Aristotle once said, "For the things we have to learn before we can do them, we learn by doing them." I believe this quote encompasses what is meant by experiential learning. I think of experiential learning simply as learning by doing.
Experiential Learning: On-Call!
Aristotle once said, "For the things we have to learn before we can do them, we learn by doing them." I believe this quote encompasses what is meant by experiential learning. I think of experiential learning simply as learning by doing.
Rethinking the Art of Pimping
Pimping is quite an old concept, as the earliest reference dates back to 1628 where Harvey, a physician, laments his students lack of enthusiasm, “O that I might see them pimped!” In 1889, Koch recorded a series of “Pimp Questions” that he later used on medical rounds. This concept has even fluttered through Johns Hopkins - in 1916 Abraham Flexer made the observation, “Rounded with Osler today. Riddles house officers with questions, like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”
Beyond Evidence-Based Medicine: Information Management
Slawson and Shaughnessy (Academic Medicine. 2005;80:685-9) discuss helping students, residents, and clinicians develop skills beyond EBM. The authors point out that although critically evaluating medical literature is an essential skill, clinicians (in training and practice) must be able to find, evaluate and use information at the point of care. The authors describe a curriculum that contains three levels of education based on experience and practice. The three core skills they describe are: selecting tools for “keeping up”, selecting the appropriate hunting tool, and developing patient-centered, not evidence centered, decision making. In helping students incorporate these skills and tools into their daily lives we foster lifelong learning.
Interprofessional Teams - Personal Reflections
On the first day, my preceptor brought me up to the medical resident’s office and told me this would be the team I would be rounding with and introduced me to the team. The team consisted of 2 medical students, two interns and one post-graduate year 3 (PGY3) medical resident. They all said “hi” and immediately returned to what they were doing. It wasn’t exactly the warm open arm welcome I was expecting, but I tried to stay positive. As we started rounds, the students or interns started to present patients and they would discuss different aspects of each patient’s disease course and medications. I noticed that one medication needed renal adjustment and therefore, after rounds I discussed it with my preceptor. With my preceptor’s approval, I felt confident about the recommendation - so I went to find the intern taking care of the patient. I approached the intern and asked if she would change the dosing on the medication based on the patient’s poor kidney function (as evidenced by her estimated creatinine clearance). The intern looked at me with dismay and said “I am not going to change anything and don’t tell me how to manage my patient’s medications.” I was in a state of shock … disbelief. I couldn’t believe she wasn’t even going to consider my recommendation. Why didn’t the medical intern understand my role as a pharmacist on the team?
As a background, I went to school in New York and had most of my rotations in city hospitals. In New York, many feel that clinical pharmacy practice still lags behind many other places in the US. Even after 10 years of pharmacists going to the state legislature in Albany to advocate for collaborative drug therapy management, laws permitting this practice still had not passed. Pharmacists just received the right to vaccinate in the past year. Many physicians in New York are not aware of what clinical pharmacists can bring to the team. After 3 years of pharmacy school, no one ever told me that I might get push back from physicians or how I should handle these types of situations. I went into my clinical rotations assuming that the medical team would be embrace me. I assumed they knew my role on the team. Well that was definitely not the case. Instead, I found myself routinely demystifying all their beliefs about pharmacists. Some of the medical students assumed pharmacists went to school the same length of time as nurses and that pharmacists only worked in retail settings or in the basements of hospitals.
Pharmacists are aware of the expertise we can provide the medical team to improve a patient’s drug therapy. However, physicians and other health professionals often are not. As a student, resident, or a new practitioner, it is less important to understand what pharmacists can bring to the team but rather knowing where to start in building a relationship with the team.
