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Impact of Introductory Pharmacy Experience on Student Learning, Satisfaction, and Clerkship Site Productivity: Assessment of the EPOC Program

Rowland J. Elwell, PharmD, Fellow, Department of Pharmacy Practice, Albany College of Pharmacy, Albany, New York.

Harold J. Manley, PharmD, Assistant Professor, Division of Pharmacy Practice, University of Missouri-Kansas City, Kansas City, Missouri.

George R. Bailie, PharmD, PhD, Professor, Department of Pharmacy Practice, Albany College of Pharmacy, Albany, New York.

Portions of these data have been presented as posters at the American College of Clinical Pharmacy Spring Practice and Research Forum, April 9, 2002, and at the American Association of Colleges of Pharmacy Annual Meeting, July 16, 2002.

Abstract

Objectives: Our Early Patient-Oriented Care (EPOC) program gives pharmacy students introductory practice experience (IPE) while providing clinical services to hemodialysis outpatients. We assessed the EPOC program to determine if it incorporates the desired attributes of an IPE, estimated its impact on student learning and clerkship site productivity, and evaluated student satisfaction.

Methods: An assessment form was developed and completed by EPOC preceptors (n = 3) and current students (n = 24) to determine if EPOC incorporates characteristics of an ideal IPE. Additionally, EPOC activities were identified and applied to two algorithms that estimate the impact of clerkship activities on student learning opportunities or impact site productivity. Finally, past EPOC students (n = 27) rated their satisfaction with the EPOC experience using a standard clerkship evaluation form.

Results: Preceptors and students similarly ranked EPOC highly as providing the desired characteristics of an IPE. EPOC activities produced optimal learning opportunity scores while having minimal but positive impact on site productivity. Student evaluations indicated a high degree of satisfaction with the EPOC experience.

Conclusion: The EPOC program incorporates the desired characteristics of an IPE, provides students with an optimal learning opportunity, marginally but positively impacts participating dialysis centers and provides students a highly satisfactory learning experience.

Key Words: pharmacy education, clerkship, experiential education, introductory practice experience

Introduction

The American Council of Pharmaceutical Education (ACPE) Accreditation Standards and Guidelines recommend that pharmacy students acquire both introductory and advanced practice experiences of "adequate intensity, breadth, and duration" as a continuum throughout the curriculum. Additionally, introductory practice experiences (IPEs) should be offered early in the curriculum to provide students the opportunity to integrate their knowledge of disease states and therapeutics with practical experience and develop the skills necessary to perform as a pharmacist.[1-3] It has been suggested by Beck et al that IPEs should incorporate certain criteria, which stem from three desired educational outcomes: professional socialization, application of pharmaceutical care philosophy, and lifelong learning.[4]

Our Early Patient-Oriented Care (EPOC) program was designed to provide students with clinical experience early in their pharmacy education while providing limited, but important, pharmacy services to hemodialysis (HD) outpatients at local dialysis centers. The EPOC experience originally encompassed four semesters and was offered to six students per year who were each assigned 12-15 HD patients. The success of the EPOC program in terms of clinical interventions has been previously reported.[5] Since this last report, the EPOC program has undergone considerable modification. A brief description of the current EPOC program follows.

The EPOC program was developed and is directed by a primary preceptor who is a full-time pharmacy practice faculty member at a private pharmacy college (Albany College of Pharmacy). Post-doctorate fellows, under the primary preceptor's mentorship, also participate as preceptors in the program. EPOC is offered to baccalaureate and doctor of pharmacy students entering the fourth year of the respective five and six year programs. Twelve students are selected per year and each is assigned three HD patients, for whom they provide continuous clinical services. The students spend several hours per week in the dialysis units obtaining medication histories through patient interviews, reviewing patient medical records and laboratory results and interacting with other healthcare professionals. Students meet with preceptors weekly to present patient cases, discuss potential interventions, and review therapeutics.

The EPOC program incorporates a progressive "see it, do it, teach it" model over the course of three semesters. During the first (fall) semester, entering fourth year students shadow the fifth year students who are completing their third and final semester of the program. The junior students see it while the senior students have the opportunity to teach it. In the second (spring) semester, the fourth year students assume responsibility for the patients and enter the do it phase. In the following fall semester, the students come full circle and now teach the new group of junior EPOC students.

Although EPOC was designed to comply with the ACPE guidelines , it is important to periodically assess the degree to which these goals are being met. In addition to assessing student learning opportunity, it is important to consider the potential for negative outcomes or consequences of clerkship placement on the productivity of a clerkship site.[6] Therefore, our objectives were to determine, using objective methods, if the EPOC model provides the desired attributes of an IPE and to assess the impact of the EPOC program on student learning and site productivity. Additionally, we evaluated student satisfaction with the EPOC experience.

Methods

Algorithms were used to provide categorical results representing both clerkship site (site productivity) and educational (learning opportunity) perspectives.[6] The site productivity algorithm (Figure 1) is based upon four criteria: level of student supervision, who may supervise, time required to train students to perform activities and the necessity of the activities. Application of the site productivity algorithm yields a category letter (A - H) representing a continuum of potential for students to have an impact on the clerkship site (A = positive impact; H = negative impact).

Figure 1. Site impact algorithm. Reprinted with permission from Am J Pharm Educ.[6] Copyright 1998, American Association of Colleges of Pharmacy.

Figure 2. Learning opportunity algorithm. Reprinted with permission from Am J Pharm Educ.[6] Copyright 1998, American Association of Colleges of Pharmacy.

