Implementing Self-Directed Learning

By Sandeep Devabhakthuni, PGY1 Pharmacy Practice Resident, University of Maryland Medical Center

Self-directed learning is basically the process in which an individual matures from a dependent learner in a highly structured environment (often a classroom) to an independent learner with the motivation to continuously self-monitor and self-manage his/her learning process. In the healthcare setting, the recent paradigm shift to evidence-based medicine requires the engagement of healthcare professional students in self-directed learning. Typically, healthcare professional schools design academic curriculums that will at minimum prepare students to become competent practitioners. While I learned a tremendous amount of information that will serve me well in my clinical practice, I realized that the program of study I completed was designed to help me achieve the minimum competencies needed to be a general practitioner. Despite having just graduated with a Doctor of Pharmacy degree, I recognize there are several ways I can improve myself. Thus, I am a big proponent for self-directed learning because I want to become a highly competent healthcare provider.

Self-directed learning is an effective (even essential) method for training healthcare professionals. But how do we motivate students to become self-directed life-long learners? Specifically, is there a need for more guidance during the didactic portion of the curriculum before expecting students to perform self-directed learning activities during their experiential learning rotations? At the University of Maryland School of Pharmacy (UMSOP), Huynh et al considered this issue by investigating the impact of advanced pharmacy practice experiences (APPEs) on student’s readiness for self-directed learning (Am J Pharm Educ. 2009; 73(4): 65-72).

In this investigation, the authors followed pharmacy students over the course of their last year in the Doctor of Pharmacy curriculum in order to assess their readiness to engage in self-directed learning activities. During their third year before starting APPEs, pharmacy students from were invited to complete a questionnaire consisting of 2 sections: the Self-Directed Learning Readiness Scale (SDLRS) and a baseline characteristics survey. A score of 150 or greater on the SDLRS instrument was correlated with a high level of readiness for self-directed learning. After completing the required APPEs, the pharmacy students were asked to complete the SDLRS instrument again. The data from the post-APPE questionnaire was compared to the results of the pre-APPE questionnaire.

The authors reported that 77 (64%) and 80 (67%) students completed the questionnaire in the third and fourth year, respectively. Of these respondents, only 46 (38%) matched pairs completed the questionnaire in both years. From the baseline characteristics analysis, none of the characteristics such as age, gender, pre-pharmacy coursework, postgraduation plans, or leadership experiences had an impact on the SDLRS score. The overall mean SDLRS score for the pharmacy students who completed the questionnaire in the third year and fourth year were 157 ± 21 and 162 ± 21, respectively. No difference was found in the mean scores on the SDLRS for students in their third and fourth years (p > 0.05), regardless of using all student data or only matched pairs (i.e., same student before and after completion of APPEs) data.

To be honest, I was not entirely surprised that the impact of APPEs on the student’s readiness for self-directed learning was minimal. Pharmacy students need to be ready to engage in self-directed learning before they begin their experiential learning rotations. If the student does not have the expectation of performing self-directed learning during the APPEs, the student will struggle during his/her last professional year. Teaching students to engage in self-directed learning during the APPEs is probably too late. The students need to be aware of the need for self-directed learning before they apply the process during APPEs. The fact that the APPEs have a minimal impact on the student’s readiness supports this observation. Instead, the purpose of the APPEs is to provide the pharmacy student opportunities to engage actively in self-directed learning. Thus, it is crucial to provide guidance to the pharmacy students before APPEs on how to successfully engage in self-directed learning activities during APPEs.

At the time of the investigation, the authors reported that the pharmacy students at the UMSOP were not provided explicit instruction regarding how to conduct self-assessments or engage in reflective learning. The good news - most students demonstrated a high readiness for self-directed learning at baseline before beginning their APPEs. The focus should shift to helping students applying self-directed learning skills during their APPEs. In other words, preceptors should evaluate whether students successfully engage in self-directed learning activities. By giving feedback regarding the quality of these self-directed activities, students will learn how to self-evaluate and take steps to improve their knowledge and skills when they begin their practice as pharmacists.

