learn English, to read, stay in school and pass citywide exams.

In a another TED talk, Dr. Melissa Crum noticed that many teachers had challenges teaching and relating to students who did not share their same cultural background.³ Most teachers today are female coming from a middle income, white background which is not a reflection of the students today. To help bridge this gap, Dr. Crum worked with a museum educator to create an arts-based professional development series that helps educators think about how they are thinking about their diverse students. Though discussion was sometimes uncomfortable, better understanding of different cultural backgrounds was essential for the educators to be able to reach the students. Dr. Melissa Crum also states that studies have shown that that students who are more engaged have high academic achievement, lessen the dropout rate, and result in more productive citizens.³

Arguably, one of the most culturally diverse states is Hawai‘i. A research study there indicated that learners thrive with culture-based education (CBE), especially indigenous students who experience positive socioemotional and other outcomes when teachers are high CBE users and when learning in high-CBE school environments.⁴ Researchers from the study believed educational progress will come from forward-oriented research and leadership that embraces the cultural advantages of students with diverse experiences of racism, poverty, cultural trauma, and oppression.⁴ As an alumni of the Daniel K. Inouye College of Pharmacy from Hawai‘i, I experienced first hand how they integrated culture into our curriculum as school. Being a student from the Mainland (the continental United States), the roles were now reversed with me having to learn the culture of the classroom. From learning local language to be able to better communicate with patients, to familiarizing myself with local customs such as paying respects to the ʻĀina, and spreading aloha spirit. I took the cultural experiences I had from when I younger and applied the same mindset to learning about another culture to expand my perspective and education. I felt that the additional training of cultural competency adding value to my education as a future pharmacist. It gave me unique opportunities to apply what I learned in the classroom to real world experiences.

Cultural competence training has grown to be a fundamental part of the work environment. It is an essential part of any new employee and professional training. It is important to apply our cultural competency training, especially as healthcare workers because our job is to help our patients achieve their optimum health no matter what background they come from. Studies have already shown that cultural competence in healthcare plays an important role in patients being satisfied with their providers, as well as patients willingly and actively participating in their treatment.⁵ This has contributed to expanding technology to bridge the language barrier in communication. As pharmacists, we are also educators and it is essential that we practice cultural sensitivity with our patients and continue to find new and innovative ways that we can educate them on their medications so they can achieve the best outcomes of their therapy.

In conclusion, practicing cultural sensitivity is another way we can improve education in our diverse communities. I am an example of applying cultural sensitivity in my education and I continue to apply what I learned and grow through my new experiences as a pharmacist. As a society, continuing to find ways to integrate this mindset into our education system is where we can start to contribute to the growth of a stronger, wiser, and understanding students. 

References:

1. Fleming M, Towey K. Delivering culturally effective health care to adolescents. Chicago (IL): American Medical Association; 2001. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/39/culturallyeffective.pdf. Retrieved August 26, 2017.
2. Hernandez, Manuel. (2015, March). Bridging the cultural gap in the classroom | Manuel Hernandez Carmona | TEDxAmoskeagMillyard. [Video File]. Retrieved from https://www.youtube.com/watch?v=Br22BFA7bAg
3. Crum, Melissa. (2015, July). A Tale of Two Teachers | Melissa Crum | TEDxColumbusWomen. [Video File]. Retrieved from https://www.youtube.com/watch?v=sgtinODaW78
4. Kana‘iaupuni SM, Ledward B, Malone NO. Cultural Advantage as a Framework for Indigenous Culture-Based Education and Student Outcomes. American Educational Research Journal. 2017;54(1):311S-339S. doi:10.3102/0002831216664779.
5. Brunett M, Shingles RR. Does Having a Culturally Competent Healthcare Provider Affect the Patients’ Experience or Satisfaction? A Critically-Appraised Topic. Journal of Sport Rehabilitation. 2017:1-14. doi:10.1123/jsr.2016-0123.

Teaching Controversial Topics Using Conflict

By James Leonard, PharmD, Clinical Toxicology Fellow, University of Maryland School of Pharmacy

“Medicine is black and white.” This is a phrase not commonly uttered in medical practice.(1) Diagnoses are based on probabilities; therapeutic decisions are based on balancing the benefits (number needed to treat) with the risks (number needed to harm). Medicine is fraught with controversy, but we teach students, residents, and new practitioners that they need to be practicing guideline directed care. There are many fields of medicine (cardiology, infectious disease, epilepsy) that have practice guidelines based on robust data and large studies. We teach these topics as right and wrong, asking students to go down the steps of adding antihypertensives based on JNC-8 or adding the “correct statin” based on a patient’s risk profile. On the other hand, my area of practice, toxicology, has a limited evidence base and practice is highly based on experience and small studies. This means that the field if full of controversy. This blog post will cover educating learners on topics filled with controversy.