To use the algorithms, core activities performed by EPOC students were identified by the EPOC preceptors. Each preceptor individually compiled a list of EPOC activities. Consensus between all contributors was reached following discussion and a final comprehensive list was produced. Each of the two algorithms were subsequently applied to each EPOC student core activity.

To obtain the students' perspective about their experiences in the EPOC program, student clerkship evaluations were assessed. Upon completion of the program, students are required to evaluate their EPOC experience using the college's standard clerkship evaluation form. The form asks students to rank various components of their clerkship experience using a scale of one to five (one = inadequate; five = extensive). The components assessed include the overall learning experience, the preceptor's performance as a teacher and practitioner, as well as the contribution to other personnel and resources at the site. All retrievable clerkship evaluations submitted by past EPOC students were reviewed.

Assessment of the desired characteristics of an IPE and student satisfaction with EPOC was carried out using rank scales, which produced ordinal data. Analysis of these data was performed using descriptive statistics and all results are reported as median and mode values. The learning opportunity and site productivity impact algorithms provide a single result for each core activity. These results are categorical and reported as such.

Results

Since its inception in 1996, 44 students have been accepted into the EPOC program. To date, 97 % (31/32) have successfully completed the program. Eleven of the 12 students accepted into the current class are still participating. Only two students have failed to successfully complete the program: one was removed and another voluntarily withdrew.

Assessment of the EPOC program in terms of the desired attributes of an early pharmacy practice experience produced similar results from preceptors (n = 3) and students (n = 20). Student assessments were performed during the fall semester (2001) and both senior students in their final semester (n = 9 of 12) and junior students in their first semester (n = 11 of 11) of the program completed the questionnaire. Scores of preceptors and students were added together. Preceptor, student, and overall results for each criterion are listed in Table 1.

Table 1. Ranking of the EPOC program based upon desired characteristics of an early pharmacy practice experience.

Nine core EPOC student activities were identified by preceptors (Table 2), to which the student learning opportunity and site productivity algorithms were applied. All activities produced a learning opportunity score of "A". Site impact scores were "D" for activities 1 through 7. Activities 8 and 9 were not evaluated for site impact, as they took place at the college, not at EPOC sites.

Table 2. Core EPOC student activities and corresponding results of learning opportunity and site impact algorithms.

Assessment of past student clerkship evaluations (n = 26) demonstrated a high degree of satisfaction with the EPOC program (Table 3). The overall learning experience was rated high, as was the preceptor for being both a teacher and practitioner. Each of these categories received a median score of 5.0. Evaluation of the variety of experiences offered and other personnel at the clerkship site each produced median scores of 4.0. All students reported that they would recommend the EPOC program to other students.

Table 3. Students' (n = 26) evaluation of the EPOC program using the college's standard clerkship evaluation form. (1 = Inadequate; 5 = Extensive)

Discussion

The principal goal of this assessment was to objectively determine the educational value of the EPOC program. To carry out our assessment, we used previously published methods. However, there is no commonly accepted method for assessing an IPE. As a result, we used a compilation of established criteria to produce a useful and comprehensive method for the assessment of any IPE.

Based on our results, we are confident that we are providing an excellent learning experience via the EPOC program. The optimal learning opportunity and high level of student satisfaction provided by EPOC demonstrates the potential educational value of an IPE and lends support to the ACPE recommendation that these types of experiences be offered to pharmacy students. Furthermore, although not the focus of this assessment, the clinical value of the IPE should not be overlooked. We have previously reported that students in the early stages of their pharmacy education can significantly impact patient care through participation in an IPE.[5]

In addition to validating the utility of the EPOC learning model, and perhaps more importantly, we have identified some areas for improvement. We are currently attempting to improve the professional socialization of our students by increasing their opportunities to interact with other health care professionals. We are also in the process of exploring opportunities to expand the EPOC program to other clinical settings to provide early pharmacy practice experience to more students at our institution.

Limitations

Although we are pleased with the overall results of our assessment, there are several limitations to our methods, which should be considered. Foremost is the relatively low number of students included. The questionnaire assessing EPOC in terms of desired attributes was completed by 20 of 23 (87%) current EPOC students. Although we would have preferred a higher number, this represented the largest group of EPOC students to be involved in the program since its inception. During the previous five years, enrollment was intentionally limited to five or six students per year and 19 students had completed the program. Our inclusion of past clerkship evaluation forms (n = 26) was intended to include these past students. However, clerkship evaluations were retrievable for only 14 of these past students. Additionally, 12 senior EPOC students, who were included as current students in the aforementioned desired attributes assessment, graduated from the program and also completed clerkship evaluation forms during the time this project was being carried out.

A second limitation involves our application of the site impact and learning opportunity algorithms.[6] These algorithms were originally developed to assess traditional advanced clerkship experiences. Although the learning opportunity algorithm is easily applied to various settings, the site impact algorithm is not ideal for evaluating the IPE. There are several limitations to our use of this algorithm. The first concerns the "time to train: time to participate" ratio. One could argue that the entire time of participation in an IPE is training time and thus the ratio is one. However, we chose to use a ratio of less than 0.5 because the students require relatively little directly observed training to actually begin their participation in the EPOC program. Additionally, most of their training takes place in the classroom, which does not adversely affect productivity in the dialysis unit.