The American College of Clinical Pharmacy (ACCP) recognizes that the delivery of interprofessional education (IPE) in the classroom and clinic can be difficult. A white paper by ACCP on IPE on addresses the terminology, levels of evidence, environment-specific models, assessment methods, funding sources, and other important implications and barriers as they apply to interprofessional education (IPE) and clinical pharmacy. In discussing IPE implementation, ACCP describes that deployment of a multidisciplinary team in which professionals from different disciplines work independently of one another, is not considered an interprofessional approach. This was the type of multidisciplinary practice I saw most commonly during my Doctor of Pharmacy curriculum. On my first day of internal medicine, my preceptor brought me up to the floor, introduced me to the team and left. Being the only pharmacy member on the team, I was not sure what my role was on the team, nor did the team. Later I found out that the preceptor never rounded with any of the teams. Therefore, there wasn’t an established relationship between the clinical pharmacist and the medical team. Even though I would present the patients to my preceptor after rounds and we would review and discuss patient’s profiles from a pharmacy perspective, it was independent from the medical team. In order to teach IPE, it is important to begin in a setting where there is a solid foundation and established relationships between the pharmacy preceptor and other members of the team. This allows for students to role model what they observe and for them to understand what is expected. Discussions between pharmacy preceptors and students should include not only the patient’s medication therapy but also how the student should approach, interact, and communicate with the medical team.
In an article by McDonough and Doucette (J Am Pharm Assoc 2003; 43(5 Suppl 1): S44-5), the authors comment on several methods for fostering the pharmacist-physician relationship. They recommend that the first initial steps should be taken to introduce and to establish yourself as a valuable resource. You should always be prepared to defend your response and recommendation toward drug therapy with reliable literature. Next they recommend reaching out to physicians, by inviting them to pharmacy-related meetings. Third, they recommend getting involved, by joining committees, groups, or other organizations. This creates a great forum for your presence to be seen and voice to be heard. Sometimes, your input may not be sought but rather initiative is required to build awareness and to demonstrate your desire to collaborate.
As a resident, I came in knowing that not everyone on the medical team will appreciate my role and accept my recommendations. But I have implemented many of the recommendations described in the ACCP White Paper and the article by McDonough and Doucette. By developing collaborative relationships with physicians and other health professionals, I know I can make a difference in patient care.
[Editor's Commentary: Developing relationships based on mutual respect and trust, not only with physicians and other health professionals but also with patients and peers, is the cornerstone of our professional lives. These relationships are built one-on-one and require the tincture of time. Through personal initiative and commitment, many pharmacists have forged strong collaborative relationships with physicians, nurses, patients, and caregivers. Trust and confidence is not automatically bestowed on every member of the medical team. Collaborative professional relationships, like friendships in our personal lives, are nurtured through a series of events. Like friendships, these relationships can be enhanced or destroyed by our actions. Zillich, McDonough, Carter, and Doucette examined factors that influenced the development collaborative relationship between physicians and pharmacists (Ann Pharmacother 2004; 38: 764-70). Not surprisingly, relationship initiation, trustworthiness, and role specification were strong predictors. Moreover, regular interaction/communication between the physician and pharmacist pair was critical. None of this should be surprising. Collaborative professional relationships are like any other human relationship. Indeed, we need to spend more time teaching people how to initiate and sustain productive professional (and personal) relationships as a core element of our curricula. While some didactic instruction may be helpful, role modeling of successful collaborative relationships is ultimately the key. -S.H.]
Interprofessional Education - Benefits and Barriers
by Victoria T. Brown, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital
The American Journal of Pharmaceutical Education (AJPE) recently published a theme issue on interprofessional education (IPE) (AJPE. 2009;Vol 73, Issue 4). The article that caught my attention utilized focus groups to identify perceived benefits and barriers to providing IPE (Smith KM, et al. AJPE 2009;73(4): Article 61). Representatives from six colleges of pharmacy separately attended a one-hour focus group session where open-ended questions were asked to assess the environment related to IPE at their respective institutions. The representatives were all considered to be leaders in education delivery at their institution. Most of the participants were affiliated with medicine (n=11, 27%) or pharmacy (n=9, 23%). However, there were also representatives from nursing, dentistry, and allied health.
