Education Reform

from UG to Consultant

Ian BatesHead of Education

The School of PharmacyUniversity of London

The professional imperative

– Better health care,

– Better patient experience,

– Better value for money

– Curricular pressuresIntegration of pharmaceutical and clinical sciences

– Dislocation of education and practice– Not competency-based

Performance of our graduates?

– Not a partnershipWith national health systems

With existing health professionals

What’s holding us back?

Short term vs Long term

– Long termThe science of medicines must be foundation of educationKnowledge half-life

– Short-term imperativesUnderstand and engage with the health agenda

A modern education…

…from undergraduate to Consultant

A cooperative policy of strategic planning using evidence

The learning experience

Syllabus – knowledge & content

Delivery & quality

Outcomes

Context – institutional, societal & cultural

Access, finance & policy

What’s holding us back……curriculum

N = 9,519 students

The Learning Experience…

Pharmacy students N = 9,519

MoneyJob issuesAltruism

Health interestScience

Motivation:

Pharmacy studies

% c

ases

(n=1

308)

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SloveniaRomania

SwissNL

PortugalSingapore

NepalAustralia

JamaicaMalaysia

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0

25

50

75 Money : Science Money : Science rhorho = = −−0.60.6

Zscore(Assessment)Zscore(goals)Zscore(Independence)Zscore(Teaching)

Category

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Yes NoHave you always wanted to be a pharmacist?

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-0.1

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0.1

AssessmentGoalsIndependenceGood Teaching

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Bates 2004University B

-0.4

-0.2

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0.2

Mea

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Clear goalsOpenessIndependenceGood teachingworkloadAssesment

High didacticHigh didactic

Low didacticLow didactic

Lectures, exams, timetableLectures, exams, timetable

University A University C

n = 787

High didacticLow didactic

Lectures, exams, timetable

Bates 2002

Pharmacy

– It varies

– Is this acceptable?

– How can we improve it?

For Pharmacy students:Environment influentialMotivation influentialOrthodoxy in Universities

The learning experience

Demographics & workforceDemographics & workforce

19701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007

900

1,200

1,500

1,800

2,100

2,400

2,700

Actual UG places in Year 1

Predicted (ARIMA modeling)

20%

Bates & Taylor 2004

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0%

25%

50%

75%

Czech Republic Kuwait Croatia Finland Switzerland Spain

Romania Poland Singapore Latvia Serbia Germany

Canada Malaysia Jamaica Israel Iceland UK

Mexico Portugal Jordan Slovenia Australia Taiwan

Japan India Netherlands Nepal Ghana Bangladesh

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N = 9,538 Bates 2007

Gender UG

By country

Who’s smarter?

OSCEs during pre-registration training

Females have a greater success rate both at start and end of pre-registration year.

(U= 4252.0, p= 0.004)

McRobbie, Bates, Davies

n = 5773P<0.0001

BoysGirls

gender

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1st 2:1 2:2 3rdDegree class

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10.00

20.00

30.00

40.00

50.00%

N = 5773

P<0.0001

Pharmacy graduates

☺+

male female

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Cer

tific

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tota

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W

W

N = 2432

p = 0.001

21% ♂

79% ♀

Post-registration, junior hospital practitioners(1994 – 2007) PG Certificate in Clinical Pharmacy Exam results

N = 9545

Pharmacy students

…and overall satisfaction with quality?(3 = neither good/bad – is this where we want to be?)

Syllabus – the Knowledge problem

…pharmacy syllabus is overcrowded

chemistry pharmacology biotechnologygenetics medicine analysis formulationphysical chemistry ethics pharmacognosyphytochemistry drug design immunologypharmacokinetics therapeutics pathologyepidemiology health economics chemical analysisphysiology proteomics statisticslaw Licensing&marketing ADRsmicrobiology medicinal chemistry biochemistrytoxicology drug metabolism genomicssocial & behavioural sciences

Content & syllabus

Too much – but unavoidable?

– Surface approaches– Emphasis on cognitive skills– Pushes imperative back onto post-

registration CE and CPD

Leads to bad habits……academic plagiarism & dishonesty

A short diversion….

