teambased teaching strategies handout version

Team‐Based Teaching Strategies and Educational Curricula for Experiential Learners

Ian B. Hollis, PharmD, BCPS AQ‐Cardiology

Kamakshi V. Rao, PharmD, BCOP, CPP, FASHP

DisclosureIn accordance with the ACPE’s and ACCME’s Standards for Commercial Support, anyone in a position to control the content of an educational activity is required to disclose their relevant financial relationships. In accordance with these Standards, ASHP is required to resolve potential conflicts of interest and disclose relevant financial relationships of presenters.

• In this session:

All planners, presenters, reviewers, and ASHP staff report no financial relationships relevant to this activity.

Learning Objectives

Identify the principles and benefits of team‐based rotational teaching.

Construct a comprehensive topic list and delivery strategy for a longitudinal curriculum based on learner type and needs.

Prioritize the needs of different layers of learners within a team‐based teaching model.

Formulate strategies to address barriers to team‐based teaching processes.

Principles Design Prioritization Barriers

2018 National Pharmacy Preceptors Conference Team-Based Teaching Strategies and Educational Curricula for Experiential Learners

©2018 American Society of Health-System Pharmacists of 18

Audience Response Question #1 How many learners (combination of students and

residents) complete experiential learning at your institution in an academic year?• <20• 21‐50• 51‐100• >100


UNC Medical CenterMedical Center 800+ bed academic medical

center Level 1 Trauma Center NCI Designated Comprehensive Cancer

Center Pediatric Center of Excellence Regional Burn and Hemophilia Centers

40,000 annual discharges (FY17) >1million annual clinic visits

Pharmacy Department 366 FTEs (404 employees)

• 120 pharmacists FTE• 136 technicians FTE• 74 administrative staff FTE• 36 pharmacy residents FTE

Decentralized, service‐line based model of pharmacy practice

Fully automated distribution system


Pharmacy Learners at UNCMC

Partnership with UNC Eshelman School of Pharmacy

Transformed curriculum introduces experiential education beginning in the spring semester of PY2




The overall picture


Components of Experiential Education

Observation and

participation based

knowledge• Rounding/ clinic visits

• Staffing• Counseling

Direct delivery of knowledge

• Topic discussions• Seminars• CEs


A mismatch in priorities

Appeals to learners

• Substantial time for topic discussions

• Flexibility to tailor rotations to interests

• 1:1 time with preceptors

Needs for preceptors

• Need for learners with consistent skill sets

• Increasing time demands of patient care and services

• Minimizing redundancies in efforts




Sample PGY1 rotation schedule

Acute Care Medicine ‐Geriatrics

Pharmacy Admin

Am Care –Endocrine

Clinic

Elective –ID

Consults

Research Month Drug Info

Acute Care Medicine –Oncology

Elective –PICU

Elective –Psychiatry

Critical Care –

Burn ICU

Appropriately broad, diverse, and meets accreditation criteria


Drawbacks of the structure

• Increased tailoring can result in larger holes in knowledge

• Is it ok to finish PGY1 training and not have a conversation about the management of Afib?

Tailored Rotations

• Increased learner burden results in monthly, repetitive topic discussions

• Sometimes, the same topic is discussed in the same month by multiple preceptors to different learners

Topic Discussions


Incorporating a Curriculum in the Experiential Setting

In order to bring consistency and efficiency to the “direct delivery of knowledge” parts of residency training, we introduced two innovative programs

Case Conference PODs




Case Conference

Purpose: to ensure all PGY1 (previously PGY1 and PY4) learners are exposed to core disease states and topics during the academic year Started in 2012, now through 4 iterations


Practice Makes “Perfect?”Version 1 Version 2 Version 3 Version 4

Weekly, 1h Weekly, 1h, offloaded prep

content

Weekly, 1h, pre‐reading

Bi‐weekly, 1hr,30min prework

Lecture Mentor Mentor

Data discussion

Discussion/ facilitation

Interactive facilitation

Case presentation

Case presentation

Interactive facilitation

PGY2

PGY1

PY4

Clinician Advisor


Application Activity

Work with 3‐5 audience members in your area using provided worksheet #1• Create a list of all topics you think would be appropriate

for inclusion in a longitudinal educational curriculum for a PGY1 resident class• How do you decide which topics “make the cut”?




