The challenge of transfer to clinical practice: The illusion of learning and illusion of teaching.

There is increasing pressure to accelerate health professions education programs and educators have the challenge of ensuring that students can effectively transfer their learning into clinical practice. In this personal view, we discuss how insights from cognitive science can inform the redesign of current curricula and highlight the challenge of implementing these new approaches for instructional design and assessment. We also recommend that educators disseminate the important lessons learned from their endeavors.

Teaching for transfer of learning in health professions education: AMEE Guide No. 176.

Transfer of learning occurs when past learning is applied to new situations, and also at a varying time from the initial time of learning. Importantly, research in both academic and clinical areas of health professions education has highlighted that transfer of learning often does not successfully occur. Successful transfer is multi-dimensional and occurs when the learner has the required motivation, mental model, metacognitive processes relevant to the task, and the opportunity to transfer their learning to different situations. An essential aspect of successful transfer is the educator. This Guide provides an overview of an integrated model of transfer that can inform a variety of practical teaching strategies in both academic and clinical areas of health professions education.

Combining adaptive expertise and (critically) reflective practice to support the development of knowledge, skill, and society.

Adaptive expertise (AE) and reflective practice (RP), two influential and resonant theories of professional expertise and practice in their own right, may further benefit health professions education if carefully combined. The current societal and systemic context is primed for both AE and RP. Both bodies of work position practitioners as agentive, learning continually and thoughtfully throughout their careers, particularly in order to manage unprecedented situations well. Similar on the surface, the roots and practices of AE and RP diverge at key junctures and we will focus on RP's movement toward critically reflective practice. The roots of AE and RP, and how they relate to or diverge from present-day applications matter because in health professions education, as in all education, paradigmatic mixing should be undertaken purposefully. This paper will explore the need for AE and RP, their shared commitments, distinctive histories, pedagogical possibilities both individually and combined, and next steps for maximizing their potential to positively impact the field. We argue that this exploration is urgently needed because both AE and RP hold much promise for improving health care and yet employing them optimally-whether alone or together-requires understanding and intent. We build an interprofessional education case situated in long-term care, throughout the paper, to demonstrate the potential that AE and RP might offer to health professions education individually and combined. This exploration comes just in time. Within the realities of uncertain practice emphasized by the pandemic, practitioners were also called to act in response to complex and urgent social movements. A combined AE and RP approach, with focus on critically reflective practice in particular, would potentially prepare professionals to respond effectively, compassionately, and equitably to future health and social crises and challenges.

Exploring why we learn from productive failure: insights from the cognitive and learning sciences.

Advances in Health Sciences Education (AHSE) has been at the forefront of the cognitive wave in health professions education for the past 25 years. One example is research on productive failure, a teaching strategy that asks learners to attempt to generate solutions to difficult problems before receiving instruction. This study compared the effectiveness of productive failure with indirect failure to further characterize the underpinning cognitive mechanisms of productive failure. Year one pharmacy students (N = 42) were randomly assigned to a productive failure or an indirect failure learning condition. The problem of estimating renal function based on serum creatinine was described to participants in the productive failure learning condition, who were then asked to generate a solution. Participants in the indirect failure condition learned about the same problem and were given incorrect solutions that other students had created, as well as the Cockcroft-Gault formula, and asked to compare and contrast the equations. Immediately thereafter all participants completed a series of tests designed to assess acquisition, application, and preparation for future learning (PFL). The tests were repeated after a 1-week delay. Participants in the productive failure condition outperformed those in the indirect failure condition, both on the immediate PFL assessment, and after a 1-week delay. These results emphasize the crucial role of generation in learning. When preparing novice students to learn new knowledge in the future, generating solutions to problems prior to instruction may be more effective than simply learning about someone else's mistakes. Struggle and failure are most productive when experienced personally by a learner because it requires the learner to engage in generation, which deepens conceptual understanding.

Productive failure as an instructional approach to promote future learning.

Productive failure is an instructional approach that requires learners to struggle as they attempt to generate solutions to problems before, rather than after, receiving direct instruction on a targeted concept. Studies demonstrate that productive failure prepares students for later learning of new, related knowledge. Our study explored the effectiveness of productive failure as an instructional intervention in health professions education with respect to (a) acquisition and application of a novel concept, and (b) learners' preparation for future learning of new, related content. Forty year-one students enrolled in the Doctor of Pharmacy program at the University of Toronto were randomly assigned to a productive failure (i.e. attempt to generate solutions before receiving instruction) or direct instruction only learning condition. After a practice phase, participants completed a series of tests designed to measure knowledge acquisition, knowledge application, and preparation for future learning (new learning is required for successful problem solving). As expected, no difference in performance was seen between participants on the acquisition and application tests. However, participants in the productive failure condition outperformed those in the direct instruction condition on the preparation for future learning test. These results emphasize the role of struggle in learning and support the theory that engaging students in solving problems that are beyond their abilities can be a productive exercise in failure. The results suggest that productive failure assists learners in acquiring the conceptual knowledge needed to facilitate learning in the future.