Another limitation to our application of the site impact algorithm stems from the questions regarding supervision. As a minimum, our state laws mandate that pharmacy students have indirect supervision by a licensed pharmacist. Since the dialysis centers do not employ staff pharmacists, the preceptor is the only one who may supervise EPOC students. These two factors automatically limit our possible results to a maximum achievable value of "D."

In fact, each activity performed at the dialysis centers did receive a score of "D," which implies only minimal, but positive impact on the dialysis centers' productivity. In the absence of a suitable alternative method for assessing the impact of an IPE on clerkship site productivity, this algorithm still provides useful data. However, because the students are providing an important service, which otherwise would not be provided at all, we believe the actual impact on the dialysis centers is very positive.

Lastly, we acknowledge that a certain level of subjectivity is inherent in any self-assessment. However, in addition to basing our assessment on established criteria/methods, we feel that having students involved in the assessment adds validity to our results. In addition to ranking the program based upon the desired characteristics of an IPE, students were included in the assessment process via their clerkship evaluation forms. Finally, the high degree of cross-validation observed among the various assessments employed lends further creditability to our findings.

Conclusion

Although recommended by ACPE, greater efforts are still needed to provide quality early pharmacy practice experiences to all pharmacy students. Once established, early experience programs should be routinely reviewed to ensure they provide certain criteria and to assess their impact on student learning as well as clerkship site productivity. The EPOC model represents a successful means of incorporating the desired attributes of an IPE and providing students an optimal learning opportunity while positively impacting patient care at local dialysis centers. In addition to these outcomes, past students have expressed a high level of satisfaction with the EPOC experience.

References

1. American Council on Pharmaceutical Education. Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree Adopted June 14, 1997. ACPE. Chicago, IL.

2. Chalmers RK. Chair report of the Study Committee on Preparing Students for the realities of contemporary pharmacy practice. Am J Pharm Educ 1983;47:393-401.

3. Talbert RL. ACCP Strategic Planning Conference: Issues and trends in clinical pharmacy education. Pharmacotherapy 1997;17:1073-8.

4. Beck DE, Thomas SG, Janer AL. Introductory practice experiences: a conceptual framework. Am J Pharm Educ 1996;60:122-31.

5. Grabe DW, Bailie GR, Manley HJ, Yeaw BF. The Early Patient-Oriented Care Program as an educational tool and service. Am J Pharm Educ 1998;62:279-84.

6. Carter JT, Draugalis JR, Slack MK, Cox ER. Algorithms for estimating learning opportunity and productivity impact at clerkship sites. Am J Pharm Educ 1998;62:258-65.

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Professionalism, Ethics and Empathy: What Pharmacy Schools Can Learn from the Medical School Experience

Gail Goodman-Snikoff, Ph.D., Associate Professor, Department of Basic and Pharmaceutical Sciences, Albany College of Pharmacy, Albany, NY 12208

Abstract

In the education of pharmacy students, it is essential that they develop a professional ethos centered on patient care. This professional ethic is one that requires the pharmacist use moral reasoning and empathy for patients in making ethical decisions. The pedagogical question for the pharmacy profession is how do we develop a professional attitude in our students? Unfortunately, the pharmacy literature does not provide a coherent body of information on the teaching of professionalism, including ethics, empathy and moral reasoning to our students. Therefore, the author has reviewed the medical teaching literature to identify strategies that aid students in developing professional attitudes and behaviors. The results of this review illustrate that many different interventions have been developed to address these issues. However, only a limited number of interventions actually demonstrate significant differences in student attitudes. The most efficacious practices include small group and active learning models. It is suggested that those methods, which enhance students' professionalism, could be incorporated into pharmacy curricula to increase professional attitudes in pharmaceutical care practitioners.

Key Words: Professionalism, ethics, empathy, moral development, pharmacy schools

Introduction

This patient-centered focus also requires the professional to develop an expanded sense of professionalism. The importance of professionalism to pharmacy in the 21st century was the subject of a recent White Paper published by the American Pharmaceutical Association Academy of Students of Pharmacy - American Association of Colleges of Pharmacy Council of Deans Task Force on Professionalism (APA-ASP/AACP-COD Task Force). Within this document, the Council defined 10 characteristics of a profession and 10 traits of a professional. The characteristics and traits identified by the APA-ASP/AACP-COD Task Force can be compressed to those identified by many other writers, who define a profession as having three basic characteristics: expert knowledge, self-regulation and a requirement to place the needs of the patient or client ahead of the self-interests of the practitioner.[2-5] In the health care professions, empathetic caring is added as an additional component.[1-5] These qualities and traits are articulated in the Oath of a Pharmacist,[6] which also asserts that pharmacists will maintain the highest principles of moral, ethical and legal conduct, in carrying out their professional responsibilities.

Although most pharmacists assume that all practitioners follow these principles, the public has recently become alarmed by dramatic evidence that this is not always the case. Recently, a Kansas City, Missouri pharmacist pleaded guilty to diluting drugs delivered to cancer patients for his own financial benefit.[7] In addition, other reports of unethical and illegal behavior by practitioners, such as Medicaid fraud, suggest that the ethical and moral tenets of professional behavior, as well as the culture of empathetic care-giving, is not fully developed in all pharmacists.[8] With the adoption of the Doctor of Pharmacy as the sole entry-level degree for pharmacy, the inculcation of professionalism in pharmacy students is more important than ever. This is true because recent studies have demonstrated a lack of professional socialization amongst pharmacists and pharmacy students.[9] The question for pharmacy educators is how do we instill a sense of professionalism in our students?

