- The expanding scope of pharmacists' practice offers many opportunities to improve patient care. (Tannenbaum, Tsuyuki) -
Tannenbaum C, Tsuyuki R. The expanding scope of pharmacists' practice: Implications for physicians. Can Med Assoc J. 2013. DOI:10.1503/cmaj.121990.
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Conclusion
The goal of this study was to create a communication-training program in the pre-clerkship study that equipped students with the skills to improve patient care and health outcomes. After receiving the training, the students were encouraged to communicate with knowledge and skill and to initiate patient-focused conversation in their pharmacy clerkship. The extra communication skill training focused on appropriate and effective communication in a short amount of time that was based on patient needs and directed to specific health outcomes for the patient. With this communicative purpose, the pharmacy students entered the clerkship, ready to use their scientific understanding of the human body, disease states, and pharmaceutics, as well as the newly acquired communication skills to enhance patient care. However, the pharmacy clerkship did not offer opportunities for all the students to practice these new communication skills, and many of them went through the clerkship focused mainly on dispensing duties. This gap between the pre-clerkship education and the reality of communication opportunities in clinical practice resulted in student responses that reflected a perceived inability and lack of confidence to communicate with patients. A change in the clerkship with the new communication-focused guidelines of 2019 will permit students to use the skills learned in the pre-clerkship training directly in the pharmacy clerkship. As the role of the pharmacist continues to expand and grow in Japan, transforming the pre-clerkship program and the clerkship experience will allow pharmacy students to develop the skills that equip them to be effective communicators in their practice.
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Recommendations for Pharmacy Education
This study of communication training in the pre-clerkship education for a positive experience in the pharmacy clerkship led to three proposals for future pharmacy education. They include changes to the present dispensing-focused clerkship guidelines and experience, a pre-clerkship program that reflects current pharmacy practice, and post-clerkship OSCE testing.
Changing the Clerkship Experience
The clerkship guidelines until now left the preceptor responsible for deciding if and when a student could move from dispensing practice at the back of the pharmacy to the counter to practice patient education and patient interaction skills. If the preceptor felt the student was not ready, there was no opportunity to communicate directly with patients. The new guidelines that will take effect in spring of 2019 bring communication to the forefront of the pharmacy clerkship experience. Even in the hospital, the students will have more opportunities to interact with patients and other medical staff on the various wards. The preceptors have voiced concerns that this change will put both the patient and the student "at risk" because the pre-clerkship education does not adequately prepare the students for face-to-face communication with patients. The eight-week communication-training course within the pre-clerkship program outlined in this study offers a temporary solution to this educational dilemma by encouraging students to develop skills, reflect, and practice for patient care before their clerkship experiences.
The Japanese pharmacy schools offer very little early exposure to pharmacist experiences during the first three years of the education program. In the first year, they observe a few hours in a community pharmacy, followed by a few hours in a hospital pharmacy. They are not permitted to interact with patients during this visit. The
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primary goal of the exposure is to place students physically in the pharmacy to observe a working pharmacist. Until the fifth year when they enter their clerkships, the students are protected from the reality of the profession in a risk-free environment, such as the classroom and laboratory. The pre-clerkship studies offer the students a chance to perform in role-play activities at a counter using set dialogues and case studies, and this creates the basic awareness of necessary skills before entering the pharmacy:
As community pharmacies become more involved in medication management services, students will also need to learn to communicate information in a more comprehensive manner, moving the knowledge from class learning to the real world setting, and to practice the skills while understanding the relationships with patients.1
The students are unable to comprehend the complexities and flexibility involved in communication with patients until they enter the clerkship and face the patients. As a result, some students can become very stressed out and nervous in the clerkship experience, hindering them from developing professional pharmacist’s skills and attitudes. The students should be exposed to real experiences in the pharmacy from the early years of study on.
When observing a fourth-year pre-clerkship physical assessment training class, some students refused to participate because they did not want to touch another person or to be touched, even for taking blood pressure and pulse. This "trainee resistance" or
"trainee anxiety" stems from not being exposed to the reality of the healthcare setting or experience.2 The lack of exposure to the human body and the health care system in the pre-clerkship studies could be blamed (or even a previous traumatic experience), but mostly, it reflects a lack of understanding about the role of a clinical pharmacist.