The benefits of IPE are well-recognized. The Institute of Medicine includes IPE in its ten tenets for reforming healthcare education to improve the quality of patient care by teaching students to work in an interprofessional practice. A book published by the National Academies Press entitled Health Professions Education: A Bridge to Quality is largely dedicated to interprofessional education and the Institute of Medicine's call to action. The benefits of IPE identified by the focus groups included: (1) enhancing student education and training, (2) capitalizing upon economies of scale, (3) expanding opportunities for research and scholarship, (4) improving communication among healthcare professions, (5) promoting teamwork, and (6) improving quality of care and patient outcomes.
The barriers to IPE are not abstract, but tangible issues related to the current structure of healthcare education. The barriers identified revolve around the themes of curricular concerns, limited resources, lack of conceptual support, and cultural challenges connected to each profession. Currently, each discipline lives in a silo with different curricular requirements, accreditation standards, and budgets. Pharmacy has perhaps taken the boldest steps to reform accreditation standards. The Accreditation Council for Pharmacy Education (ACPE) Standards 2007 holds schools accountable for training students to provide patient care as a member of the interprofessional health care team. I would agree with the authors that until accreditation standards explicitly require interprofessional education there will be little external motivation for changing the current structure.
My initial reaction to the move towards more IPE was one of excitement and opportunity. As a new practitioner, I often wish I understood more about the training of other healthcare professionals. More so, I often wish they understood more about my training. Nevertheless, the barriers presented in this paper are very real, especially those related to financial constraints. With the economy being what it is, completely redesigned curriculums for multiple disciplines is a low priority for most institutions. Therefore, my prediction is that the changes towards IPE will be made in small incremental steps and will focus initially on service-learning activities and elective courses. As a student, I took two elective interprofessional courses. One of the courses focused on creating services for an urban middle school. The other course was an ethics course in which interprofessional groups discussed various ethical dilemmas related to patient scenarios. In neither of these courses was I learning pathophysiology or drug therapy alongside my colleagues in medicine or nursing. However, at the end of the course, I left with an appreciation for their thought process and experiences. When providing patient care together, these insights may be more valuable than knowing we learned similar scientific information. The article indicates that a couple of the programs have their students participate in interprofessional cases or OSCEs (objective, structured clinical examinations). This would seem to be the next logical step following service-learning or elective courses. In practice, the expectation will be to care for the patient in this manner. This takes team-based learning to an entirely new level.
Finally, the authors conclude that new faculty will be called on to deliver IPE as never before. For me, this is a strong call to learn all I can during my residency from physicians, nurses and other allied health professionals. By taking this opportunity now, I hope to have the skills and evidence to breakdown some of the barriers. In the end, patients will reap the benefits from a healthcare team which is working together.
[Editor's Commentary: Implementing interprofessional education in a meaningful way throughout the curriculum is a major challenge. Beyond the logistical issues, such as physical space and scheduling, there is a lack of expertise (e.g. faculty who have the knowledge, skills, and attitudes needed to teach interprofessional skills) and a pervasive fear that professional identity will be lost. If all healthcare professionals are trained in a similar way, what special knowledge or skills will each professional bring to the team? Pharmacy faces unique challenges because many (indeed most) work in places (such as community pharmacies) where the physical proximity to other members of the team is a structural barrier. While clinically trained pharmacist often work along side physicians, nurses, dietitians, and social workers in teaching hospitals, this model of care has not yet been widely adopted. And even in teaching hospitals, team-based interprofessional collaboration is less than optimal. Just because a group of people walk around together from room-to-room doesn't mean they are functioning as an effective team. We have a lot to learn! The American College of Clinical Pharmacy recently published a comprehensive White Paper on Interprofessional Education and an official Position Statement. I believe the key to changes in interprofessional care are linked to the payment model. It is only through a payment system that emphasizes quality and provides incentives for interprofessional collaboration will we see major changes in the structure of health care delivery ... which in turn will necessitate major changes in the structure of health professional education. In the mean time, health professional educators will need to continue to experiment with various of models of care AND interprofessional education to prove that these new models are indeed worth adopting! -S.H.]