The development of a professional ethos, embodying caring, morality and ethical behavior, in both pharmacy and medicine occurs through a process that Miederhoff calls professional socialization.[9] Unfortunately, because this socialization often occurs as an implicit part of the education experience, embedded in a "hidden curriculum," the outcomes are often different from that which is desired.[1,2,9-11] Miederhoff contends that there are conflicting forces in socializing pharmacy students, including faculty, practitioners and peers.[9] Additionally, pharmacists must contend with two different professional identities, businessperson and health care professional.[11,12] Because socialization occurs in so many settings under a number of different influences, there is a lack of consistent socialization leading to students and pharmacists who demonstrate an inadequate professional ethic.[9,11] In addition, while pharmacy faculty speak of pharmaceutical care and patient-centered values, the majority of our students will work in product centered (often retail pharmacy) settings. This conflict between academia and the workplace, leads to the confusion, frustration and dissatisfaction that is observed as a lack of professionalism or as professional disillusionment.[12-14] A similar situation has been observed in medical students, where medical education has been shown to decrease the innate altruistic and humanitarian virtues of individuals entering medical school;[2,3,5,10,15-20] thus, in both medical and pharmacy schools achieving a caring professional ethos is a challenge that must be addressed.

Recently, there has been increased recognition that professional attitudes are necessary for the delivery of pharmaceutical care and the importance of empathy as an essential element of pharmaceutical care has been acknowledged.[1,11] However there has not been a consistent effort within the pharmacy community to examine the best way to nurture the quality of caring in students and help them to develop a professional ethos. Because of a lack of data on professional socialization of pharmacy students, the experience of medical educators in developing methods for inculcating appropriate professional attitudes among students may be instructive.

As the profession of pharmacy enters a period where the emphasis is on patient care, rather than solely on dispensing, pharmacy education is emulating many of the features of medical education, including clerkships, residencies and fellowships. Medical educators have found that professional health care concepts of ethics, altruism and caring can be taught in an explicit or in an implicit manner.[15] However, it is the unspoken socialization process, that occurs as part of the educational experience that appears to be most powerful in shaping student attitudes.[1-3, 5,11,13-18] In medical education literature, solutions to the problem of producing caring professionals are numerous and include: modeling the desired behavior,[2,3,5,21] courses in ethics and/or empathy, [4,5,22-26] specific teaching styles,[19,27] early patient experiences,[28, 30] supporting moral development [8,18] and generally creating a professional atmosphere. [2-5,22] The pharmacy education literature advocates developing faculty-student relationships that are characterized by cooperation and respect, early experiences with patients, mentoring, use of the Oath of a Pharmacist, and the white coat ceremony as mechanisms for developing professional attitudes.[1,11] All of these courses of action have been attempted with varying degrees of success by medical educators. The pros and cons of the modalities used to mold attitudes and behaviors will be discussed below.

Modeling Behaviors

Courses

Ethics

A recent innovative course at Tulane University Medical School integrates teaching of professional values and medical ethics across the curriculum during the four years of medical school.[22] In addition to explicitly integrating the ethics course through the entire curriculum, it is experienced by permanent teams made up of students in each of the four years with faculty facilitators and mentors. This integrated and team approach provides a safe, stable learning environment and continuity throughout the medical school experience. In addition to didactic work, the students had the opportunities for small group discussion and role-playing, as well as time for personal reflection and introspection. In addition, each exercise had clearly defined goals. These exercises were evaluated by questionnaires following each exercise and the authors reported that this was a successful mechanism for teaching medical ethics. In contrast, the authors found that large-group exercises with limited discussion and participation were ineffective for teaching desired attitudes and behaviors. Unfortunately, other integrated programs have been less successful. A series of integrated courses at the University of Glasgow Medical School showed that teaching ethics over three years was not significantly better than a single year of instruction. The authors attributed the lack of gain in ethical reasoning in the latter years of the program to two factors. The first factor that the authors cited was that during first year, the ethics teaching took place in small classes with time for discussion. While in the second and third years, the ethics was taught in a large lecture format without the opportunity for active participation. The second factor that the authors felt contributed to failure to gain skills in ethical reasoning was the lack of formal assessment in these years.[34] Thus, in two courses designed to integrate teaching of ethics across a medical school curriculum, both sets of authors concluded that teaching these concepts in small groups with opportunities for discussion was more effective than teaching the same material in large lecture settings.

Pharmacy colleges have been less likely to develop required courses that explicitly teach ethics. Reports from pharmacy education journals include surveys of pharmacist and pharmacy student attitudes concerning ethical dilemmas in pharmacy. These surveys reveal that both groups are concerned about patient welfare, but students were less concerned about issues of economic self-interest [30] (this could and does lead to pharmacists acting in their own self-interest, rather than in the interest of the patient[7]). Literature on courses related to pharmacy ethics described teaching ethical theory and developing student skills in defining and solving ethical dilemmas,[35, 36] general classroom considerations with regard to course content,[36, 37] and integration of case studies and discussions into clinical clerkships.[38] The effectiveness of most of these interventions has not been studied. The only study that examined the effect of the intervention on students' ability to make ethical decisions was the one that integrated case studies and discussion into clinical clerkships. The authors found that integrating ethics into clinical clerkships sensitized pharmacy students to ethical issues, but did not increase the students' ability to practice ethical, patient care or justify patient care decisions[38] as assessed by questionnaires of responses to ethical dilemmas. A preliminary study at Albany College of Pharmacy examined students' responses to ethical dilemmas after a single lecture and discussion session and after 45 weeks of clerkship training, where ethical decision-making was modeled, but not explicitly discussed. The lecture focused on autonomy, beneficence, non-malfeasance and justice. The results of this study revealed that for cases involving assisted suicide, pharmacist resignation following a medication error and sedation of unruly patients, there was not a significant change in student responses to the case study. However, significant differences were found when students were asked about rationing high cost drugs, although this did not correlate with a single training phase. In addition, following the lecture and clerkship there were changes in the student responses to recommending hormone treatment to allow parole of sex offenders. The authors concluded that a single lecture and discussion with a group of 20-40 students does not alter their ethical decision-making and that clerkships without explicit discussion of ethics also do not alter students' ability to make ethical decisions. The authors suggested that a consistent, intentional and ethical component should be included in pharmacy education. In addition, they recommended that it be a part of the clerkship experience.[38]

