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Geoffrey Harding is on the staff
of Peninsula College of Medicine and Dentistry, Exeter
Kevin Taylor is on the staff
of the School of Pharmacy, University of London |
The Broad spectrum feature is
open to any reader. Contributions of around 1,100 words commenting
on topical issues
may be posted to Graeme Smith, managing editor, or
e-mailed to graeme.smith@pharmj.org.uk for consideration
|
Contemporary practice increasingly requires pharmacists to exercise
their judgement and make decisions, many of which are necessarily based
on
their professional expertise, value structures and experience rather
than exclusively on known facts and evidence. This raises questions about
the appropriateness of undergraduate training in equipping pharmacists
to make these judgements and decisions, which are not exclusively founded
on codifiable facts.
We recently conducted interviews with groups of first-year and third-year
students at four UK pharmacy schools to explore their experiences of
undergraduate education and their expectations of professional practice.1,2 These students indicated that, in the initial years of the MPharm course,
a clearly perceived imperative was for them to acquire a large established
body of knowledge, most often by a process of rote learning. The formative
education of pharmacists, then, involves a considerable emphasis on the
necessity to accumulate and understand facts and principles.
Only after acquiring this immense “knowledge base” are students
introduced to the application of this knowledge in the context of professional
practice. This incremental model of pharmacy education correlates with
the traditional model of medical education, which had distinct pre-clinical
years followed by years of clinical training. We identified a predominant
perception among the pharmacy undergraduates we interviewed that the
professional activities of pharmacists, and consequently the aim of the
pharmacy degree, rested on the acquisition of scientific knowledge and
the scientific skills of precision and accuracy, particularly in relation
to the process of dispensing medicines.
As we talked with students, a recurrent theme that emerged was their
conceptualisation of a highly constrained professional identity for pharmacists,
exemplified by a perceived imperative to avoid at all costs the risk
of making mistakes in practice. That is, successful professional practice
was defined in negative terms — “not making an error” — rather
than in terms of positive outcomes. The pharmacy degree was seen by students
as a vehicle for transmitting the facts, principles and skills required
to eliminate the risks of mistakes associated with dispensing, which
they viewed as the key role of pharmacists:“
… it’s about being professionally competent … not making
a mistake because that could kill someone.”
Consequently, some students had formulated a restrained, risk averse
model of pharmacy practice. Traditional modes of law, ethics and practice
teaching, clearly still present in contemporary courses, seem to glory
in tales of miscreant pharmacists being struck from the Register, reinforcing
the message that mistakes must at all times be avoided: “So you
see when people have gone wrong, and how they have been punished and
taken off the Register.”
Students appear to commence their training with a developed sense of
their professional identity being founded upon absolutist principles.
These involve adherence to formulaic practices — most obviously
in ensuring that their dispensing practices are safe and effective. This
would suggest that, at least in the first three years of their degree,
they are inculcated with a tendency towards risk aversion, ie, actively
to avoid risk.
Clearly, averting or minimising as far as is possible any risk of errors
in dispensing is entirely appropriate and, in practice, risk minimisation
in this largely technical activity may be achieved with the use of standard
operating procedures, computer technology and dispensing robots.
Yet learning how to manage health-related risks associated with medicines
use is equally important, as pharmacists are called upon to advise patients
and other practitioners regarding medicines use, often in the absence
of all the pertinent facts, and in so doing may also be expected to communicate
the attendant risks of medicines use. However, in contrast to undergraduate
medical training, where from the outset students are confronted with
how best to manage the risks facing patients and practitioners, pharmacy
undergraduates receive relatively little exposure to, and training in,
risk management.
Comparison with the contemporary model of medical education bears further
scrutiny. The modern medical curriculum places medical students in general
practice right from the start of their training in order that they observe
medicine being practised. This exposes medical students to practising
role models and practice environments where they can learn the “facts” associated
with professional practice in the context of how medical knowledge is
applied to patients.
Problem-based learning styles support and reinforce
a sense that professional practice is as much to do with dealing with
issues that require an informed appropriate value judgement as it is
with identifying a definitive solution. In such cases, making an appropriate
decision based on a set of professional values is not the same as making
the absolutely correct decision. Although some pharmacy schools are attempting
to address the context of learning using techniques such as problem-based
learning and inclusion of practice placements these are the exception
rather than the norm.
The ability to balance the application of certain principles and specialist
knowledge with judgements based on managing uncertainty, marks pharmacists
out as professionals. In practice, absolute facts and uncertainty are
not independent entities. Currently, the uncertainty associated with
professional practice is either poorly represented in MPharm curricula,
or is introduced to students late in the MPharm course after the “facts” associated
with the pharmaceutical sciences and the legal, accurate and ethical
practice of pharmacy have been learnt and internalised by the students.
Inculcation
of absolutist principles by students from the outset of their training
potentially undermines future confidence in developing professional
judgement formed in the absence of all the facts. In turn, an opportunity
is missed to facilitate students in developing an identity at the core
of which is an ability to combine knowledge and practice uniquely in
order to generate a professional judgement. We would argue that the pharmacy
curriculum should develop such that, as pharmacists’ activities
expand, they acquire the confidence to manage uncertainty and risk. References
1. Taylor KMG, Harding G. How do pharmacy students learn? Final Report
to the Pharmacy Practice Research Trust. London: School of Pharmacy,
2006.
2. Taylor KMG, Harding G. The pharmacy degree: the student experience
of professional training. Pharmacy Education 2007;7:83–8. |
The
Pharmaceutical Journal