[Editor's Commentary: Why are some people more successful in their professional lives then others? What keeps some people "on top" of their field for many years? Is it strictly a matter of internal motivation? An intrinsic personality trait? An inherent need to understand the world? Intellectual curiosity? Or is self-directed learning a learned behavior? A set of skills, habits, and attitudes learned by observing other successful people in our lives (e.g. parents, role models). Can these skills, habits, and attitudes be taught in school? Few of us have received explicit instruction about how to "be" a self-directed learner. Not surprisingly, students who are admitted to schools of pharmacy are very bright and successful. It seems likely that one of the ingredients for their success is their ability to independently recognize gaps in knowledge and skills ... and engage in self-development activities to close these perceived gaps. Indeed, the "best and brightest" often become involved in research projects (or "special projects" or "independent study") during their years in pharmacy school and pursue residency or fellowship training after graduation. And yet, these are the individuals who are most competent and best prepared to entry practice without doing a residency or fellowship. Is the ability to successfully engage in self-directed learning an intrinsic quality or a learned behavior? Is it nature or nurture? An age old debate. -S.H.]

Passive versus Active Learning

By Josephine Heinz, Pharm.D., PGY1 resident, Sinai Hospital of Baltimore

I remember the long hours I sat through my pharmacokinetic classes wondering what all the symbols my instructor was talking about meant. Wow, I thought, does all this really happen in a patient? Most of the equations were meaningless abstractions to me and it didn’t make any more sense to me at the end of the lecture.

Healthcare concepts are most often learned through traditional methods where the instructors figuratively pour information onto their students and students sit passively hoping they could retain all the knowledge and recall it for an exam. I had flashbacks to my experience as a pharmacy student when I read an article by Robert Dupuis and Adam Persky (Am J Pharm Educ 2008; 72(2): Article 29.) The investigators applied the principles of active learning to enable students to develop critical thinking, self-direction and practical application of information related to pharmacokinetics. Students were divided into small groups, assigned cases and had to present it to the entire class in the presence of the instructor. Individual responsibility was also emphasized by assessing each student’s preparedness for the presentation by quizzing them before class and also comprehensive examinations. Members of each group were chosen by the instructor based on their knowledge and skills rather than permitting students to make the groups for themselves. By placing students with various knowledge and skills together, this allowed students to understand how others think through problems. In their study, the authors compared the new teaching strategy to a traditional, passive approach of teaching the material. They found that not only did the students like this active teaching approach better; they could also relate the concepts to clinical practice and felt comfortable and confident when addressing real patient cases.

This study answered some questions that perplexed me as a pharmacy student. The traditional educational paradigm is like a "Container-Dispenser model" – it assumes the transference of knowledge is primarily the instructor's job and students' minds are like empty receptacles (Bonwell CC, Eison JA. Active learning: Creating excitement in the classroom. ASHE-ERIC Higher Education Report No. 1. Washington, DC: The George Washington University, School of Education and Human Development; 1991). Students are expected to passively absorb information in silent isolation during a lecture and later on, recall the knowledge when given a test or assessment. A lot of passive teaching occurs in pharmacy schools, and most students only get to apply the knowledge they have acquired during experiential rotations in the final year of the curriculum. This leaves the students feeling frustrated and inadequate because they cannot answer commonly encountered medication problems. This year, during my residency, I’ve heard students say “I just want this rotation to be over,” because they feel they have no time to sit down and read through all the lecture notes they have accumulated over the years. This is a concern for our profession. Do we have to force all graduates from doctor of pharmacy programs to get an additional year of practical training, or can we address the current curriculum to include more self-directed and active learning?

I recommend that we follow the example of Dupuis and Pesky by incorporating more active learning strategies into the pharmacy curriculum. Active learning is more than just "doing" but requires the student to "think about the things they are doing.” With active learning, the responsibility for learning shifts from the instructor to the student. Let us create an environment similar to what students will face in the real world so that they do not flounder when they get into practice. The challenge today is to encourage students to move beyond standard technical solutions and apply clinical reasoning. Active learning promotes the development of abilities in addition to knowledge, attitudes that employers require, and behaviors that better meet the demands of professional practice.