Surveys of course content of ethics programs in pharmacy schools, reveals that they are theoretical and often business-oriented, [35, 36] and pharmacy colleges as a whole have not developed the core patient-centered curriculum in ethics that the medical schools have developed. [23, 34] Courses that focused on patient-centered dilemmas would enhance patient-oriented pharmaceutical care skills. As discussed above, the most successful of medical school programs suggest that the goals of an ethical curriculum are best achieved through the use of long-term, stable small group educational experiences shared with faculty mentors.[22,34]

Empathy

Empathy is defined as the action of understanding, being aware of, being sensitive to and vicariously understanding the feelings, thoughts and experiences of another.[40] It is generally believed that empathy is a required trait for delivering compassionate, patient-centered care.[23] Therefore, programs have been developed to increase student empathy. At medical schools, these programs were developed in response to repeated reports that student empathy decreases over time. [2,3,10,15-17,41,42] Approaches for increasing empathy in students include specific courses on empathy and communication, [24,43-45] early patient experiences [28, 29,46-50] and specific teaching styles. [19,27]

Courses on empathy usually focus on communication skills, teaching students how to interview a patient and respond with empathetic responses.[24,43] With medical students, it was found that approximately 80% of students felt that the course made them better prepared to conduct patient interviews. However, objective testing showed that only about two-thirds of the students actually improved in their ability to make empathic responses to patient statements, as measured by analysis of interviewing skills.[24] When evaluating the effectiveness of workshops on developing empathy, another group found that only students attending small interpersonal skills workshops gained in empathy; therefore, having teachers participate in the workshop and transmit the information was not effective. Again, the skills assessed were demonstration of empathetic responses in patient interview situations.[43]

Structured courses on communication and empathy have also been offered to pharmacy students. [44, 45] Reports of these courses demonstrated that communication skills aided in recognition of empathic responses and increased empathic listening in pharmacy students.[44] While specific empathy training significantly increased the ability of students to respond empathetically to clients, it did not enhance their ability to appropriately counsel patients.[45] In both instances these results were based on student responses registered in situations that measured patient interaction and counseling skills. This finding is consistent with the reported results that training clerkship students in ethical dilemmas does not increase their ability to solve the problem or justify the solution.[38]

The importance of patients in the education of health professionals has long been recognized.[46, 47] A report by Spencer et al [47] provides a framework for evaluating the role of patients in educating health care practitioners. This report deals with the role of a patient, rather than a standardized or simulated patient (actors or individuals trained in appropriate responses to questions found in medical interviews) in medical education, and suggests that real patients have a great deal to contribute to the educational process. However, there is little data on the value of real, rather than simulated patients. Another report suggests that real patients may indeed be better than standardized patients, because students have trouble developing empathy with standardized patients due to failure of the standardized patient to convey emotions realistically. [48] Four reports deal directly with the ability of students to develop empathy with patients and three of these take place in an outpatient setting and one involves a hospitalization experience.[28,29,49,50] In one report, students are assigned as "navigators" for patients diagnosed with cancer. It is the student's job to help the patient find the clinic and to simply be with the patient through physician encounters and treatments. This was a one-on-one experience and most students reported it to be a positive learning experience.[28] This type of experience is challenging to administer because of its individualized nature. At other universities and teaching hospitals, standardized patients or more correctly, actors portraying patients, are used as a way to teach interviewing and examination skills to students.[49, 50] The use of actors as standardized patients was initiated by Brown University and has been copied at the State University Medical Center in Syracuse. In general, students, patients and clinical instructors report high levels of satisfaction with this teaching method. While there was no data available on measures of empathy, the program provided rapid feedback to the student and in a controlled environment. Because the patients are actors, the students actions will not harm the patient and because of the actors it is likely that the emotional content of the visit is more realistic than with a simple standardized patient.

Medical students may also become acquainted with a patient's experience by becoming a patient themselves. This exercise was developed at UCLA and based on anecdotal evidence that physicians' attitudes were altered following their own hospitalizations.[29] For the experience, nine second-year medical students were admitted to the hospital for problems ranging from dehydration secondary to AIDS related diarrhea, acute back pain following an automobile accident and acute loss of consciousness for several minutes following a fall from a ladder. The admission teams were blind to the experiment and students in general were treated as real patients. Following admission and discharge, the students were surveyed for their responses and shared the experience with other second-year students. Key ideas that emerged from the students' experience were a profound loss of privacy; distress at the coldness and distance they felt from the medical staff and appreciation for the quality of care and caring attitude provided by the nursing staff. Following the experience, students also reported that they would be interested in improving the human aspects of patient care. According to the authors, while this experience appeared to be highly worthwhile for the students, it is both time and money intensive.

