The clinical educator's guide to fostering learner motivation: AMEE Guide No. 137.

Motivation theory and research remain underused by health professions educators. Some educators say it can seem too abstract. To address this, we applied health care language to learner motivation theories. Using a familiar metaphor, we examined the indications, mechanism of action, administration, and monitoring of learner motivation interventions. Similar to the treatment monographs in medicine compendia, we summarized each motivation intervention in the form of a monograph. The purpose of this guide is for health professions educators to develop an understanding of when (i.e. indication) and how (i.e. mechanism of action) learner motivation interventions work. With this information, they can then access ready-to-implement strategies (i.e. administration) to increase their learner interest and assess the effects of these interventions (i.e. monitoring).

Recommendations for Evaluating Practice-Related Activities of Pharmacy Faculty.

OBJECTIVE: To develop definitions of who pharmacy practice faculty and partners are, identify indicators to measure practice-related activities, and provide guidance for evaluating pharmacy practice faculty. METHODS: A 4-round, online Delphi was conducted. Panelists with experience evaluating pharmacy practice faculty were invited. Consensus was achieved when there was agreement by at least 70% of panelists. Round 1: Panelists were asked to identify the essential distinguishing characteristics of pharmacy practice faculty and practice partners as well as metrics that could be used to measure practice productivity and quality. Responses were grouped into common themes. Round 2: Panelists were asked to agree, agree with changes, or disagree with themes and metrics identified. Round 3: Panelists were asked to agree, agree with changes, or disagree with definitions of pharmacy practice faculty and practice partners. Panelists were asked about procedural elements of evaluation processes that colleges/schools should adopt. Round 4: panelists were asked about areas of uncertainty that had not yet achieved consensus. RESULTS: A total of 17 experts participated. Consensus definitions for pharmacy practice faculty and practice partners were achieved . From 291 submitted indicators, 14 productivity and 10 quality indicators reached consensus along with recommended frequencies for collection and review. Peer review was identified as an important quality indicator. Recommendations regarding who should participate in the evaluation process and how the data should be used also achieved consensus. CONCLUSION: Formal mechanisms for evaluating the practice-related activities of pharmacy faculty are critical to ensure this area of responsibility is fairly recognized and considered.

Beliefs and behaviors of professionally engaged pharmacists.

OBJECTIVES: To define professional engagement and establish a list of beliefs and behaviors characteristic of professionally engaged pharmacists. DESIGN: A 4-round online Delphi consensus technique. Round 1: Panelists were asked to identify the beliefs and behaviors characteristic of professionally engaged pharmacists. Investigators then crafted representative statements. Round 2: Panelists agreed with statements as written, agreed with changes, or disagreed. Round 3: Panelists distributed 100 points among the modified belief and behavior statements, reflecting the relative weight and importance of each. Round 4: Panelists rated overall agreement with statements and the definition of professional engagement with the use of a 4-point Likert scale. SETTING: Not applicable. PARTICIPANTS: Fifteen pharmacists with a deep interest in and knowledge of professional engagement. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Consensus statements regarding the beliefs and behaviors characteristic of a professionally engaged pharmacist and a consensus definition of professional engagement. RESULTS: From 128 submissions regarding beliefs provided by panelists in round 1, 18 statements were crafted and 12 statements achieved consensus. From 72 submissions regarding behaviors provided by panelists in round 1, 15 statements were crafted and 9 statements achieved consensus. Panelists' agreement with each of the final statements achieved a mean score greater than 3.9 on a 4-point Likert scale. Consensus was achieved regarding the definition of professional engagement. The professionally engaged pharmacist "thinks and behaves in ways that positively affect patients' health and advance the profession's values and societal mission." CONCLUSION: Professional engagement in pharmacists is composed of cognitive, behavioral, and affective components. This work provides a framework to describe professional engagement and lays the foundation for future scholarly work. The ability to measure professional engagement will allow us to correlate professional engagement with outcomes and design interventions to catalyze increased engagement in the profession.

Treatment Approach to Patients With Severe Insulin Resistance.

In Brief Patients with severe insulin resistance require >2 units/kg of body weight or 200 units/day of insulin. Yet, many patients do not achieve glycemic targets despite using very high doses of insulin. Insulin can cause weight gain, which further contributes to worsening insulin resistance. This article describes the pharmacological options for managing patients with severe insulin resistance, including the use of U-500 insulin and newer agents in combination with insulin.

Reconsidering Pharmacy: We Need to Turn Career Regret into Career Options.