[Editor's Commentary: Active learning strategies - engaging students in meaningful activities - work. Active learning strategies generally require students to find the information (facts) for themselves and to apply this newly acquired (and their existing) knowledge to solve a problem. Many teachers (at schools of pharmacy and elsewhere) have embraced these strategies and use them extensively throughout their courses. Others are experimenting and use these strategies sporadically. Still others are unwilling or, perhaps, afraid to try. Admittedly, active learning strategies are a bit messy and the teacher must relinquish control of the content and the process. And if you extensively employ active learning strategies you can't tell students about all the great knowledge YOU possess. And isn't teaching all about sharing your wisdom with others? Not exactly. The teacher's knowledge and wisdom is no doubt important. It should help guide the creation of meaningful learning activities and authentic assessments of performance. Teachers and experts are great resources to students during their learning voyage. But telling people about everything YOU know isn't particularly helpful ... and it won't help a student construct their own understanding of the material and how to apply it. If you want to include more active learning strategies in your classroom, check out the Active-Learning Inventory Tool created by Jenny Van Amburgh and her colleagues at Northeastern University. -S.H.]

Mobile Technology in the Classroom

by Sherry Kelishadi - Doctor of Pharmacy Candidate (2011), University of Maryland School of Pharmacy

As a 3^rd year pharmacy student at the University of Maryland School of Pharmacy, an article entitled Mobile Computing Initiatives Within Pharmacy Education by Cain and colleagues caught my attention for various reasons [Am J Pharm Educ. 2008; 72: Article 76]. Mobile computing technology has impact me personally during my journey through pharmacy school. During my first semester at Maryland, I was transitioning from handwriting my notes to typing them. I was concerned because I wasn’t sure if laptops would have a positive or negative impact on my learning in the classroom. I was attracted to those students who were typing rapidly on their laptops, seemingly able to jot down every word that came out of the professor’s mouth. Over the years, I have adapted to my laptop. I can research answers to drug information questions, access learning materials on Blackboard, and download notes and references. My personal belief is that all pharmacy students should use mobile computing devices in class because they give greater access to resources. However, they should only be used for educational purposes. In other words, browsing the internet and not paying attention during a lecture/case study/ or group discussion is unacceptable and can lead to poor performance.

The article by Cain discusses the impact that laptops and personal computers have had on pharmacy student’s education. More and more pharmacy schools are using laptops – and many require them. There are several advantages and disadvantages to using these technologies. The advantages include students being able to have online access to Micromedex/Epocrates/Facts and Comparisons during lectures in institutions where internet is accessible. Also, students have immediate access to lecture materials and cases. The disadvantages: professors becoming frustrated by students distracted playing puzzles, shopping, instant messaging, posting on facebook, engaging in online fantasy sports games, and web browsing. Personally, I have witnessed first hand the advantages and disadvantages of mobile technology. Daily I see students browsing the internet during a lecture or case study. And I suspect this leads to poor test scores. Indeed, in one study that I found, students who multitasked with laptops during lectures performed significantly lower on simple measures of lecture content recall than those who did not multitask [Hembrooke H, Gay G. The laptop and the lecture: The effects of multitasking in learning environments. J Comput Higher Educ. 2003;15:46–64].

These manuscripts tie into Educational Theory and Practice in many ways. As this course discusses effective ways to teach, it’s important to engage students with the material and not be distracted. Is it more effective to use computers in the classroom or should students just take notes the old fashioned way? I personally believe it doesn’t matter what technology is used (computer vs. pen & paper). The crucial part is the teacher-student relationship. For example, a recent professor of mine was lecturing on HIV and during 2 hours looked up at students only twice. Thirty minutes into the lecture, EVERYONE was doing something other than note taking. Professors should engage their students by periodically asking questions throughout the lecture and making eye contact. This will help students to stay focused on the material regardless of how they are “writing things down.” In addition, professors should have “mini quizes” periodically at the conclusion of lectures to determine what students learned and this will create an incentive for them to pay attention.