None of these studies examined student empathy or patient-oriented behavior before or after the experiences. Therefore, the use of patients or standardized patients, to teach empathy and patient-care skills, has not been evaluated beyond examining student attitudes. While these experiences would seem intuitively to increase empathy, there is no objective data that this is true.

Research also supports enhancing moral development or reasoning as a mechanism for enhancing empathetic patient care.[8,18] Clinical performance has also been correlated with moral development, the higher the individual's moral development, the more likely they were to have good clinical skills.[8] Branch has found that the process of moral development is inhibited by the medical school culture and that the opportunity for internal reflection is able to help students deal with the dissonance created by the clash between their personal values and the "ward culture."[18] By providing educational opportunities for critical reflection, in small groups, the students are better able to maintain their personal moral development and maintain or increase their empathic skills. While the goal of these programs is critical reflection and moral development, Branch emphasizes the importance of small group interactions with specially selected, caring faculty mentors, in the process of moral development.[18] With regard to pharmacy, when Latif and Berger compared pharmacy students' moral development scores with clinical performance, they found that the practitioners with the highest moral development make the best clinical decisions.[8] Latif and Berger did not attempt to modify the moral development of the students whom they surveyed. In their conclusions, they recommend developing coursework to stimulate moral reasoning and using scores of moral reasoning ability as a criterion for admission to pharmacy schools.

Personality Characteristics

Acknowledgements
The author gratefully acknowledges by William Millington, Angela Dominelli, John Faragon, and Robert Hamilton for their careful reading, criticism and editorial aid in the preparation of this manuscript.

References

1. American Pharmaceutical Association Academy of Students of Pharmacy - American Association of Colleges of Pharmacy Council of Deans Task Force on Professionalism. White Paper on Pharmacy Student Professionalism. J Am Pharmaceut Assn 2000; 40:96-100.

2. Stern DT. Practicing what we preach? An analysis of the curriculum of values in medical education. Am J Med 1998; 104:569-75.

3. Ludmerer KM. Instilling professionalism in medical education. JAMA 1999; 282:881-882.

4. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA 1999; 282: 830-833.

5. Stephenson A, Higgs R, Sugarman J. Teaching professional development in medical schools. The Lancet 2001; 357:867-870.

6. University of Arizona Student Handbook (cited 1/6/03): Available from http://www.pharmacy.arizona. edu/ handbook/appendix/a.shtml

7. Missouri Releases List Of Doctors In Drug-Dilution Case. State, Federal Authorities Work To Notify Doctors, Clinics. The Kansas City Channel. (cited 9/9/2002):Available from http://www.kansascitychannel.com/kc1/news/stories/news-142089820020426-130420.html

8. Latif DA, Berger BA. Cognitive moral development and clinical performance: implications for pharmacy education. Am J Pharm Educ 1999; 63:20-27.

9. Miederhoff PA. Can a professional ethos be taught? A clinician's point of view. Am J Pharm Educ 1984; 48:401-406.

10. Wilkes M, Raven BH. Understanding social influence in medical education. Acad Med 2002; 77:481-488.

11. Chalmers RK, Adler DS, Haddad AM, Hoffman S, Johnson, KA, Woodward JMB. The essential linkage of professional socialization and pharmaceutical care. Am J Pharm Educ 1995; 59:85-90.

12. Buerki, RA. Pharmacist Smyth and Druggist Smith - a study in professional aspirations. Am J Pharm Educ 1977; 41:28-33.

13. Schwirian PM, Facchinetti, NJ. Professional socialization and disillusionment: case of pharmacy. Am J Pharm Educ 1975; 39:18-23.

14. Buerki RA, Vottero, LD. The changing face of pharmaceutical education: ethics and professional prerogatives. Am J Pharm Educ 1991; 55:71-74.

15. Rezler AG. Attitude changes during medical school: a review of the literature. J Med Educ 1974. 49:1023-30.

16. Coulehan J, Williams PC. Vanquishing virtue: The impact of medical education. Acad Med 2001; 76:598-605.

17. Albanese M. The decline and fall of humanism in medical education. Med Educ 2000: 34:596-597.

18. Branch WT. Supporting the moral development of medical students. J Gen Intern Med 2000; 15:503-508.

19. Maheux B, Beaudoin C, Berkson L, Cote L, Des Marchais J, Jean P. Medical faculty as humanistic physicans and teachers: the perception of students at innovative and traditional medical schools. Med Educ 2000; 34:630-634.

20. Sulmasy DP. Should medical schools be schools for virtue? J Gen Intern Med 2000; 15:514-515.

21. Shapiro J. How do physicians teach empathy in the primary care setting? Acad Med 2002; 77:323-328.

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Influence of Classroom and Clinical Experience on the Ethical Decisions Made by Doctor of Pharmacy Students

Rowland J. Elwell, PharmD, Fellow, Department of Pharmacy Practice, Albany College of Pharmacy, Albany, New York.

George R. Bailie, PharmD, PhD, Professor, Department of Pharmacy Practice, Albany College of Pharmacy, Albany, New York.

An abstract of this work was presented at the American College of Clinical Pharmacy Spring Practice and Research Forum in Savannah, GA, April 9, 2002.