Declining interest in pharmacy as a career is a growing concern. This commentary investigates the factors contributing to career regret among pharmacy graduates, based on data from the American Association of Colleges of Pharmacy National Graduating Student Survey. We identify 3 key contributing factors: workplace environment, professional identity formation, and marketing of the Doctor of Pharmacy degree. We argue that students observe, in many work environments, a lack of autonomy, repetitive tasks, and unfulfilling work. This leads to diminished job satisfaction and disillusionment. Additionally, marketing tactics and curricular structures can inadvertently contribute to career regret. We propose potential interventions, emphasizing the need for improved working conditions, more versatile roles in pharmacy, and enhanced career development services within colleges/schools of pharmacy. Additional research is needed to fully understand career regret and the steps that academic institutions can proactively take to mitigate career dissatisfaction among their graduates.

Exploring the Utility and Fairness of a Multi-institutional Situational Judgment Test.

OBJECTIVE: To pilot a situational judgment test (SJT) developed to assess empathy, integrity, and teamwork and explore differences in performance between first-year (P1) and fourth-year (P4) student pharmacists based on gender, race or ethnicity, and geographical region. METHODS: An SJT was developed to assess empathy, integrity, and teamwork, using best practices. The SJT was piloted tested with P1 and P4 student pharmacists at 5 institutions. Scores were adjusted for elevation and scatter to minimize the subgroup differences in response styles. RESULTS: The unadjusted mean SJT scores for P1 and P4 student pharmacists were 79.7 % and 80.7 %, respectively. The adjusted scores for P1 and P4 student pharmacists were 86.3 % and 87.2 %, respectively. Small differences were observed across institutions which can likely explained by multiple factors. The mean scores were higher among students who were older, female, identified as White, and spoke English as their first language. The subgroup differences persisted even after adjusting scores for elevation and scatter. CONCLUSION: Performance on an SJT designed to assess empathy, integrity, and teamwork was similar to others in the literature; however, differences in performance were observed across subgroups. Additional research is needed to determine whether these differences reflect test bias or other possible factors.

New pharmacologic methods to prevent venous thromboembolism in older adults: a meta-analysis.

OBJECTIVE: To conduct a meta-analysis of randomized controlled trials that used newly approved drugs to prevent venous thromboembolism (VTE) in older adults. DATA SOURCES: PubMed, EMBASE, and International Pharmaceutical Abstracts (through July 2012). STUDY SELECTION AND DATA EXTRACTION: Full-text clinical trial reports were included if they (1) had a randomized controlled design, (2) used a pharmacologic method approved or anticipated to be approved in the US, (3) enrolled at least 300 subjects, (4) enrolled subjects with a mean age of 65 years or older or performed a subgroup analysis in adults in that population, and (5) scored at least 7 of 8 on quality criteria for clinical trials. Twenty unique studies met the inclusion criteria. DATA SYNTHESIS: The most common indications for pharmacologic VTE prophylaxis in the identified studies were orthopedic procedures involving the lower extremities and general surgery. Only 2 studies enrolled acutely ill patients admitted to hospital medical services. Fondaparinux (5 studies) was more effective than enoxaparin in preventing VTE (OR 0.5, 95% CI 0.37-0.67; p < 0.00001) but had more bleeding (OR 1.48, 95% CI 1.05-2.08; p = 0.03). Dabigatran 150 mg once daily (3 studies) was less effective than enoxaparin in preventing VTE (OR 1.30, 95% CI 1.09-1.56; p = 0.004) with a similar bleeding risk (OR 0.74, 95% CI 0.46-1.22; p = 0.24). Dabigatran 220 mg once daily (4 studies) was as effective as enoxaparin in preventing VTE (OR 1.02, 95% CI 0.83-1.26; p = 0.84) and had similar bleeding (OR 1.08, 95% CI 0.66-1.76; p = 0.76). Rivaroxaban (4 studies) was more effective than enoxaparin in preventing VTE (OR 0.38, 95% CI 0.23-0.61; p < 0.0001) with a trend toward a higher rate of bleeding (OR 1.8, 95% CI 0.90-3.60; p = 0.09). Apixaban (5 studies) was more effective than enoxaparin in preventing VTE (OR 0.64, 95% CI 0.43-0.96; p = 0.0002) and had a similar rate of bleeding (OR 0.71, 95% CI 0.42-1.21; p = 0.21). CONCLUSIONS: When compared to enoxaparin, newer drugs exhibit slightly different safety and efficacy profiles when used for VTE prevention in older adults undergoing major orthopedic surgery. There are insufficient data for other indications. The benefits and risks of new pharmacologic methods of VTE prevention are unclear in the oldest old (age ≥ 85 years) and in those admitted to a hospital for an acute medical illness or to a skilled nursing facility.