Twelve tips for designing curricula that support the development of adaptive expertise.

An essential component of expertise is a clinician's ability to adapt to uncertain, complex, or novel situations while maintaining their competence in routine situations. Adaptive expertise provides a framework for understanding and developing experts who have the skills to effectively balance and support these dimensions of work using both procedural and conceptual knowledge. It is important for educators to understand that often the training which fosters adaptive expertise does not require new tools or approaches, but rather a reconceptualization of training using many of the same instruction and assessment formats already available. The twelve tips discussed in this paper showcase ways in which education can be transformed to support the development of adaptive expertise including the significance of instruction that combines various forms for knowledge, the value of productive struggle, and shifting the design of assessments to support learning and performance beyond retention and direct application.

A Call to Action: Impact of Pharmacy Education on Rural Practice.

Rural populations are steadily growing, yet residents in these areas face significant disparities in health care access compared with their urban counterparts. This commentary examines the role of pharmacy education in addressing the challenges of rural pharmacy practice. With a focus on strategies outlined by the World Health Organization, the authors explore interventions such as admitting students from rural backgrounds, establishing health professional schools outside major cities, and providing clinical rotations in rural areas. Drawing on examples from Australia, Canada, the United States, and New Zealand, the authors highlight various approaches taken to bridge the rural pharmacy education gap. These include adapting admission criteria for pharmacy schools, integrating rural content into curricula, and offering rural-focused rotations and certificate programs. In addition, the authors discuss the importance of addressing student perceptions of rural practice, which often include concerns about social isolation, limited collaboration opportunities, and lifestyle factors. Looking ahead, the authors suggest future directions for pharmacy education, emphasizing the need to prioritize rural health issues in curricula, increase opportunities for rural placements, and engage pharmacists from rural backgrounds in teaching roles. By implementing these recommendations, pharmacy educators can better prepare students for rural practice, ultimately improving access to health care and reducing disparities in underserved communities.

Direct rotation from a fentanyl patch to a buprenorphine patch in a patient with chronic pain.

Transitioning a patient with chronic pain from a fentanyl patch to a buprenorphine patch has not been well described in the literature. Even after a patient removes their fentanyl patch, the residual fentanyl in the skin continues to be absorbed for hours. Due to the risk of precipitated withdrawal when initiating buprenorphine, this transition is a more challenging opioid rotation to plan safely. We report a case of a patient who had been using a fentanyl patch for over 10 years and was successfully rotated directly to a buprenorphine patch.

Two for One: Merging Continuing Professional Development and Faculty Development in the CATE Curriculum for Pharmacy Preceptors.

Background: Continuing professional development (CPD) and faculty development (FD) are not traditionally combined, although there is evidence that integrating them enhances knowledge acquisition. Objective: To explore preceptors' perceptions and the effectiveness of CATE (Clinical And Teaching Education), an education model that blends clinical content with the application of that clinical knowledge through a specified teaching technique. Methods: Thirty-five hospital and community pharmacy preceptors from the Leslie Dan Faculty of Pharmacy, University of Toronto, participated in CATE, which consisted of a 2-hour synchronous, online workshop integrating clinical content about depression with the "One-Minute Preceptor" (OMP) teaching skill. Qualitative and quantitative data were collected longitudinally using surveys and semistructured interviews. Participant and process outcomes were explored through descriptive and thematic analysis using a modified Kirkpatrick framework. Results: Participants valued the incorporation of educational theory and opportunities to practise the OMP using scripted role plays based on the depression-related content. The combination of FD and CPD was appealing, although participants wanted more clarity about their integration. The CATE model positively influenced their approaches to serving as preceptors, and using the OMP helped to reveal learners' knowledge gaps. There was a desire to share the teaching technique with colleagues to provide a more cohesive approach to teaching. Conclusions: Integrating CPD and FD in a synchronous, online environment was feasible and well received, and it helped to solidify preceptors' roles as educators. Combining CPD and FD represents an effective strategy to build the clinical and educational expertise of preceptors, which in turn has the potential to improve the quality of experiential learning for pharmacy students. This novel method of fostering the pedagogical growth of preceptors could be a model for other health professions.