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From the first year in pharmacy school, the students should be in the pharmacist's frame of mind, wearing the white lab coat with pride, and understanding professional duties. Early exposure to physical assessment and the human body are necessary in the early years of the pharmacy program, not only restricted to the fourth-year of the pre-clerkship program. The students usually begin with opportunities to practice the learning from class in a safe, risk-free environment, such as role play activities that,
“provide an opportunity to practice and rehearse communication skills in the same way that practice with simulated patients does, without having to spend large amounts of money on training and selection of patients."2 The communicative activities in school with working pharmacists or standardized patients also provide more realistic exposure to the pharmacy setting that motivates students to pursue communication opportunities.
The change in services for patient education and patient care in the community pharmacies led the pharmacy schools in the USA to offer more exposure to the patient care services, beginning with the first professional year of the six-year PharmD program. It has been explained that, "the quality of the practice pharmacy experiences will be a direct indication of hours preparing the students to assume patient care roles," meaning that students need more time in clinical practice. 3 In the first three professional years of the pharmacy program, the students are exposed to direct interaction with patients in the pharmacy through taking medical histories and data collection. By the fourth year, they can move into professional responsibilities such as monitoring medical plans. The early exposure to the medical team's interactions also promotes a higher level of learning and understanding that each member shares responsibility for the patient's health outcomes. This training builds self-confidence and experience that support the skill development of the clerkship experience.
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Changing the Pre-clerkship Education
Many of the pre-clerkship students tend to still define the role of a pharmacist as a "druggist" or a "chemist,” not as a healthcare provider, based on the attitudes observed toward patient care and group activities in the pre-clerkship education:
The 'shopkeeper' image has been cited as a barrier to inter-professional collaboration and the public's perception of the role of pharmacists as health professionals, undoubtedly, amplified by the product sales focus of burgeoning chain, discount, and warehouse pharmacy models.4
It is also reinforced by the emphasis on the science-based learning of the pre-clerkship training years. The balance between the science-based pharmacy courses and technical compounding skills and the social and communication skills of patient care are necessary to a successful pharmacist's professional development. The compounding and dispensing focus of pharmacy training in Japan remains strong, and this is vital to the future role of pharmacy.
Robots are increasingly taking over the dispensing roles, but compounding is a trade unique to the pharmacist. "In the context of patient-centered care, compounding may contribute to professional status by being recognizable by patients and medical practitioners as a unique and valuable skill possessed by pharmacists."4 The goal is not to eliminate these technical skills from the education, but to increase the social component within the training. It is necessary to develop social skills to interact with human patients and to be prepared for the unpredictable facets of such communication, which are not possible for robots.
Team-based learning strategies should also be introduced in the first year of pharmacy school to train students how to be a responsible group member and develop
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independent study skills. Many of the students entering university from high school are still accustomed to individualized, rote learning. First-year classes often produce strong evidence of students who need social skills for participating and sharing in group activities. Initially, students can be introduced to partner activities and encouraged to use their voices for communicating to each other to solve problems. The observed response of many students is to withdraw from the encounter, rather than establishing eye contact and facing the partner while verbally expressing an idea or discussing a question. Extension of these partner activities includes adding in members and making small groups. It takes time and patience to train the students to participate in SGDs and to be flexible in solving problems that do not have just one answer. Beginning early in the six-year program with such group activities guarantees that the students will be accustomed to solving problems as a group in the advanced years.
Team-based learning also requires that each member of the group take responsibility for preparing and sharing knowledge to solve the problem. "One of the barriers to the success of integrating team-based learning was students' initial resistance to self-directed learning," because they must understand their responsibility to the team, develop critical thinking skills, and become confident in decision-making.5 The supervising faculty member assists by providing guidance and giving feedback to the students about behavior and attitude and encouraging students to prepare by doing more self-study outside of class to prepare for the group interaction. A modern trend in medical education is that of "flipped learning" where the professor supplies modules and materials online that must be reviewed and studied before class to be able to participate in class. It changes a paper-based course into a blended learning course,
"allowing learners to use classroom time to work through problems and collaborate with their peers."6 Combining the learning methods of online study at home with
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in-class group activities will prepare the students for a realistic approach to responsible group behavior.
A Post-Clerkship OSCE
The pre-clerkship training concludes with the OSCE, a practical exam to show achievement in the necessary skills for the clerkship. Following the clerkship, though, the students go through a year of preparing for the written graduation and national licensing exams, forcing distance between students and clinical practice as they focus on these knowledge-based exams. There is presently no way to know if the students are able to meet the standards of clinical practice post-clerkship. The clerkship provides an opportunity to practice the learned skills with patients in a real setting and receive feedback to improve those skills, which leads to "the highest level of learning" with the clinical practice.5 A post-clerkship OSCE would give the students a chance to showcase their skills and attitudes, proving their readiness for interaction with patients as professional pharmacists.
