Pharmacy Schools – Hidden Curriculum?

Changes must be made in our healthcare system. Healthcare professionals must be able to provide patient-centered care by working in interprofessional teams.

This is redefining and expanding the roles of many health professions. For some disciplines, such as pharmacy, current practitioners may not feel qualified to instruct students and recent graduates in interprofessional care.

There is a lag between graduating and becoming an experienced professional trained in this new approach. As a result, a deficit of seasoned mentors may exist for many years. Will healthcare reform occur at a rate too fast for pharmacy to catch up?

How can pharmacy students efficiently transition from being in the classroom to functioning as advanced healthcare professionals capable of contributing to an interprofessional team?

A look at the formal and informal training in medicine may provide guidance on how medical students develop into professionals. Stern and Papadakis remind us that not all teaching is done in the classroom or in small group discussions.

Significant learning occurs over coffee, in the hospital, and from stories recounted of complex patients. These informal experiences are perhaps more effective in teaching ethics, professionalism, and humanism than traditional didactic lectures.

Such attributes are frequently taught in the hidden curriculum – a curriculum of rules, procedures, expectations, and fears taught through role modeling by interns and residents, often when no faculty are around.

Many of the concepts in the hidden curriculum are conveyed by the telling of parables. These stories frequently involve a difficult case or challenge the morality or ethics of a trainee. They can be powerful in their ability to convey the essence of being a professional.

In the book by Samuel Shem, The House of God, a senior resident teaches the young interns the unofficial Laws that will help them survive their training. One rule, GOMERs go to ground, is now widely recognized and resulted in fall precaution guidelines.

Generally, medical students have two didactic and two clinical years before graduation followed by three to six years of intense postgraduate training. The evolution from being a medical student to being a competent professional occurs over many years.

Most pharmacy schools in the United States have a four-year curriculum. The first three years are predominantly didactic in nature; the fourth year consists of Advanced Pharmacy Practice Experience (APPE) rotations.

The Draft Standards 2016 of the Accreditation Council for Pharmacy Education (ACPE) requires that each student complete community/ambulatory care, hospital/health system, and elective experiences.

In 2015, approximately 15,000 pharmacy students graduated. Unfortunately, there were less than 1,000 American Society of Health-System Pharmacists (ASHP) accredited PGY-1 residency slots available.

Therefore, the majority of pharmacists do not have any post-doctoral training but must be competent to practice conventional pharmacy upon graduation. The transition from being a student to being a professional occurs over a few months.

During this short period, who will be their role model?  What parables will be passed on? Many will have limited exposure to the type of hidden curriculum that medical students encounter. How then, does a pharmacy student become a professional?

Preceptors are the answer! They are a valuable resource, yet preceptors may not realize how important their knowledge and experiences are. Students need to see firsthand how senior practitioners resolve issues with third party payers, interact with physicians and patients, or manage personnel problems.

During a busy, chaotic day a preceptor can demonstrate to the student how to differentiate the important from the benign and collaborate with the patients care team. This is part of our hidden curriculum.

In the classroom, teachers strive to prepare the students for actual practice by using problem-based learning or role playing. These contrived vignettes can never generate the intense emotions and uncertainties that real problems create.

The need for developing professional attitudes and behaviors of students external to the classroom is addressed in the ACPE Draft Standards 2016, Standard 14 (Co-Curriculum).

The definition of interprofessional care requires contributions from professionals in at least two disciplines.  Pharmacists are often excluded or overlooked by other professionals, and the public is frequently unaware of their capabilities and training.

Retail pharmacists are highly trained professionals who interact with their patients on a regular basis and can provide vital information regarding a persons health status. The profession does not have five or ten years for the new generation to become active members in team-based care.

As educators, we must ensure that pharmacists become professionals in time to be a part of the health care revolution. If not, the consequences could be catastrophic.

References:

Doherty RB, Crowley RA, for the Health and Public Policy Committee of the American College of Physicians. Ann Intern Med 2013;159.

Stern DT, Papadakis M. The developing physician-Becoming a professional. N Engl J Med. 2006;355:1794-1799.

Samuel Shem. The House of God. 1979. ISBN 0-440-13368-8.

Accreditation Standards and Key Elements for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Accreditation Council for Pharmacy Education. Draft Standards 2016, released 2-3-2014.