Contexte: Le développement professionnel continu (DPC) et le développement professoral (DP) ne sont pas traditionnellement combinés, même s'il existe des éléments probants indiquant que leur intégration renforce l'acquisition des connaissances. Objectif: Examiner les perceptions des précepteurs et l'efficacité du CATE (Clinical And Teaching Education): un modèle pédagogique qui allie le contenu clinique à l'application de ces connaissances cliniques grâce à une technique d'enseignement spécifiée. Méthodologie: Trente-cinq précepteurs de pharmacies d'hôpitaux et communautaires de la Faculté de pharmacie Leslie Dan de l'Université de Toronto ont participé au CATE, qui consistait en un atelier en ligne synchrone de deux heures intégrant un contenu clinique sur la dépression avec la compétence pédagogique « précepteur-minute ¼. Les données qualitatives et quantitatives ont été recueillies longitudinalement à l'aide d'enquêtes et d'entretiens semi-structurés. Les résultats des participants et du processus ont été étudiés au moyen d'une analyse descriptive et thématique utilisant un cadre de Kirkpatrick modifié. Résultats: Les participants ont apprécié l'intégration de la théorie pédagogique et des occasions de pratiquer la compétence du précepteur-minute à l'aide de jeux de rôle scénarisés basés sur le contenu lié à la dépression. La combinaison du DP et du DPC était attrayante, même si les participants souhaitaient plus de clarté sur leur intégration. Le modèle CATE a influencé positivement leurs approches en matière de préceptorat, et l'utilisation de la technique précepteur-minute a contribué à révéler les lacunes des connaissances des apprenants. Il y avait une volonté de partager la technique d'enseignement avec des collègues pour offrir une approche plus cohérente de l'enseignement. Conclusions: L'intégration du DPC et du DP dans un environnement en ligne synchrone était réalisable et a été bien accueillie; elle a contribué à consolider le rôle des précepteurs en tant qu'éducateurs. La combinaison du DPC et du DP constitue une stratégie efficace pour développer l'expertise clinique et pédagogique des précepteurs, ce qui, à son tour, a le potentiel d'améliorer la qualité de l'apprentissage expérientiel des étudiants en pharmacie. Cette nouvelle méthode visant à favoriser la croissance pédagogique des précepteurs pourrait constituer un modèle pour d'autres professions de la santé.

Adaptive Expertise in Undergraduate Pharmacy Education.

Pharmacy educators are grappling with concerns around curriculum overload and core pharmacist competencies in a rapidly changing and increasingly complex healthcare landscape. Adaptive expertise provides a conceptual framework to guide educators as they design instructional activities that can support students on their journey towards becoming pharmacists who can perform procedural tasks efficiently, as well as creatively handle new and difficult-to-anticipate problems that arise regularly in pharmacy practice. This article explores undergraduate pharmacy education through a cognitive psychology lens and foregrounds three instructional design strategies which support the development of adaptive expertise: (1) cognitive integration, (2) productive failure, and (3) inventing with contrasting cases. These three evidence-based strategies cultivate long-term learning and provide a practical mechanism to combat curriculum overload and backwards-facing assessments. Pharmacy education can encourage the development of procedural and conceptual knowledge and position pharmacy students to excel as they move into more complicated and ambiguous roles in our healthcare system.

The Influence of Intersectionality on Professional Identity Formation among Underrepresented Pharmacy Students.

OBJECTIVE: The objective of this study is to explore professional identity formation (PIF) among student pharmacists from underrepresented groups (URGs). METHODS: In this qualitative study, 15 student pharmacists from the University of Georgia and Midwestern University Colleges of Pharmacy were recruited for interviews to explore the influence of intersectionality of race, ethnicity, and gender on PIF. Interview data were analyzed using constructivist grounded theory to identify themes and then further analyzed using Crenshaw's theory of intersectionality, namely structural, political, and representational intersectionality. RESULTS: Intersectionality of identities created situations where participants expressed advantages belonging to certain social categories, while simultaneously being disadvantaged belonging to other social categories. This awareness led to strategies to overcome these collective obstacles for themselves and their communities. Participants then described ways to shift perceptions of how society depicts pharmacists and the pharmacy profession. The results depict these processes and how intersectionality influences PIF for URG student pharmacists. CONCLUSION: The sociocultural aspects of race, ethnicity, and gender influence the PIF of student pharmacists who belong to URGs. Intersectionality helps us better understand the ways in which inequality compounds itself, and this results in URG student pharmacists creating opportunities for belongingness and representation. Resultantly, URGs create opportunities for inclusivity and representation. To continue to facilitate this it is essential for educators and university systems to promote ways to foster and incorporate PIF in student pharmacists.