Case Conference – 2018‐19 Topic ListDate Topic

September 10 DVT / PE / HITSeptember 24 Heart FailureOctober 8 Psych EmergenciesOctober 22 Chemo 101November 5 Transplant ImmunosuppressionNovember 19 Peds Respiratory d/oDecember 10 Peds 101January 7 Renal FailureJanuary 28 ACSFebruary 4 Anxiety / DepressionFebruary 18 Onc EmergenciesMarch 4 DiabetesMarch 18 HIVApril 1 StrokeApril 15 Sodium DisordersApril 29 CirrhosisMay 13 ToxicologyMay 27 COPD

Balanced representation of institutional service lines:

‐ Medicine/Psychiatry‐ Critical Care/Surgery‐ Heart/Vascular‐ Pediatrics‐ Oncology


Case Conference Topics

Medicine

HIV

Diabetes

Cirrhosis

COPD

Psychiatry

Anxiety & Depression

Psych Emergencies

Critical Care &Surgery

Transplant Immunosuppression

Renal Failure

Sodium Disorders

Toxicology

Pediatrics

Peds Respiratory D/O

Peds 101

Oncology

Chemo 101

Onc Emergencies

Heart & Vascular

DVT/PE/HIT

Heart Failure

ACS

Stroke


Case Conference – Feedback Drives Success

Each iteration was adjusted based on learner feedback to maximize value to the targeted layer – PGY1

In current state, seen uniformly as a value‐add and worth the time away from rotation activities• Desire to limit pre‐reading or prep work to a

max of 30 minutes




PODs (Patient Oriented Discussions)

Success of case conference led to adoption of a similar approach to teaching within specialty areas• Particularly effective in areas where there are

several preceptors within a specialty

Heart & Vascular

Ambulatory Care Oncology

Pulmonary/ Infectious Disease

Administration Psychiatry


PODs ‐ Structure Targets PY4 and PGY1 learners (some areas include

early learners and PGY2s) Core topics within a group of preceptors are presented

on a weekly basis to all learners on any of the rotations• e.g.‐ PID POD includes all PY4 or PGY1 learners on

inpatient ID, ID consults, stewardship, or pulmonary medicine

Discussion led by an appropriate specialist


Variability within specialtyOncology Administration Heart and Vascular

Timing Weekly Weekly Bi‐weekly

Pre‐POD requirement

Presenter composed resources or clinical trials

Articles, book chapters or TED talks

Clinical trials, guidelines, prereading questions

Presenter Clinical Pharmacist Director or Manager Clinical Pharmacist or PGY2

POD Discussion

Case application, didactic lecture

Power point presentation Didactic lecture, journal club and case application

Topics Pain ManagementAnticoagulationImmunologyTarget Therapies

LeadershipMedication SafetyFinancesMedication Use System

Afib ManagementInvasive Procedures ACSHeart Failure




Patient Oriented Discussions (PODs)

Benefits

• Learners

• Exposed to more core topics in a specialty• Less redundancies in topic discussions• Interactions and learning between learners

• Preceptors

• Additional time while learner is away with specialist on topic discussion

• Less required individual discussions

Challenges

• Learners

• Only one clinician’s opinion represented vs discussion between multiple clinicians

• Without 1‐on‐1 accountability, learners have the ability to not participate in discussion

• Preceptors

• Requires >1 preceptor• Lose Socratic method due to learners asking

more high level questions• Facilitation across multiple levels of learners


Application Activity Work individually using provided worksheet #2

• Review the “start up” questions regarding team‐based teaching planning and organization questions

• Complete the sections regarding • Teaching area• Potential team members, early adopters• Scheduling• Resources required• Challenges/barriers


ASHP Appendixes for each PGY2 program

“Appendix” found at the end of each program’s “Required competency areas, goals and objectives” document

Language often refers to “didactic discussions, reading assignments, case presentations, written assignments, or direct patient care experience”• Required patient care experience• Required case‐based or topic discussion• Elective patient experience and/or topic discussion




Example ASHP Appendix – PGY2 CardiologyTopic Areas Required patient experience Required case‐based or

topic discussion approach acceptable

Elective patient experience and/or case‐based or topic discussion

Atherosclerotic disease

Atherosclerosis Acute coronary syndromes (STEMI/NSTEMI/USA) Cardiovascular testing Chronic coronary artery disease Percutaneous coronary intervention

Quality measures Peripheral arterial disease Cerebrovascular disease

‐‐‐‐

Heart Failure Acute decompensated heart failure Cardiogenic shock Cardiorenal syndrome Stable HFrEF/HFpEF Drug induced Cardiomyopathies

Cardiac transplantation Quality Measures

Cardiomyopathies Myocarditis Amyloidosis Sarcoidosis

Cardiac Critical Care

Advanced cardiac life support Hypertensive urgency/emergencies Vasopressors/inotropes

Hypothermia Intravascular hemodynamic monitoring devices (e.g., Swan Ganz)

Sedation/analgesia/delirium Acid/Base disorders Palliative care


Example ASHP Appendix – PGY2 Oncology

Hematologic malignancies• Required

• Acute lymphoblastic leukemia (ALL)• Acute myelogenous leukemia (AML)• Chronic lymphocytic leukemia (CLL)• Chronic myelogenous leukemia (CML)• Hodgkin lymphoma• Multiple myeloma• Non‐Hodgkin lymphoma

• Elective• Amyloidosis• Myelodysplastic syndromes• Myeloproliferative disorders• Primary CNS lymphoma• Waldenströms macroglobulinemia

Pediatric Malignancies • Required (These required areas may be

accomplished through didactic discussion, reading assignments, case presentations, written assignments, and/or direct patient care experiences.)