Abstract

Purpose: Ethical decisions made by doctor of pharmacy students following classroom discussion and clerkship experience were compared.

Methods: From 1996 to 2001, students were presented five cases describing ethical dilemmas and asked whether a pharmacist should dispense medications for assisted suicide, sedate an unruly patient, recommend treatment to allow parole, ration drugs, or resign their position for making an error. Anonymous questionnaires assessed reactions (yes, no, don't know) at three study phases. Phase 1 preceded and phase 2 followed classroom debate. Phase 3 followed 45 weeks of clerkship training. Responses were analyzed by Chi-square (x2) method.

Results: The study included 112 students [median (range) age = 23 (22 - 46) years; 60 % females]. Responses were similar for all cases, except parole and drug rationing (p < 0.05). Responses in phases 1 and 2 (n = 65) were different from phase 3 (n = 39) for the parole case (p < 0.01). Trends observed for the parole and drug rationing cases suggest that students adopted a more patient-oriented approach following clerkship.

Conclusion: Classroom and clerkship experience did not significantly impact the ethical decisions of pharmacy students.

Key Words: pharmacy education; ethics; clerkship

Introduction

This longitudinal, observational study was performed in conjunction with a unique ethics teaching methodology. The ethics class was taught as part of a required course during the fifth year of the six-year doctor of pharmacy degree. The ethics class was also taught to the first year of the two-year post-baccalaureate doctor of pharmacy degree programs at Albany College of Pharmacy (Albany, NY). Participating students were presented with a series of five previously published cases which describe the following ethical dilemmas for a pharmacist.

1. Assisted suicide.[11]
2. Asking a pharmacist to resign for making an error.[12]
3. Sedation of an unruly patient.[13]
4. Rationing of high-cost drugs.[14]
5. Recommendation for treatment that would allow parole.[15]

An anonymous questionnaire, used to assess students' reactions, presented case-specific questions to which students should answer "yes", "no", or "don't know" (e.g., Should a pharmacist dispense medications knowing they are intended for assisted suicide?). The questionnaire was administered at three study phases. A summary of each of the cases and the accompanying post-case questions is contained in Appendix A.

Phase 1 of the study occurred at the beginning of the ethics class and consisted of a brief lecture on the ethical principles of autonomy (informed consent), beneficence, non-maleficence, and justice.[16] Subsequently, students were asked to read the aforementioned cases individually and respond to the questionnaire without any classroom discussion. Students recorded and submitted their answers for each case.

During phase 2, the class was evenly divided into two groups. Each case was then openly discussed with one group arbitrarily assigned to argue in favor of the action suggested in the case scenario. Alternatively, the other group was instructed to argue against the suggested action. Students were instructed to use the above ethical principles to develop and defend their responses. Following this group discussion, students were asked to reevaluate their individual responses and anonymously resubmit answers to the post-case questions. At this time, the pre-and post-discussion results were shared in class to generate further classroom discussion.

Phase 3 of the study was performed approximately two years later, after students had completed 45 weeks of experiential clerkship training. Just prior to or soon after graduation, students were mailed the same cases along with the post-case questionnaire. They were again asked to respond to the corresponding questions. Response to this survey was voluntary and anonymous. Surveyed students/graduates were asked to reply to the questionnaire within two weeks. After four weeks had elapsed from the time of mailing, all students were sent a reminder postcard. Replies were accepted up to eight weeks from the initial mailing. As an incentive to respond, students were also sent a raffle entry, which they could return with their survey response. To maintain the anonymity of responses, a secretary separated raffle entries from survey responses prior to forwarding them to the investigators. Four raffle winners received a sweatshirt bearing the college logo.

Responses to questions for each study phase were analyzed using the Chi-square (x2) statistic with significance based a priori upon alpha = 0.05. The x2 method simply determines if a difference exists among the responses observed at each study phase. To identify exactly where any differences might be (e.g., phase 1 vs. phase2; phase 2 vs. phase 3; or phase 1 vs. phase 3), multiple-comparisons were performed using the Bonferroni inequality. The Bonferroni inequality is a standard multiple-comparison method in which p-values are adjusted based on the number of comparisons made.[17] Statistics were performed using Microsoft® Excel 2000 (version SR-1, Microsoft, U.S.A.).

Results

Between August 1996 and November 2001, a total of 112 students participated in the study. All students participated in phases 1 and 2. However, phases 1 and 2 responses were not retrievable for the graduating class of 2001. As a result, phases 1 and 2 responses were available for 65 students. Phase 3 questionnaires were mailed to all students, except the class of 2000. Of the 89 surveys mailed, 39 (43.8% response rate) were returned completed. A breakdown of the number of participants and responses received at each phase, as well as demographic data, is listed in Table 1.

Table 1. Number of survey responses for each participating class year at each study phase. Demographic data is also given for the entire group (n = 112).

Student responses for each of the cases at each study phase are illustrated in Figures 1 - 5.

Figure 1. Student responses to question about assisted suicide (Case 1). Overall, p = 0.056

Figure 2. Student responses about asking a pharmacist to resign (Case 2). Overall, p = 0.52

Figure 3. Student responses about sedation of an unruly patient (Case 3). Overall, p = 0.063

Figure 4. Student responses about restricting high-cost drugs (Case 4). Overall, p = 0.045

Figure 5. Student responses about medication to permit parole (Case 5). Overall, p = 0.000

Overall, there were no statistically significant differences observed for the cases concerning assisted suicide (p = 0.056; Figure 1), asking a pharmacist to resign for making an error (p = 0.52; Figure 2), or sedation of an unruly patient (p = 0.063; Figure 3). Regarding the rationing of high-cost drugs, there was an overall statistically significant difference (p = 0.045; Figure 4). However, multiple comparisons did not identify significant differences between specific study phases for this case. A statistically significant difference, overall, was observed for the case involving hormonal treatment that would allow parole (p = 0.00; Figure 5). Statistically significant differences were also observed between each study phase for this case (p < 0.05).