From 2020, all medical universities in Japan will adopt a standardized post-clerkship OSCE to ensure that students are ready for medical practice with the basic skills for a medical interview, physical exam, and clinical procedures.7 The post-clerkship OSCE will evaluate achievement in the clinical skills to practice professionally in hospitals and clinics. A post-clerkship test on communication skills guarantees that students met the clinical standards by the end of the clerkship.8 Those skills go beyond initial patient interviews to discussions with the patient and the medical team about health care management and therapy plans. It is recommended that a pharmacy post-clerkship OSCE also be included in the six-year program of study, challenging students to develop confidence in their role as pharmacists in dispensing, compounding, and providing patient care and patient education before graduation. The
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changes in pharmacy practice are advancing rapidly toward patient care and health reforms, forcing the pharmacy education programs to adjust and prepare students for the success in the clinical role of the modern pharmacist.
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References
1. McDonough RP, Bennett MS. Improving communication skills of pharmacy students through effective precepting. Am J Pharm Educ. 2006; 70(30): Article 58.
2. Lane C, Rollnick S. The use of simulated patients and role-play in communication skills training: A review of literature to August 2005. Patient Educ Counsel. 2007;
67:13-20. DOI: 10.1016/j.pec.2007.02.011
3. Kennerly J, Weber RJ. Role of pharmacy education in growing the pharmacy practice model. Hosp Pharm. 2013;48(4):338-342.
4. Giam JA, McLachlan AJ, Krass I. Community pharmacy compounding: Impact on professional status. Int J Clin Pharm. 2011; 33:177-182.
5. Ofstad W, Brunner LJ Team-based learning in pharmacy education. Am J Pharm Educ. 2013;77(4):70. DOI: 10.5688/ajpe77470
6. Fraser S, Davies W, Enokida K, Tatsukawa K. Using ICT to create a medical English flipped learning course. J Med Eng Educ. 2017;16(3):62-67.
7. Son D, Kaneko E. How to evaluate ability with OSCE at graduation. [in Japanese]
Igaku-Shoin: Tokyo. 2017 Mar 13;3215. Available from:
http://www.igaku-shoin.co.jp/paperDetail.do?id=PA03215_01.
8. Yoshida M. Implementation and challenges of objective structure clinical examination after clinical clerkship. [in Japanese]. Igaku kyouiku. 2015;
46(1):18-22. Available from: http://doi.org/10.11307/mededjapan.46.1_18.
Acknowledgements
- Our perceptions of others affect the way we communicate with them. (Medina) -
Medina MS. Teaching self-concept and self-esteem in a clinical communications course. Am J Pharm Educ. 2006;70(5): Article 99.
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Acknowledgements
First of all, I would like to thank the research team at Kyushu University who met regularly with me and guided me through this research project since 2013. Dr.
Takao Shimazoe supervised the project through the process of creation to completion, and welcomed me into his lab (臨床育薬分野). Dr. Daisuke Kobayashi instructed me in the writing process and provided support with the data analysis. Dr. Motofumi Yoshida, now at the International Welfare University in Chiba, acted as advisor on medical education in Japan and educational research. Dr. Toshio Kubota, now at Daiichi University of Pharmacy, advised me from the beginning on the research process, presentations, and helped with translating the questionnaire and papers. Ms.
Yui Urayama, who was an undergraduate student, helped me with translations, as well as got the ball rolling on statistical analysis with the initial data. Dr. Junji Kishimoto from the medical faculty instructed me in the statistical analysis. Also, Dr. Makoto Kikukawa from the medical education department at Kyushu University allowed me to join the medical education research camp for three consecutive years and provided important advice on improving the project and the data analysis.
I would also like to thank Daiichi University of Pharmacy for providing me with a venue to do my research and time to work on this project over the five years.
The support of the ethics committee, the pharmacy professors, and the administration allowed me to collect workable data and to try out new ideas in my teaching and research. Dr. Hironori Aramaki, Dr. Toshio Kubota, Dr. Masao Ohmitsu, Dr. Hiroshi Moriuchi, Dr. Yukiko Fujii, and Dr. Wakano Ogawa continually offered guidance and support in making this project successful.
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Of course, a special "thank you" goes to Dr. Chiaki Hara (Daichi University of Pharmacy) and the late Dr. Thomas Mattei (Duquesne University) who both believed in me and challenged me to do this PhD in the first place.
