Practice makes perfect: A graduate’s reflection on curricular gaps in skill development

By Trager Hintze, PharmD; Kasidy McKay, PharmD, BCPS; Shanna K. O’Connor, PharmD

My role in the development, management, and delivery of a Medication Therapy Management (MTM) service during my 3rd professional year at Idaho State University College of Pharmacy revolutionized my education, and prepared me for Advanced Pharmacy Practice Experiences (APPE). Through delivery of this community pharmacy service, I was able to apply what I was learning in the classroom to practice.

My development through work with MTM

The MTM service was typical of those offered under Medicare Part D and involved both Complete Medication Reviews (CMRs) and targeted interventions through two major online platforms.^1-5 During this 10-month longitudinal experience, I created a workflow process, renewed national contracts, and delivered patient care. I was lead on the project and worked closely with a community-based resident. The skills in which I have seen noticeable improvement as part of this service are outlined in Table 1.

Table 1: Student perspective: Benefits of the experience

Skill	How I improved through the MTM service
Verbal Communication	Explained medications and disease states to patients in simple language. Communicated to providers actions performed and patient preferences.
Written Communication	Prescriber communication forms required concise recording of the interventions made during the MTM assessment.
Recall Ability	Consistently reviewing common medications, disease states, and monitoring parameters reinforced classroom lessons.
Clinical judgement	Knowing when to appropriately make, or not make, an intervention when speaking to a patient.
Self-awareness	Presenting patients to a pharmacist allowed for self-reflection which helped tailor education to my needs.
Managerial skills	Managed billing and reimbursement documentation.
Confidence	Frequent patient encounters and feedback from my instructor, increased my confidence for future experiences.

How I noticed a gap in the curriculum

After managing the MTM service, I had the opportunity to train another student to take over the program. As I reflected on my role in the project and how to best translate my responsibilities to another student, I recognized a curricular gap that could be remedied through course revision processes established at the college. During the first few years of the pharmacy curriculum, I perceived few opportunities to practice genuine direct patient care and there was a reliance on overly-simplistic case scenarios within the didactic courses. In the classroom, mock cases and scenarios were frequently titled with the intervention and disease state, reducing case authenticity and encouraging students to deliver an overly-scripted rote presentation rather than practice problem solving. Real patients are complex and students need to develop verbal communication skills to critically assess and determine specific interventions, based on communications with the patient. In a patient encounter, emphasizing medication knowledge is helpful, but listening to a patient’s concerns and knowing when to interject and educate the patient on their medication or disease state is even more critical. The skill of active listening is one that I also recognized a disparity between classroom and practice activities. Even though we had required interprofessional and Introductory Pharmacy Practice Experiences (IPPE), they did not contribute to my growth as much as the MTM service did. Many of these activities were unstructured and functioned more as a shadowing experience versus the full immersion that the MTM service provided.

Strategies to help your students:

1. High quality active learning strategies in didactic coursework: Incorporate an element of accountability for students across both large and small-group learning. This may include a formal deliverable or the anticipation of being called on to answer a question. Any expectation that mimics that of a real patient encounter will help better prepare students for practice. It would also be helpful to ensure the practice you’re giving students allows for some ambiguity in the outcome to encourage students to think.
2. Offer courses with real, practice-based components and early genuine patient encounters. Whether required or elective courses, push students wherever possible to get out into practice, engage with patients, and think critically. Some colleges have successfully implemented mock MTM activities into the curriculum, but the didactic curriculum can only go so far– students need genuine patient encounters. Engaging with real patients can be difficult for students because of the fear of making a mistake. Aside from well structured IPPEs, other methods to provide these critical experiences is through Objective Structured Clinical Examination (OSCEs), co-curricular activities, or simulation. These can be difficult to design and costly to organize, but I believe the students would be better served by these authentic practice experiences.

Conclusion

I recognize that not every student will have the opportunity to create a patient-centered service and that MTM opportunities may be limited. However, students can enter APPEs with more confidence to practice at a higher level if given early exposure to genuine direct patient communication through intentionally designed activities. Where mock scenarios are needed, creating scenarios as close to real life as possible could prove effective. What could you do to better help students prepare for practice?

References

1. Melody KT, Shah CJ, Patel J, et al. Implementation of a student pharmacist-run targeted medication intervention program. J Pharm Pract. 2017;30(1):109-114.
2. Eukel HN, Skoy ET, Frenzel JE. Provision of medication therapy management to
   university faculty and staff members by third-year pharmacy students. Am J Pharm Educ. 2010;74(10):Article 182.
3. Oladapo AO, Rascati KL. Review of survey articles regarding medication therapy
   management (MTM) services/programs in the United States. J Pharm Pract. 2012;25(4):457-70.
4. Hata M, Klotz R, Sylvies R, et al.  Medication therapy management services provided by student pharmacists. Am J Pharm Educ. 2012;76(3):Article 51.
5. Vande Griend JP, Rodgers M, Nuffer W. Effect of an Advanced Pharmacy Practice Experience on Medication Therapy Management Services in a Centralized Retail Pharmacy Program. J Manag Care Spec Pharm. 2017;23(5):561-565.

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