Undergraduate Student Perceptions of Pharmacy Entrustable Professional Activities.

Introduction: With declining applicant numbers, pharmacy education seeks to effectively communicate the value of the pharmacist on the health care team to attract learners to pharmacy. The American Association of Colleges of Pharmacy (AACP) published entrustable professional activities (EPAs) to outline the expected roles and responsibilities of new pharmacy graduates. However, it is unknown whether these statements resonate with the general public and could potentially attract learners to pharmacy. Description of Innovation: Students in PHAR1001: Orientation to Pharmacy, and online undergraduate course were surveyed using EPA statements. The survey was administered to all students before and after the completion of an undergraduate overview of pharmacy course. Participants were to respond "yes" or "no" to statements assessing the relevance of each EPA to pharmacy practice and the expectation of the activity to occur in all pharmacy practice settings. Findings: A total of 283 students participated in the pre-course survey, with 258 students completing the post-course survey. Pre-course, 11 of the 15 EPA statements had a high level of agreement (>80%) for relevance to practice. The high level of agreement continued in the post-course survey with five EPA statements exhibiting a significant increase in both the relevance and expectation of the role in pharmacy practice. Conclusions: Most students, regardless of prior knowledge of pharmacy, found the EPAs illustrative of pharmacist activities even prior to completing the pharmacy course. Entrustable professional activity statements may be a reasonable means to communicate the value of the pharmacist to the general public.

Guidance for Pharmacy Curricula to Incorporate Health, Wellness, and Health Inequities Stemming From Climate Change: The Report of the 2022-2023 AACP Argus Commission.

The 2022-2023 American Association of College of Pharmacy Argus Commission was charged to provide guidance to schools, curriculum committees, and faculty on how to incorporate health, wellness, and health inequities stemming from climate change into pharmacy curricula. The Argus Commission does not advocate for major changes in the curriculum or standards but suggests a concerted effort across the Academy to enhance the awareness of graduating students of the potential impact of climate change on health both now and in the future. Various examples, along with recommendations and suggestions, are provided of how the impact of climate change on health is currently being integrated into curricula in member schools, as well as a list of resources faculty can use to enhance their awareness of issues related to climate change and health. The Commission was also charged to provide guidance to the American Association of College of Pharmacy regarding future fundraising and business development opportunities. Recommendations in that regard are also included in this report.

Opening the Black Box: Agreement and Reliability of a Situational Judgment Test Across Multiple Institutions.

OBJECTIVE: The primary objective of this study was to examine the levels of agreement and reliability of a situational judgment test (SJT) using a diverse pool of pharmacy practice faculty as subject matter experts. Secondary aims included analyses to build support for test validity and fairness. METHODS: An SJT containing 18 scenarios and 118 responses assessing empathy, integrity, and teamwork was developed and delivered to pharmacy practice faculty at 5 schools of pharmacy across the United States. Reliability was assessed by examining internal consistency, inter-rater reliability, and split-half reliability. Only responses which attained an inter-rater agreement>0.7 were included in the final version of the SJT. All responses were scored using a near-miss system, allowing higher scores for answers more closely aligned with the key, which was determined by the faculty who completed the SJT. Test fairness was reported using descriptive statistics. RESULTS: Thirty-nine faculty across the 5 participating institutions completed the SJT. The final version of the SJT included 105 responses, achieving an inter-rater agreement of>0.7 (inter-rater reliability of 0.98). Split-half reliability was 0.72. The average score was 85.7%, and no differences in performance were observed based on demographic characteristics. CONCLUSION: An SJT designed to assess empathy, integrity, and teamwork achieved reasonable levels of reliability among pharmacy practice faculty across the United States, and the results provided initial support for test validity and fairness. These results support a pilot to assess this SJT among students representing multiple institutions.

Development of an Entrustment-Supervision Assessment Tool for Pharmacy Experiential Education Using Stakeholder Focus Groups.