Whether a pharmacy school requires its students to use laptops or not, it need not have a negative impact on learning. I believe the crucial part of learning isn’t what technology the students use, but rather how the professors engage students with the material. Students can become distracted with or without a laptop. I have sat through many boring lectures in pharmacy school but also lectures that kept us on our toes. As we have been learning in this course, there are two sides: effective learning and effective teaching. It’s important for both the professor and student to understand their roles and responsibilities … and to use technology effectively to maximize the learning and teaching process.

[Editor's Commentary: I think there is little doubt that mobile technologies can be both a positive and destructive force in the classroom. We've all suffered through "boring lectures." In the past (before mobile technologies infiltrated every aspect of our lives), we'd simply zone out or doodle or have a side bar conversation to pass the time. Now, rather than doodle away, we can engage people inside and/or outside the classroom in virtual dialog, we can shop, we can pull up our notes for tomorrow's big exam, or we can play highly engaging games without leaving our seat. Its all there - at our finger tips. And because we (and our students) have become accustomed to engaging with our mobile devices during even the briefest moments of "down time" (even when driving a car), it's hard to keep us continuously focused for long periods of time. Of course, we never could stay focused for long periods of time ... but now we have something readily available that allows us to be more "productive" ... and distracted. Obviously, these distractions (mobile technology-induced or otherwise) aren't conducive to learning. Unfortunately, mobile technologies - particularly laptops, can be distracting to other students in the environment too - just like those students who sat in the row behind you and constantly whispered to one another did in the past! Just seeing another student in front of you searching for the best deals on a cruise to Hawaii or playing fantasy football can catch your eye ... and suck you in! So what is a teacher to do? The strategies are the same as they have always been. Engage students by (re)gaining their attention, fostering a dialog, and allowing the students to use the power of technology in meaningful ways to achieve a learning objective. In other words, teachers need to harness the technology for OUR purposes ... otherwise students will find better ways to use the technology for THEIR purposes ... like fill in the void caused by boredom. S.H.]

Innovations In Teaching

by Tanya Telegadis, Pharm.D. - PGY2 Pain and Palliative Care Pharmacy Resident, University of Maryland School of Pharmacy

Boesen KP, Herrier RN, Apgar DA et al. Improvisational Exercises to Improve Pharmacy Students’ Professional Communication Skills. Am J Pharm Ed. 2009; 73: 1-8.

This article caught my eye because I have a special place in my heart for effective communication. As pharmacists, we are the most trusted healthcare professional and this is in large part due to our accessibility to the public. Patients rely on us for sound medical advice and as a platform to bounce ideas off of and to vent frustrations. In a community pharmacy setting, we have one, two, maybe three minutes with a patient and in this time, we need to establish a relationship with them. We need to be able to listen to what is said, come up with an appropriate response and then relay the information in an effective and appropriate matter (urgency, emergency, sympathy, empathy, concern, etc). In interactions with pharmacists throughout the years, I have seen those who I try to model and those who, quite frankly, make me thankful I am not the patient. In school, we do an excellent job of training in the necessary sciences and technical evaluation skills. My fear is that communication skills are compromised as students hone in on proficiency in the information they need to know and the technical skills they need to demonstrate. This article looks at improvisation, a very interesting way to incorporate communication skills into the pharmacy school curriculum.

The authors implemented twelve 1-hour improvisational sessions into an existing communication course in order to improve listening, observing and responding. They require a course in interviewing and communication skills for the first year students. In this course, students must pass a mock-patient (instructor) interview assessment by demonstrating minimum competencies in interviewing and counseling techniques as well as be able to adapt these to real world situations. They found that a majority of the student struggled with how to quickly recognize cues that would tell them when to address the patient’s emotional state and new physical symptoms. The students were so focused on gathering the information that they missed the cues, so much so that the mock-patient had to resort to exaggerated cues before students recognized a need to change their interview techniques. With this realization, the instructors decided to implement this improvisation plan into their course. They used standardized patient exams to assess student performance in communication skills (the success of their educational program), and reflective journaling and student evaluations to evaluate student’s perceptions of the improvisational exercises.