• Acute lymphoblastic leukemia • CNS Tumors • Neuroblastoma • Non‐Hodgkin lymphoma • Wilms tumor

• Elective • Ewing sarcoma • Osteosarcoma • Retinoblastoma • Rhabdomyosarcoma


Comprehensive “Topic Curriculum” – Core Principles

Standardization of “foundational” content Delivery by/involvement of most qualified preceptor in

specialty team• Subspecialty practitioners

Higher‐level discussions in the absence of younger learners Ensures lack of “donut holes” in content/practice knowledge

• Rare but important clinical scenarios do not get missed• Patient populations not present at your institution




Finding the right balance for a PGY2

“Science” “Art” Pre‐work and preparation is key to the PGY2 discussion success• Resident owns the “science”,

and appropriate interpretation of literature

• Preceptor can then bring the real world application and considerations, to bring finesse and “art” perspective


Comprehensive “Topic Curriculum” – PGY2 Cardiology

Area Topic Literature Lead Back‐Up

Coronary Artery Disease

PGY1/PY4 POD Readings (required in POD)DAPT & Early ACS

CURE; TRITON; PLATO;COMMIT; SWEDEHEART ACE/ARB Analysis (JACC 2016), FOURIER

Megan & Jonathan

Dual Antiplatelet Therapy: Duration and Patient Selection (n=5)

Required Readings:Selection: PRAGUE‐18 (JACC 2018), Consensus (Circ 2017); TRILOGY (NEJM 2012) Duration: DAPT (NEJM 2014); ACC Review (Circ 2016)

FYI Readings: CHARISMA (NEJM 2006); CURRENT‐OASIS‐7 PCI (Lancet 2010); CREDO; PLATO Geographic Sub‐analysis ; PEGASUS TIMI‐54 (NEJM 2015); DAPT Review (2017)

Megan Jonathan

Triple Antithrombotic Therapy (n=5)

Required Readings:WARIS‐II (NEJM 2002); WOEST (Lancet 2013); ISAR‐TRIPLE (JACC 2015); PIONEER‐AF (NEJM 2016); RE‐DUAL PCI (NEJM 2017)

FYI Readings: Triple Therapy Cohort (Circulation 2012)

Jonathan Megan


Comprehensive “Topic Curriculum” – PGY2 CardiologyArea Topic Literature Lead Back‐Up

Other Cardiovascular Disorders

Stroke (n=5)

Required Readings:AHA Guidelines (Stroke 2013)Adherence to 3‐4.5 hour exclusions & Outcomes: GWTG (Stroke 2014)Alteplase in Acute Stroke (Curr Atheroscler Rep 2016)AHA/ASA Rationale for alteplase inclusion/exclusion (Stroke 2016)SPORTIAS: Variability of thrombolysis (J Stroke Cerebrovasc Dis 2013)FYI Readings:Antiplatelets: ESPRIT; MATCH; PRoFESS ESPS‐2; CAPRIE; tPA: NINDS (NEJM 2002); ECASS‐3 (NEJM 2008); SAMMPRIS (NEJM 2011) Guidelines: CHEST

Leah Megan or Jonathan

Valvular Heart Disease (n=5)

Required Readings:TAVR Review (Pharmacotherapy 2018); On‐X OAC vs. DAPT (JACC 2018); Drug Therapy (Circulation 2015); VKA after Bioprosthetic Valve (JAMA 2012); On‐X Valve (JTCVS 2014)FYI Readings: Warfarin vs ASA in Bioprosthetic (Circ 2004); Apixaban TAVR (JACC CV Int 2017) Thromboemboli after Bioprosthetic Valve (JACC 1995);

Ian Philip

PAD (n=5)

Required Readings:Antiplatelet: CAPRIE (Lancet 1996); CHARISMA PAD (EHJ 2006); WAVE (NEJM 2007) Review: Intermittent Claudication (NEJM 2007); Antithrombotic Therapy (JACC 2018)Guidelines: ACCF/AHA 2011 PAD Update (JACC 2011) – read recs onlyFYI Readings: Fem‐Pop; HOPE; Systematic Review (Curr Card Rev 2009); EUCLID (2016)