Opioid Utilization and Management in the Setting of Stewardship During Inpatient Rehab Care.

Background: Opioid utilization and management in an inpatient rehabilitation setting have not been widely described, despite the unique opportunities that exist in this setting to support opioid stewardship across transitions in care. We aimed to characterize opioid utilization and management by interprofessional teams across a large, inpatient rehabilitation setting after incorporation of opioid stewardship principles by pharmacists as part of their daily practice. Patients and methods: This was a retrospective chart review at Toronto Rehab, University Health Network, Toronto, Canada. Patients with admission orders for any opioid from November 2017 to February 2018 were included. Complex continuing care and palliative care patients were excluded. Descriptive statistics were primarily used to describe the data as well as univariate linear regression to compare associations with milligram morphine equivalent (MME) reduction. Results: A total of 448 patients were included. A reduction in total daily MME was seen in 49% (n=219) of the patients during their inpatient stay, with 73% (n=159) of these patients having a reduction of ≥50%. Sixty-nine percent (n=311) of the patients received an opioid prescription at discharge, with most scheduled (90%, n=98) with a supply of less than 30 days. Rehabilitation length of stay was correlated with a MME decrease during rehab (p<0.01), suggesting that longer lengths of stay contributed to a greater reduction in MME. Patients with chronic opioid use prior to acute care admission (p=0.01), and those who started extended-release opioids during acute care (p=0.02) were significantly less likely to discontinue opioids during rehab stay. Conclusion: Opioid utilization and management in the setting of opioid stewardship across inpatient rehab and transitions of care were characterized. Opportunities exist for further quality improvement initiatives within inpatient rehabilitation and acute care settings to identify and support patients with complex pain management needs.

Adaptive Expertise in Continuing Pharmacy Professional Development.

Pharmacists are facing rapid changes and increasing complexity in the workplace. The astounding rate of both the evolution and the development of knowledge in pharmacy practice requires that we develop continuing professional development (CPD) to foster and support innovation, creativity, and flexibility, alongside procedural expertise. Adaptive expertise provides a conceptual framework for developing experts who can both perform professional tasks efficiently as well as creatively handle new and difficult-to-anticipate problems. This article approaches knowledge production in daily pharmacy practice and CPD through a cognitive psychology lens, and highlights three educational approaches to support the development of adaptive expertise in the workplace: (1) explaining not just what to do, but why you are doing it, (2) allowing and encouraging struggle, and (3) asking "what if" questions to encourage meaningful variation and reveal underlying core concepts. These three evidence-based strategies will cultivate long-term learning and will support pharmacists as we move into more complicated and ambiguous roles. Pharmacy CPD can be transformed to support the development of both procedural and conceptual knowledge in a local environment to support learning and innovation.

Vascular quality of care pilot study: how admission to a vascular surgery service affects evidence-based pharmacologic risk factor modification in patients with lower extremity peripheral arterial disease.

BACKGROUND: Peripheral arterial disease (PAD) guidelines recommend aggressive risk factor modification to improve cardiovascular outcomes. Recommended pharmacologic therapies include antiplatelets, angiotensin converting enzyme (ACE) inhibitors, and HMG-CoA-reductase inhibitors (statins). PURPOSE: We studied the degree to which patient admission to a vascular surgery service increased the use of these therapies. PATIENTS AND METHODS: The authors conducted a retrospective chart review of 150 patients with PAD admitted to the vascular surgery service at a large Canadian tertiary care hospital. The use of recommended pharmacologic therapies at the time of admission and discharge were compared. A multidisciplinary clinical team established criteria by which patients were deemed ineligible to receive any of the recommended therapies. Angiotensin receptor blockers (ARBs) were considered an alternative to ACE inhibitors. RESULTS: Prior to hospital admission, 64% of patients were on antiplatelet therapy, 67% were on an ACE inhibitor or ARB, and 71% were on a statin. At the time of discharge, 91% of patients were on an antiplatelet (or not, with an acceptable reason), 77% were on an ACE inhibitor or an ARB (or not, with an acceptable reason), and 85% were on a statin (or not, with an acceptable reason). While new prescriptions were largely responsible for improved guideline adherence with antiplatelets and statins, most of the apparent improvement in ACE inhibitor and ARB use was the result of identifying an acceptable reason for not having them prescribed. CONCLUSION: This hypothesis generating pilot study supports the findings of others that there is suboptimal prescription of pharmacologic risk reduction therapies in the PAD population. Admission to a vascular service increases these rates. Nevertheless, some patients are still not receiving evidence-based treatment at discharge even after consideration of acceptable reasons. Strategies are needed to improve PAD guideline adherence in both the community at large and the vascular surgery service.