The purpose of these exercises was to enable students to: (1) develop additional expertise in the “art” of basic communication skills (2) improve the ability to think on their feet (3)understand the importance of emotion and relation in communication (4) become more comfortable in communicating in large groups (5) recognize basic dynamics of group communication and (6) learn to stay “in the moment” focusing on the patient/healthcare provider while recognizing when to change techniques and avoiding the temptation to anticipate. I think that all of these attributes are extremely important to being an effective patient educator … and even during non-professional interactions. These are life skills that some students already possess but can improve … and other students need to acquire.

The researchers addressed each goal with a specific exercise. In the interest of time, I will not explain each exercise but get at what the exercises were intended to achieve. They used “repeated patterns” as not only an ice-breaker but as a means of teaching students to listen for cues, respond accordingly, and ignore everything else in the environment. This is important because pharmacies are busy places and this should not compromise one’s attention to the patient's needs.

A second exercise involved advancing a conversation with “yes and…” Students were given their relationship to one another, their environment, and a topic to discuss. The goal was to continue to move the conversation forward. This technique was then applied to short scenarios with the goal of stressing the importance of status and emotion in every conversation.

Group communication focused on the dynamics of group communication. The goal was to maintain a single focus verbally and nonverbally.

The exercises that they implemented were very successful. Students improved on their skills (and grades!) significantly. The authors admit that some exercises made some students very uncomfortable. But I suspect that these are the students who most benefited from the exercises. Students who felt uncomfortable improve just as much as those who did not complain of discomfort. It is important for all pharmacy students to have good communication skills when working with patients and other healthcare providers.

In Educational Theory and Practice we talk about learning styles, teaching styles and implementing courses/lectures/classes successfully. It is important to keep in mind that many students are driven by grades and will easily lose sight of the whole-picture. When they lose sight of the whole picture, they are losing sight of the “whole patient”. It is our job, as educators, to emphasize the importance of good communication skills and seeing the details in the big picture. It is also our job to serve as role models of these skills and focus not just on the details but the “whole” student. Improvisation helped these researchers achieve their goals. Improvisation appears to be a innovative and fun way to teach an important but difficult skill.

[Editor's Commentary: Communication is a fundamental skill and, more than any other skill in modern life, closely correlated with one's success in nearly every profession and field. Our ability to communicate as health care professionals is a key ingredient to achieving optimal patient outcomes. As educators, pharmacists must be able to effectuate behavior change in various audiences - peers, patients, and prescribers. However, just as lecturing is not the most effective way of teaching our students, simply conveying information is not the most effective method of communicating with our patients. Both require us to know our audience, to care about them, and to listen (and talk less). Both require us to be attuned to the unspoken, non-verbal clues that our patients (and students) send to us ... and to adapt and respond to their needs. Some people are innately gifted communicators (and teachers). The rest of us can build our skills through guided practice and feedback. Teaching students to become effective communicators is perhaps the greatest gift any teacher could aspire to "give" ... and yet, its something we spend far too little time exploring and developing with our students and trainees. We need not do so in explicit ways (as the authors of this teaching innovation did) but in implicit ways by embedding opportunities to build our communication muscles in every course and learning experience. S.H.]

Integrated Medical School Curricula

by Julie Waldfogel, Pharm.D. - PGY2 Pain and Palliative Care Pharmacy Resident, Johns Hopkins Hospital

I recently passed a stand with the Johns Hopkins Hospital in-house newspaper and on the front cover was an article about the School of Medicine’s complete restructuring of their curriculum. I found the story intriguing and grounded in many of the fundamental principles of learning we’ve been discussing in this course.

The restructure curriculum is called Genes to Society – a curriculum that integrates basic science with clinical practice throughout the entire 4 year program of study. With this new model, first year medical students see patients within the first 6 months and 4^th year students combine their clinical training with bench work in the lab. Students also get the chance to work at the Simulation Center, practicing procedures and assessment techniques before using them on real patients.