Phillip Ian




Comprehensive “Topic Curriculum” – PGY2 Oncology









Hybrid learning structure that combines didactic component and team‐based learning Pharmacists/preceptors within the specialty

team may attend and receive CE credit Incorporated into a longitudinal (quarterly)

PharmAcademic evaluation• Resident peer‐to‐peer evaluations• Preceptor evaluation of residents

• Individual resident and team‐based assessments


Comprehensive “Topic Curriculum” – Other formats

Recurring group session with all program preceptors in attendance• Facilitates clinical discussion amongst preceptors that

residents can observe and engage in

Blended sessions across PGY2 programs• Infectious Disease and Critical Care “Clinical Debates”


Comprehensive “Topic Curriculum” – Planning/Scheduling

Program must commit to set schedule and participation amongst all involved• Sessions are highly prioritized, workflow adjusted

to ensure they occur• Team‐based scheduling tools are crucial

• Outlook invites, Google calendars, etc.




Comprehensive “Topic Curriculum” – Planning/SchedulingPrinciples Design Prioritization Barriers

PGY2‐specific team‐based content instruction

No language specifically directed at this concept in the ASHP Accreditation Standard for PGY2 Pharmacy Residency Programs

Possible evaluation location• Goal R1.1, Objective R1.1.5: (Creating) Design, or

redesign, safe and effective patient‐centered therapeutic regimens and monitoring plans (care plans) for patients with cardiovascular diseases.

• Criteria: • Best evidence, including clinical guidelines and the most recent literature

• Effective interpretation of literature for application to patient care


Audience Response QuestionThe most challenging barrier to implementation of these concepts will be..? Ability to free up precepting time Size of my precepting “team” Availability of precepting expertise Sustained commitment to a process Other




Active Participation Time!

Using the barriers you identified as a group, create a list of

strategies for overcoming them at your (or any) institution

(worksheet #3)


Precepting Time Barriers Longitudinal curriculum teaching can be done in

as little as 15‐20 minutes per session• Prior to patient care in the AM• During lunch breaks• Pre‐planned times where job responsibilities

are offloaded to a teammate• Pager, order verification, etc.


Size of a Precepting Team

2 preceptors = a “core curriculum” team! Divide topics and alternate sessions

• Scheduling/logistics much easier to manage Can actively recruit other qualified members

once they see the system at work




Precepting Content Expertise

Most preceptors can become a content expert in a discrete topic Establish core readings, key practice points to

be delivered, a mental POD “outline” Repetition will improve performance/delivery


Creating a Team Precepting Culture

Incorporate positive resident/student feedback• Periodic surveys

Create team goals/initiatives around precepting As precepting team “leader”, find ways to

encourage preceptor commitment and performance, support participation


Key Takeaways Incorporating a structured curriculum within the experiential setting can

bring efficiency and reduce redundancies found in traditional experiential education• Conducting an initial assessment of redundancies can help determine initial

targets

Delivery of a structured curriculum requires the buy‐in and engagement of ALL participants, including learners and preceptors• Preceptors must prioritize the times dedicated to teaching/learning for all to

derive the most benefit

Creating a well‐rounded topic list and a method to ensure the delivery of appropriate content is a good first step in building a longitudinal curricular learning experience



ASHP NPPC Session:

Team Based Teaching Strategies and Educational Curricula for Experiential Learners

Worksheet #2 – Team teaching planning

Teaching area:

PG1 or PGY2

For PGY2, which specialty: _________________________

Potential team members

Preceptors who would teach in a core, longitudinal curriculum:

Preceptor 1: ___________________________

Preceptor 2: ___________________________

Preceptor 3: ___________________________

Preceptor 4: ___________________________

Others: _______________________________

Early adopters

From the above list, which preceptor would be the first one you would approach to begin this process?

____________________________________

Scheduling

Goal number of session per week (or per month) for initial roll-out: ______________________

Length of sessions: ______________________

Day of week, time of day of sessions: __________________________

Resources required

Free response: ___________________________________

Challenges/barriers

Free response: ___________________________________



ASHP NPPC Session:


Worksheet #3 – Overcoming Barriers

Please list potential strategies for overcoming the following barriers to implementation of a team

taught core curriculum

Ability to free up precepting time

Size of my precepting “team”

Availability of precepting expertise

Sustained commitment to a process

Other



ASHP NPPC Session:


Worksheet #1

Topic Brainstorm: Core Curriculum content for PGY1 (+/- PY4) learners

Content Area (i.e. critical care, psychiatry)

Topic

Importance 1 = critical

2 = preferred 3 = optional

2018 National Pharmacy Preceptors ConferenceTeam-Based Teaching Strategies and Educational Curricula for Experiential Learners


teambased teaching strategies handout version

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