Academic cheating!for example…

– unattributed Internet cut and paste

– Copies from journal with using quotation marks

– Photocopy friend’s work

– Make up lab results

– Borrows work for “ideas”

.9% 98.0% 1.0%

24.4% 52.5% 23.1%

1.2% 97.7% 1.1%

63.5% 15.4% 21.1%

4.5% 89.3% 6.3%

27.1% 54.8% 18.1%

26.0% 51.6% 22.5%

15.6% 70.3% 14.1%

26.0% 55.4% 18.6%

53.9% 29.0% 17.1%

39.6% 38.7% 21.8%

Concealed exam Notes.

Lenient peer marking

Notes on arm.

Borrows work for Ideas.

Photocopies friends work, w/o permision.

Photocopies friends work, with permission.

Unattributed internet cut and pasting.

Copies journal without using quotation marks

Makes up lab results.

Talks to neighbour in practical exam.

Hand down work to lower years.

%

No

%

Yes

%

Unsure

Academic cheating? n = 1165

Total ‘dishonesty’ score by subject

Davies & Bates 2003

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BIOMEDICAL SCIBUSINESS STUDIES

HUMANITIESPHYSIOTHERAPY

EDUCATION

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PHARMACY

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n = 1132 students

Academic dishonesty & Gender

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And so…?

– MethodsPBLNear to patient casesClinical contact

ExperientialSubject Integration

– DesignsScientists as practitioners

Adult learning & self-directionPragmatic & meaningful in situ LLL

Competency →Competence →

Performance

Fit to practise?

And finally…outcomes

Post registration

– CPD?

– Kolb and his learning cycle !!

CPD - Yes or No ?

Maybe not

Ward et al, Pharmaceutical Journal, 1999Matalia, Pharmaceutical Journal, 2005Hughes et al, Int Journal Pharmacy Pract, 2002

Attewell et al, Int Journal Pharmacy Pract, 2002Bell et al, Int Journal Pharmacy Pract, 2001Ward et al, Int Journal Pharmacy Pract, 2000Rees et al, Int Journal Pharmacy Pract, 2003

Bell et al, J Soc Admin Pharm, 1998Hanson and DeMuth, Am J Pharm Educ 1991; 1992

James et al, Pharmacy Education, 2000

Recurrent themes…

TimeMoney

…and disengagement from CPD process

Recurrent themes…

– Repetitive

– Esoteric and useless diversion (Zeichner; Hall)

– Lack of pragmatism and “how to”

– “Reflective practice” tedious, not practical (students, practitioners, professions)

Reflective learning?

Significantly theoretical – including Schön

Where does it leave novices?

Not “transforming” - but self-confirming – a risk for novice practitioners

Too introspective, unchallenging, ego-centric and self-limiting

(Bleakley 2000; Land 2003; Moon 2000)

Recurrent themes in CPD…

Little educational motivation…

…(mandatory process; where are the outcomes?)

Why ?

…I have my theories….

Competency →Competence →

Performance

Fit to practise?

Where are the outcomes?

In summary

– UG education probably needs reform– Problems with LLL set in early– No outcomes are measured

(Ready to practise?)

“CPD” remains an issue…even mandatory CPD…

Where are we going?

– Practitioner development

– Mapping agreed levels of practice

– Mapping back to UG

Pharmacist Development Strategy

Consultant pharmacist

Higher level practitioners(incl. PhwSI)

General practitioner

Competency progression Development

Contributingknowledge

& skills

Acquiring Knowledge

& skills

Research & teaching

Doctoral

PG M level

PG Dip level

Entry M levelRegistered pharmacist

10%

20%

30%

40%

50%

60%

70%

1996/97 1997/98 1998/99 2001/02

Pharm Care Competencies(OSCE)

60%

30%

Graduation

One year later

McRobbie et al

Skills

Behaviours

Knowledge

Valuesattitudes

Competency

““CompetenceCompetence”” is a complex educational constructis a complex educational construct……...with new currency value...with new currency value