Discussion

Overall, the results of our study indicate that classroom discussion (phases 1 and 2) and practical experience (phase 3) did not have a significant effect on the ethical decisions made by pharmacy students. Statistically significant differences were only observed for two of five cases. And of those, specific inter-phase differences were only found for a single case. Although we consider these to be pilot data and more rigorous study is needed, we have made some generalizations based upon the responses observed.

The cases involving parole and drug rationing presented dilemmas where a pharmacist has to weigh the benefits to the patient in comparison with risks or costs to society. The responses observed in phases 1 were similar to phase 2 for each of these cases. At phase 3 there was a large increase in the number of students who would recommend the treatment to allow parole, as well as in the number that would not recommend restricting the use of expensive drugs. These changes may reflect a shift from a societal preference in the classroom to a more patient-oriented approach following clerkship. Students also appeared to become more decisive regarding the parole case, as a trend toward fewer "don't know" responses were observed.

The results for the assisted suicide, sedation, and resignation cases are more difficult to interpret. Again, responses were virtually identical at phases 1 and 2. However, at phase 3 fewer students were willing to dispense a lethal dose of medication to the terminally ill patient. In contrast, more students would dispense the sedative for the unruly patient at phase 3. For both cases, one could argue whether or not the majority of responses are patient-focused. Additionally, experience did not appear to make students more decisive regarding these issues. The number of "don't know" responses for both cases was greatest at phase 3. Regarding the request for a pharmacist's resignation, students overwhelmingly responded "no" (the pharmacist should not be asked to resign) at every study phase.

Limitations

Interpretation of these results is difficult and requires consideration of important limitations in our study design. Foremost, we employed a non-validated assessment tool incapable of determining the ethical appropriateness of a given response. That is, because there are no "correct" answers to the post-case questions, whether students became more or less ethical could not be answered by our study. Additionally, any phase 3 observations cannot be considered the result of clerkship training alone. There is currently no consistent, well-designed, deliberate approach to teaching our students ethics during clerkship. Furthermore, factors such as life experiences and normal maturation are likely to contribute to the students' ethical development during the two years separating phases 2 and 3.

A final consideration is our sample size, which was fairly small, particularly in phase 3 (n = 39). Given that p-values were generally low and trends were observed, a larger sample might have yielded significant results.

Acknowledging these limitations, we simply sought to determine if there were noticeable changes in the ethical decisions made by students at different points in their education. Although we have concluded that classroom and clerkship experiences did not impact the ethical decisions made by pharmacy students, we believe that they should. As stated previously, our curriculum does not currently provide a deliberate and consistent ethical component to the clerkship experience. After a review of ethics literature in medicine and pharmacy, Goodman-Snitkoff found that pharmacy schools lag considerably behind medical schools in the integration of ethics into the curriculum. Additionally, medical schools were found to use a more patient-oriented approach to teaching ethics.[18] We believe a patient-oriented, clerkship-based approach could enhance ethics education and is worthy of further study. We are currently making efforts to more effectively design and study alternative approaches to ethics education during clerkship, and throughout the pharmacy curriculum.

Conclusion

Classroom discussion and experiential clerkship training did not have a significant impact on the ethical decisions made by pharmacy students. To enhance the ethical development of pharmacy students, a practical clerkship-based approach to ethics education is suggested.

APPENDIX A. Abbreviated Ethics Cases

1. "Physician-assisted suicide and the issue it raises for pharmacists" [15]

A terminally ill cancer patient wishes to "get this over with." The physician orders a lethal dose of morphine sulfate. Question: Should the pharmacist dispense the medication knowing it is to be used for assisted suicide?

A model pharmacist accidentally dispensed an IV dose of chemotherapy to the wrong patient. That patient was terminally ill, but died sooner as a result of the error. The pharmacist is devastated, but she does not feel compelled to resign. The attorneys and administrators at the hospital tell the pharmacy director to make her resign. Question: Should the director request the pharmacist's resignation?

A homeless man is admitted to the hospital for frostbite. He is incoherent and shouting at passers by. Other patients complain about the noise, but he is posing no physical danger to himself or others. An intern orders an intravenous sedative. Question: Should the pharmacist dispense the sedative?

A known IV drug abuser with AIDS is anemic, neutropenic, oliguric, and in septic shock. He has no financial means, but is receiving many expensive medications and hemodialysis. The physician suggests that the monies being spent would be better used to treat patients with curable diseases and asks the pharmacist for her opinion. Question: Should the pharmacist recommend restricting the high-cost drugs?

A man infected with the human immunodeficiency virus is serving a prison term for rape and child molestation. If a psychiatrist determines that his sex drive can be controlled, he will be eligible for parole. Weekly hormonal injections would accomplish this and could be made a condition of the parole. However, the pharmacist knows that the man cannot pay for the treatments and there is no mechanism for him to get them free of charge. Question: Should the pharmacist recommend the hormonal treatment?

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April 14, 2003