Objective To devise a pharmacy-specific, expanded entrustable professional activities (EPA) entrustment-supervision scale that would frame preceptor ratings in a prospective and retrospective manner for use in experiential learning settings.Methods A series of focus group sessions were conducted to solicit expert opinion on how to develop and refine two entrustment-supervision scales. Purposive sampling was used to identify experts from different professional groups (physicians, pharmacy experiential administrators, and pharmacy practice faculty) who had extensive knowledge regarding EPAs and at least one publication related to EPAs. Panelists were invited to participate via email. Three focus sessions were conducted via videoconferencing between June and September 2019. The primary outcome was development of a pharmacy-specific EPA entrustment-supervision assessment tool. Secondary outcomes were individual entrustment-supervision statements across five levels of the entrustment-supervision scale.Results The focus group consisted of four pharmacy practice faculty, two experiential administrators, and one academic physician. Four concepts emerged from the focus group discussion: need for more granularity in entrustment-supervision scales; limitations due to differences in licensure requirements across the United States; present and ongoing use of expanded scales by schools and colleges of pharmacy; and uncertainty regarding how to rate entrustment-supervision when a student exhibits unprofessional behavior.Conclusion A pharmacy-specific, expanded EPA entrustment-supervision scale will be useful to support longitudinal assessment of learners in experiential settings where an EPA framework is utilized. Determining when to use a prospective versus retrospective perspective requires further evaluation.

Substituting warfarin products: what's the source of the problem?

Many clinicians have expressed concerns about the bioequivalence of warfarin products, and data suggest that substituting warfarin products may increase the risk of major bleeding and thromboembolic complications. Anecdotal reports and some retrospective studies have reported differences in anticoagulation control after a warfarin product substitution. But the best available evidence-prospective, randomized, blinded clinical trials-has failed to validate these observations. Indeed, interpatient and intrapatient variability in anticoagulation control observed before and after warfarin product substitution is very similar. So, while differences in product standardization, bioavailability, and bioequivalence make a convenient explanation, the problem lies elsewhere. Perhaps poor communication, fractionated systems of care, and errors are the culprits.

The Impact of Two Longitudinal Professionalism Courses on Student Pharmacists' Empathy.

Objective. To determine whether empathy increased in first-year student pharmacists after completing longitudinal professionalism courses at two schools of pharmacy, identify potential moderators, and assess whether students' conceptualization of empathy changed with time.Methods. Surveys to assess empathy and other variables were administered to student pharmacists at baseline and at the end of two professionalism courses. Baseline and follow-up scores were compared to detect changes over time. Multivariable analysis was used to identify predictors of empathy scores. Factor analysis was performed to ascertain changes in the dimensionality of empathy.Results. Students' demographics and baseline empathy scores differed between the two schools. Predictors of empathy at baseline included age, female gender, prior health care experience, and altruism score. A small increase in empathy was observed at one school but not in the combined cohort. Empathy was more likely to increase among female students, those with less health care experience, and those who did not work during the school year. Factor analyses suggested that students' conceptual clarity about empathy improved over time and became more consistent with existing models.Conclusion. Although an increase in empathy was not observed in the overall cohort, subgroups of students who may derive greater benefit from empathy-related interventions were identified. Factor analyses suggested that students' conceptual understanding of empathy improved, representing a potential alternative outcome assessment for affective domains. Given differences in demographics, instructional methodologies, and changes in empathy at each school, this study reinforces the importance of replication and multicenter studies to understand the generalizability of educational research.

How to use the Delphi method to aid in decision making and build consensus in pharmacy education.

OUR SITUATION: As pharmacy educators, we often encounter situations such as designing new curricula or establishing shared values for an organization that may be ambiguous or controversial. To generate effective solutions, it is often necessary to build group consensus with key stakeholders. The purpose of this paper is to describe and provide recommendations for using the Delphi method, a process for facilitating discussions and aiding in decision making. METHODOLOGICAL LITERATURE REVIEW: An overview of the Delphi method, including its multiple variations, is presented. Steps necessary to complete a Delphi study (building a protocol, developing a research question, defining panelists and panel size, piloting the protocol, round one item creation and analysis, round two and beyond, consensus, increasing clarity, and reporting) is described. OUR RECOMMENDATIONS AND THEIR APPLICATION(S): Practical recommendations are provided to support use the Delphi method to build consensus in research. These recommendations include: (1) clarify the purpose of the Delphi, (2) ensure the research questions are grounded in the literature and are relevant, (3) carefully consider panelist processes, (4) determine any definitions that should be given to or developed by panelists, (5) determine methods for enhancing clarity, and (6) employ methods to reduce attrition. POTENTIAL IMPACT: The Delphi method provides a systematic approach to generating consensus in pharmacy education for commonly encountered situations such as committee meetings, research studies, faculty retreats, classroom activities, and lab meetings.