When viewed as an educational model, Genes to Society incorporates the major educational theories: Behaviorism, Constructivism and Social Learning. Behaviorism is a theory that learners follow a pattern dictated by the teacher. This is most visible in the traditional class structure of lectures and exams and is still present in the new John’s Hopkins curriculum. Constructivism relies more heavily on the learner for independent study and self-motivation and is seen through the school’s focus on clinical practice. Students will be seeing patients almost immediately and this environment is more conducive for self-directed learning. And the use of Social Learning is seen through the application of the Simulation Center. Social Learning is based on the theory that students learn best through example. By being able to observe a procedure and then practice it themselves, students get the benefit of modeling a behavior before applying it . By combining all three educational theories into their curriculum, the Johns Hopkins School of Medicine is building a program that engages multiple types of learners at once.

But the Johns Hopkins University is not the only program moving away from the traditional medical educational model. For example, McMaster University in Canada has developed the COMPASS curriculum. This model focuses on problem based learning (PBL). Students are divided into small groups, each with their own mentor. These small groups are given a series of problems from which they develop their own learning objectives and negotiate how to approach their learning tasks. Students in this curriculum are also exposed early in their training to clinical practice and patients. From the description of this curriculum, it’s easy to see that the major paradigm shift at McMaster is away from Behaviorism and towards a curriculum that focuses primarily on Constructivism and Social Learning as the major educational models.

But medical schools are not the only ones that can learn from these changes. Pharmacy is another health profession that could benefit from incorporating multiple educational theories into its teaching model. While I was in pharmacy school, the majority of my learning was in lecture-based format. In part due to the relatively rigid format and partly due to the nature of multiple choice exams with a single correct answer, I saw many choices as black and white. Medication decisions were clear-cut because they were based on guidelines and evidence-based medicine. However, as I’ve progressed through my residency training, many of the certainties that I once learned as a student have taken on shades of grey; because medicine is patient specific. And every day, as new information arises about the genetic basis for disease, the practice of medicine becomes even more personalized.

It’s this shift in the medical approach that has necessitated a change in medical education. With Genes to Society, it’s the cohesiveness of the curriculum that makes the model so appealing and so applicable to today’s medical practice. It integrates biological, societal and environmental components to help medical students evaluate the entire patient and provide the best care possible.

Of particular interest to me is the rejection of the concept of “normal” biology. In the classic medical educational model, students are taught to think of the body like a machine. A patient’s body is “broken” by a disease and it’s up to healthcare professionals to “fix” it. But many health professionals lack training regarding the emotional, spiritual, societal and ethnic issues that can also impact a person’s health. With their new curriculum, the Johns Hopkins University Medical School is saying “…no one is ‘normal’. Everyone is on some kind of continuum, and we need to understand why they’re presenting the way they do at any given moment in time.” The result is, hopefully, a more balanced clinician who can see each patient as an individual and has experience in addressing all aspects of health.

Whether this new curriculum helps produce better practitioners remains to be seen. But I’m relieved that the effort is being made to move us forward and into a new era of medical education.

[Editor's Commentary: From its founding in the late nineteenth century, the Johns Hopkins Hospital and the Johns Hopkins School of Medicine have been leaders in medical education. It was the first teaching hospital (as we understand them today) where the hospital, the medical school, and its faculty were fully integrated. It was not uncommon at the turn of the twentieth century for medical schools to be diploma mills in rented facilities with little or no clinical training prior to graduation. It wasn't until the publication of the Flexner report in 1910 that modern medical education took shape - and the model he espoused was largely based on the Johns Hopkins model of integration between didactic and clinical education. In the century that has since passed, other medical schools have adopted equally bold and innovative curricula. Problem based learning was pioneered at McMaster University in the 1970's and the concept was taken even further in the Compass Curriculum adopted a few years ago. But are these innovations in medical education really all the revolutionary? Not really - Maria Montessori developed curricula for pre-school and elementary education in which children were free to explore and learn in a carefully constructed environment. In this method, students directed their own learning through their interactions with the environment and with teachers as guides. Its seems medical (pharmacy and nursing) curricula are moving closer and closer to Montessori's vision. One wonders whether we need a didactic component in our curricula at all. S.H.]