Competence → Performance

Outcomes

Miller’s pyramid

Does

Shows how

Knows how

Knows

performance assessment in vivo

performance assessment in vitro

clinical context assessment

factual assessment

Practice-based, MiniPAT, MiniCEX, etc

OSCE style

Case studies/ PBL /Portfolio

MCQ / Exams

From UG to post-registration development

Characteristics and Traits

Knowledge, Skills and Abilities

Competencies

Performance

Education and training

Integration

Experience

Innate

Developed

Bundled

Deployed

OSCE, simulation

Mini-CEX, mini-PAT, CbD

MCQ, MEQ

Assessment Strategies

Competency hierarchy

Two principal approaches

CompetenceSimulation – Objective Structured Clinical

Examination (OSCE)Knowledge : MCQ/MEQ

PerformanceMapped against a validated competency

framework – The GENERAL LEVEL FRAMEWORK (GLF)

“active” CPD Portfolio – the “experience”MiniPAT; MiniCEX; CbD

Mini–PAT form

Mini-PAT (Peer Assessment Tool)

Mini PAT results

0

1

2

3

4

5

6

Patient Consultation

Need for DrugSelection of Drug

Drug specific issues

Provision of drug product

Medicines Information and Patient Information

Monitroing of Drug Therapy

OrganisationEffective communication skills

TeamworkProfessionalismGathering Information

KnowledgeAnalysing Information

Providing Information

Overall, how do you compare yourself to a pha

competency

Mea

n Sc

ore

Your rating

Rating achievedGroup rating

Clinical Evaluation Exercise (mini-CEX)

The strengths of the mini-CEX include:– Evaluate trainees performance with a

real patient

– Oservational – assessment of performance with feedback

– Trainees have a complete and realistic challenge

– Quick (20 to 30 mins – includes feedback)Therefore can do it often. A good thing.

Mini–CEX example

Please grade the following areas using the scale below:

Significantlybelow

Below Borderline Meets expectations

Above Significantlyabove

Unable to comment*

Delivery of Patient Care

1 Patient consultation1 2 3 4 5 6 7

2 Need for drug

Johari’s Window

An example..

Drug-drug interactions:-

– Theory, knowledge

– Examples (from lectures, books, case studies, etc)

– MCQs etc

Moving from “knowing” (theory)…

towards…“doing” (performance)

The pharmaceutical imperative

– Bring our pharmaceutical science into healthcare practice

– Demonstrating performance

Predominantly FDL and e-modes

Predominantly face-to-face modes

Cohort learners

Lone learnerOn-site (HEI)learning

Off-site (work)learning

FDL, e-modesoff-site, experientialIndependentCareer driven

Learning modality with time/career pathway

UGIntern

Post-reg

Higher

General and Higher level practice: Growing the next generation

– Developmental and competency frameworks are sector independent [Hospital? Community? – it makes no difference!]

– They work

– The strategic approach is educational and developmental

– “General” can be highly specialist

Pharmacist Development Strategy

Consultant pharmacist

Higher level practitioners(incl. PhwSI)

General practitioner

Competency progression Development

Contributingknowledge

& skills

Acquiring Knowledge

& skills

Research & teaching

Doctoral

PG M level

PG Dip level

Entry M levelRegistered pharmacist

Low ActivityHigh Activity

Key performance indicators F1(medical)

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70 80 90 100 110 120

Mortality Rate Index

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R-Square = 0.16

R-Square = 0.76

Mortality rate Index

Num

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harm

acis

ts

Challenges

Assess competence & performance in UG developmental learning frameworks– the new competence.

Define performance criteria

Workforce issuesPractitioner developmentHigher level practiceDeveloping pharmacists with specialisms

Where is our professional ‘centre of gravity’?

Patient-focussed, medicines-centred

Bibliography

Antoniou S, Webb DG, McRobbie D et al. A controlled study of the general level framework: results of the South of England competency study. Pharmacy Education 2005: 5: 201-7

Dreyfus HL, Dreyfus SE. Mind over Machine. Oxford: Blackwell, 1986

Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA 2002; 287: 226-235

McRobbie D, Webb DG, Bates I, et al. Assessment of clinical competence: designing a competence grid for junior pharmacists. Pharmacy Education 2001; 1: 67-76

Meadows N, Webb DG, McRobbie D et al. Developing and validating a competency framework for advanced pharmacy practice. Pharm J2004; 273: 789-792

Miller GE. The assessment of clinical skills/competence/performance. Acad Med 1990; 65(suppl): S63-S67

Schön DA. The Reflective Practitioner: how professionals think in action. London: Temple Smith, 1983

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New Models forPractitioner Development

Professor Ian BatesProfessor Graham Davies

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