Critical moments in student learning on international advanced pharmacy practice experiences.

INTRODUCTION: The purpose of this study was to evaluate self-perceived critical moments that were transformative to learning in students who participated in an international advanced pharmacy practice experience (APPE). METHODS: Twenty-two pharmacy students from Purdue University College of Pharmacy, the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, and the University of North Carolina Eshelman School of Pharmacy who went on an international APPE participated in a one-hour focus group evaluating self-perceived critical moments that impacted their learning. Focus groups were coded using a conventional content analysis approach and went through a two-cycle open coding process to identify major themes according to country income classification. RESULTS: Twenty-two students participated in the focus groups with 18% going to a high-income country (HIC) and 82% going to a low-to-middle income country (LMIC) location. Major themes identified within HIC locations included witnessing an innovative patient care technique and experiencing interprofessional healthcare team dynamics. Major themes identified within LMIC locations included engaging in a sensitive patient interaction, experiencing healthcare system barriers, going out of their comfort zone, and making a difference. CONCLUSIONS: International APPEs in both HIC and LMICs provided students with disorienting experiences that facilitated transformative learning and led to changes in their perspectives on patient care and pharmacy practice. While critical moments were different across country income locations, both provided valuable experiences that could be translated into local context.

Entrustable Professional Activities (EPAs) for Global Health.

PURPOSE: As global health education and training shift toward competency-based approaches, academic institutions and organizations must define appropriate assessment strategies for use across health professions. The authors aim to develop entrustable professional activities (EPAs) for global health to apply across academic and workplace settings. METHOD: In 2019, the authors invited 55 global health experts from medicine, nursing, pharmacy, and public health to participate in a multiround, online Delphi process; 30 (55%) agreed. Experts averaged 17 years of global health experience, and 12 (40%) were from low- to middle-income countries. In round one, participants listed essential global health activities. The authors used in vivo coding for round one responses to develop initial EPA statements. In subsequent rounds, participants used 5-point Likert-type scales to evaluate EPA statements for importance and relevance to global health across health professions. The authors elevated statements that were rated 4 (important/relevant to most) or 5 (very important/relevant to all) by a minimum of 70% of participants (decided a priori) to the final round, during which participants evaluated whether each statement represented an observable unit of work that could be assigned to a trainee. Descriptive statistics were used for quantitative data analysis. The authors used participant comments to categorize EPA statements into role domains. RESULTS: Twenty-two EPA statements reached at least 70% consensus. The authors categorized these into 5 role domains: partnership developer, capacity builder, data analyzer, equity advocate, and health promoter. Statements in the equity advocate and partnership developer domains had the highest agreement for importance and relevance. Several statements achieved 100% agreement as a unit of work but achieved lower levels of agreement regarding their observability. CONCLUSIONS: EPAs for global health may be useful to academic institutions and other organizations to guide the assessment of trainees within education and training programs across health professions.

Co-curricular assessment plan for developing pharmacy professionals (RxPro) after the first professional year.

INTRODUCTION: To measure changes in student professionalism from co-curricular activities. METHODS: A prospective cohort study followed first-year pharmacy students at The University of Texas at El Paso School of Pharmacy. Students completed one co-curricular activity each semester. Learning was assessed using the RxPro VALUE rubric and Professionalism Assessment Tool (PAT) at the beginning and end of the first professional year. The RxPro VALUE rubric included six domains (connections to experience, lifelong learning, diversity of communities and cultures, civic identity and commitment, empathy, and reflection and self-assessment) and was rated from 0 (not yet applied) to 4 (exemplary). The PAT contained 33-items in five domains (reliability, responsibility, and accountability; lifelong learning and adaptability; relationships with others; upholding principles of integrity and respect; and citizenship and professional engagement) and was rated from 1 (knows) to 5 (teaches) (maximum score = 165). RESULTS: Mean scores on the RxPro VALUE rubric increased (p < 0.05) from baseline to end of year in five domains: connections to experience (1.44 vs. 2.07), diversity of communities and cultures (1.75 vs. 2.3), civic identity and commitment (1.34 vs. 2.33), empathy (1.44 vs. 2.37), and reflection and self-assessment (1.53 vs 2.19). No significant changes were seen in PAT scores from baseline (M = 114.19, standard deviation = 32.832) to end of year (M = 119.56, standard deviation = 29.63, p = 0.35). CONCLUSIONS: The RxPro VALUE rubric detected growth in professional behaviors among first-year doctor of pharmacy students, while no significant change was observed in the PAT.