Dr. Hiroshi Okada introduced me to clinical pharmacy research and taught me about pharmacy education, research, and the work of community pharmacists. He inspired me to move forward in educational research and encouraged me in my teaching, as well as my research, to find new ways to teach the pharmacy students.
Thank you for the advice and support.
I extend the most grateful "thank you" to my friends and family who assisted regularly with editing and proofreading throughout the past few years. I especially would like to thank my husband, Hiroshi Nishiyama, for being patient and supportive the past five years. He was my sounding board and encouraged me to never give up.
Denise Epp
Appendices
Appendix 1: Daiichi University Ethics Review Board Statement Appendix 2: Kyushu University Ethics Review Board Statement Appendix 3: Research Protocol (in Japanese)
Appendix 4: Mini-Test Questions
Appendix 5: Course Resources and Materials Appendix 6: Questionnaire Reference List
Appendix 7: Original Communication Questionnaire (in English) Appendix 8: Final Version Year 4 Communication Questionnaire (in
Japanese)
Appendix 9: Trial Communication Questionnaire (in Japanese)
Appendix 10: Final Version Year 5 Communication Questionnaire (in English)
Appendix 11: Final Version Year 5 Communication Questionnaire (in Japanese)
Appendix 12: Pharmacy Clerkship Student Daily Report Appendix 13: Pharmacy Clerkship Student Progress Report Appendix 14: Pharmacy Clerkship Final Preceptor Report Appendix 15: List of Figures and Tables
Appendix 1. Daiichi University of Pharmacy Ethics Review Board Statement
Appendix 2. Kyushu University Ethics Review Board Statement
Appendix 3. Research Protocol (in Japanese)
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「研究計画書」
0. 題目
臨床薬学の実務実習を改善するためのプレ実務実習・薬学教育プログラムにおける コミュニケーション・トレーニング
研究責任者：九州大学大学院薬学研究院臨床育薬学 准教授 島添 隆雄 共同研究者：九州大学大学院医学研究院医学教育学 教授 吉田 素文 九州大学大学院薬学研究院臨床育薬学 准教授 窪田 敏夫 九州大学大学院薬学研究院臨床育薬学 助教 小林 大介 九州大学大学院薬学府臨床育薬学 大学院生 Denise A. Epp 九州大学薬学部臨床薬学科 学部 5 年生 浦山 由衣
1. 研究目的
プレ実務実習のコミュニケーショントレーニングが、薬局実習におけるコミュニケーシ ョンや患者指導にどのような効果をもたらすのかを評価する。
2. 研究の背景と意義
日本には薬の処方と調剤を分ける「分業」と呼ばれるシステムがあり、薬剤師に薬の調 剤という特定の役割を与えている（JPA, 2013, p24）。これは薬剤師を患者ケアやカウンセ リングの役割から遠ざけた。このため、薬剤師は薬に関すること以外のコミュニケーショ ンは期待されておらず、多くの薬学生はプレ実務実習で薬に関するコミュニケーションし か教わっていない。その一方で「将来薬剤師は病院や地域のコミュニティでヘルスケアチ ームの一員としてより大きな役割を果たすことが期待されている」と報告された（p16）。
またある研究では、患者の健康状態が薬剤師とのコミュニケーションや薬剤師から受けた 生活の質・アドヒアランスについての指導によって良くなることを示した（Babinec 2010, Mesquita 2010, Okada 2013）。もしプレ実務実習のコミュニケーショントレーニングで病 気や薬についての知識と同時に、生活習慣のアドバイスなどについて学べるならば、その ようなコミュニケーションは将来薬剤師業務や医療システムに大きな利益を与えるだろう。
本研究では、4 年次のプレ実務実習でコミュニケーショントレーニングを受けたグルー プと受けていないグループにおいて、5 年次の薬局実習後にコミュニケーションに関する アンケートを行い、その結果を比較することにより、コミュニケーショントレーニングが 薬局実習におけるコミュニケーションや患者指導にどのような効果をもたらすのかを評価 する。
3. 被験者の選択あるいは対象
・適格基準
グループ 1：第一薬科大学 2015 年度の 4 年生約 100 人
（2015 年春にコミュニケーショントレーニングを受け、5 年次に薬局実習へ行く）
グループ 2：第一薬科大学 2015 年度の 5 年生約 100 人
（4 年次にコミュニケーショントレーニングを受けず、薬局実習を完了している）