What is controversy?

Controversy is a type of conflict where one person’s understanding and conclusions are incompatible with another’s.(2,3) It is incredibly easy find controversy in issues rooted in ethical, r

eligious, or political beliefs.(3) Most of these issues are more difficult to study with hard science and are dependent on emotional and experiential arguments. On the other hand, medical practice is primarily based on experimental “facts” and practicing outside of those facts is often deemed unreasonable. With our history of medical reversal (disproving what is “known” about a medical practice through completion and publication of superior trials; think about beta-blockers as contraindicated in heart failure prior to the 1990s), it is important to question the facts and learn to practice with an understanding that there is always controversy in medicine.(4)

How can we use it to teach medicine?

We can use controversy to teach medicine more thoroughly than most other methods. In their article “Energizing Learning: The Instructional Power of Conflict,”(2) Johnson and Johnson describe using controversy to teach by a few simple steps. First, you assign students either alone or in small groups to learn “their” side of a controversy. Next, both sets of students present their arguments in a situation that is not a conventional debate; there is no winning. The instructor plays devil’s advocate, chimes in with experience, and acts as mediator. Next there is an open discussion with students presenting facts, supporting their positions, and engaging with each other. The fourth step requires students to swap perspectives and learn and argue the other side of the issue or other aspects of treatment. Finally, students get together to devise a new, integrated solution. The authors hypothesize that this method provides a higher level of understanding of their original side of the controversy, challenges their understanding, and then sparks their epistemic curiosity, leading to seeking out new knowledge. I think of this process as very similar to forcing students along the Dunning-Kruger curve by challenging their understanding of a topic by immediately introducing healthy doubt (Dunning and Kruger presented the idea that people often do not know what they do not know, but will be confident in their abilities regardless of their knowledge. The graphs from their seminal article have been combined as shown and elaborated on by some authors).(5) Additionally, more experienced practitioners can step in to remind learners that patients do not read textbooks to know how they should present or react to therapies. The teaching certificate course utilizes different teaching theories and use of controversy in combination with other theories can add to our arsenal of teaching methods.

What problems occur with controversy?

The setting needs to be right and rules need to be put into play. Learners need to have the emotional quotient to poke holes in only ideas and not attack others personally. Additionally, learners need to recognize that their opinions are being challenged. There is a fear that emotions can get heated in the classroom and things may get “out of hand.” Warren and Center provided a series of tools to manage students that get heated and to encourage learning despite controversy.(6) Some of their most useful tools include only letting students attack ideas and if the conversation gets too heated, intervene and have students leave the conversation temporarily. If students do not have open minds, they can misunderstand the exercise and get emotionally attached to their side of the topic.

Has controversy been used to teach medicine before?

In short, the answer is yes. The Social Media and Critical Care annual conference utilized debates in medicine taking on hot topics like code status, use of c-collars, and the evolution of emergency medicine. These are debate style discussions, but often assign speakers to promote the side they have been publicly against.

Medicine is full of controversy whether we like it or not. Teaching students underlying evidence and presenting their summaries with opposing opinions can enhance the learning of everyone involved. Preceptors can act as mediators, play devil’s advocate, and offer experiences that stimulate conversation. This method of teaching, while time-intensive, encourages learners to get excited about topics and has potential to revolutionize education.

References:

1.   Simpkin AL, Schwartzstein RM. Tolerating Uncertainty - The Next Medical Revolution? N Engl J Med. 2016 Nov 3;375(18):1713–5. Full Text

2.   Johnson DW, Johnson RT. Energizing Learning: The Instructional Power of Conflict. Educational Researcher. 2009 Jan 1;38(1):37–51. Full Text

3.   Hendricks JS, Burkstrand-Reid B, Carbone J. Teaching Controversial Topics. 2011. Full Text

4.   Prasad V, Cifu A. Medical reversal: why we must raise the bar before adopting new technologies. Yale J Biol Med. 2011 Dec;84(4):471–8. PMC3238324

5.   Kruger J, Dunning D. Unskilled and unaware of it: how difficulties in recognizing one's own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999 Dec;77(6):1121–34. Full Text

6.   Warren L, DB Center. Managing hot moments in the classroom. Cambridge. 2006. Full Text