Global Health Learning Outcomes in Pharmacy Students Completing International Advanced Pharmacy Practice Experiences.

Objective. To examine the global health learning outcomes of Doctor of Pharmacy (PharmD) students from three US schools who participated in international advanced pharmacy practice experiences (APPEs). Methods. A mixed-methods, prospective study was used to assess fourth-year PharmD students at three US pharmacy schools who participated in an international APPE during the 2017-2018 academic year and a matched cohort (control group) of PharmD students who did not participate in an international APPE. To evaluate students' self-perceived growth in the Consortium of Universities for Global Health (CUGH) competencies, all students completed a 13-item retrospective pre-post instrument using a five-point Likert scale. The students who had completed an international APPE were invited to participate in a focus group (N=22). Paired and independent t tests and multiple linear regression were used to analyze data. Qualitative open-ended questions and focus group data were mapped to knowledge, skills, and attitudes themes. Results. The students who completed an international APPE (N=81) showed significantly more growth in CUGH competencies than students who did not (mean improvement in total score of 10.3 [7.0] vs 2.4 [6.0]). International APPE participation was the only significant predictor of growth in CUGH competencies. The international APPE students reported improvements in cultural awareness and appreciation, communication skills, problem-solving skills, adaptability, self-awareness, personal and professional outlook, and global health perspective. Conclusion. Pharmacy students' participation in international APPEs led to significant improvement in all CUGH competencies. The CUGH competency framework appears to be a suitable instrument to assess pharmacy students' global health learning outcomes.

Global Health Learning Outcomes by Country Location and Duration for International Experiences.

Objective. To determine the impact of country income classification and experience duration on learning outcomes for student pharmacists participating in international advanced pharmacy practice experiences (APPEs). Methods. A mixed-methods, longitudinal study evaluated 81 fourth-year student pharmacists participating in an international APPE through one of three US universities. A pre-post survey was administered to evaluate students' self-perceived growth across 13 competencies established by the Consortium of Universities for Global Health (CUGH). The survey included four additional open-ended questions. Student pharmacists were also invited to participate in a focus group. Paired and independent t tests and multiple linear regression were conducted. Qualitative survey and focus group data underwent a two-cycle, open-coding process using conventional content analysis. Results. Students who completed their APPE in a low- to middle-income country had greater growth in all CUGH competency statements compared to those who completed their APPE in a high-income country. Completing the APPE in a low- to middle-income country and prior travel for non-vacation purposes were significant predictors of student growth. Students who went to a low- to middle-income country demonstrated increased cultural sensitivity, more patient-centered care, and skill development, while students who went to a high-income country displayed increased knowledge regarding differences in health care system components, pharmacy practice, pharmacy education, and an appreciation for alternative patient care approaches. Conclusion. Learning outcomes differed between students who completed an APPE in a high-income rather than a low- to middle-income country, with both types of locations providing valuable educational opportunities and professional and personal development.

Continuous subcutaneous insulin infusion therapy: A primer on insulin pumps.

OBJECTIVE: To summarize the role, benefits, and risks of continuous subcutaneous insulin infusion (CSII) therapy for treating diabetes. DATA SOURCES: A literature search was conducted in Medline (1996 to July 2008) using the search terms intensive insulin therapy, insulin pump, and continuous subcutaneous insulin infusion. Reference lists from comprehensive review articles were also used to identify additional original research publications. STUDY SELECTION: Review articles and studies evaluating the role, benefits, and risks of CSII. DATA SYNTHESIS: More than 300,000 individuals use CSII to treat diabetes. Many experts believe that CSII is the best insulin delivery method for highly motivated patients with type 1 diabetes who are technologically savvy and have the means to pay for the device and infusion sets. CSII is also useful for patients with type 2 diabetes who require multiple daily injections and experience wide fluctuations in blood glucose throughout the day or who experience severe hypoglycemia. A variety of CSII systems are currently available. All CSII systems provide precise insulin delivery throughout the day and improve the accuracy of bolus dose calculations, thereby achieving improved glycemic control with less frequent and severe hypoglycemic episodes. Patients who choose CSII report improved quality of life. Potential risks associated with CSII include mechanical problems leading to diabetes ketoacidosis, infections at the infusion site, hypoglycemia, and lipodystrophy. CONCLUSION: CSII is an attractive treatment option for many patients with diabetes. Given the widespread use of CSII, all health professionals should be familiar with the basic features of insulin pump technology, the potential risks and benefits of CSII, and how to troubleshoot common problems.