Letters from Pharmacy Preceptors : Pearls for Success [1 ed.] 9781585286461, 9781585286454

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Letters from Pharmacy Preceptors PEARLS FOR SUCCESS Joshua N. Raub, PharmD, BCPS Clinical Pharmacist Specialist - Internal Medicine Program Director, PGY1 Pharmacy Residency Detroit Receiving Hospital & University Health Center Detroit, Michigan

Cathy L. Walker, BS Pharm Assistant Director, Education and Training Residency Program Director, PGY1 Pharmacy Department of Pharmacy The Johns Hopkins Hospital Baltimore, Maryland

Sara J. White, MS, FASHP Director of Pharmacy (Ret.) Stanford University Hospital and Clinics Palo Alto, California

Any correspondence regarding this publication should be sent to the publisher, American Society of HealthSystem Pharmacists, 4500 East-West Highway, Suite 900, Bethesda, MD 20814, attention: Special Publishing. The information presented herein reflects the opinions of the contributors and advisors. It should not be interpreted as an official policy of ASHP or as an endorsement of any product. Because of ongoing research and improvements in technology, the information and its applications contained in this text are constantly evolving and are subject to the professional judgment and interpretation of the practitioner due to the uniqueness of a clinical situation. The editors and ASHP have made reasonable efforts to ensure the accuracy and appropriateness of the information presented in this document. However, any user of this information is advised that the editors and ASHP are not responsible for the continued currency of the information, for any errors or omissions, and/or for any consequences arising from the use of the information in the document in any and all practice settings. Any reader of this document is cautioned that ASHP makes no representation, guarantee, or warranty, express or implied, as to the accuracy and appropriateness of the information contained in this document and specifically disclaims any liability to any party for the accuracy and/or completeness of the material or for any damages arising out of the use or non-use of any of the information contained in this document.

Vice President, Publishing: Daniel Cobaugh Editorial Project Manager, Special Publishing: Ruth Bloom Production Manager: Johnna Hershey Cover & Page Design: David Wade Editorial Consultant: Toni Fera, BS Pharm, PharmD Library of Congress Cataloging - in - Publication Data Names: Raub, Joshua N., editor. | Walker, Cathy L., editor. | White, Sara J., 1945- editor. Title: Letters from pharmacy preceptors : pearls for success / Joshua N. Raub, Pharm.D., BCPS,Clinical Pharmacist Specialist - Internal Medicine, Assistant Director, PGY1 Pharmacy Residency, Detroit Receiving Hospital & University Health Center, Cathy L. Walker, B.S. Pharm, Assistant Director, Education and Training, Department of Pharmacy, The Johns Hopkins Hospital, Sara J. White, MS, FASHP, Director of Pharmacy (Ret.), Stanford University Hospital and Clinics, Past President ASHP,Palo Alto, California. Description: Bethesda : ASHP, [2019] | Includes bibliographical references. | Summary: “The Work will be led by Co-Editors Joshua Raub, Sara J. White, and Cathy Walker. It will be comprised of 22 letters from successful pharmacy preceptors in various types of practice roles and organizations. Contributors would be drawn from various aspects of health-system pharmacy practice (clinical, informatics, leadership, ambulatory, etc.) as well as academia, corporate, and federal service, etc., and include winners of the ASHP Residency Excellence award that recognizes the achievements of residency programs and practitioners who have demonstrated excellence and leadership in the training of pharmacy residents. In addition to reflecting on their experiences, the contributors will be asked to share what has inspired them to be preceptors and the rewards of service to learners”-- Provided by publisher. Identifiers: LCCN 2019031853 (print) | LCCN 2019031854 (ebook) | ISBN 9781585286454 (paperback) | ISBN 9781585286461 (adobe pdf) Subjects: LCSH: Pharmacy--Study and teaching. | Medicine--Study and teaching (Preceptorship) Classification: LCC RS110 .L48 2019 (print) | LCC RS110 (ebook) | DDC 615.1076--dc23 LC record available at https://lccn.loc.gov/2019031853 LC ebook record available at https://lccn.loc.gov/2019031854

© 2019, American Society of Health-System Pharmacists, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without written permission from the American Society of Health-System Pharmacists. ASHP is a service mark of the American Society of Health-System Pharmacists, Inc.; registered in the U.S. Patent and Trademark Office.

ISBN: 978-1-58528-645-4



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DEDICATION This book is dedicated to each pharmacy student and resident who makes precepting possible. The profession of pharmacy continues to expand its impact on the delivery of safe and evidenced-based patient care. The role of the preceptor in training the future of our profession is crucial for teaching the art and science of pharmacy.

ACKNOWLEDGMENTS We are thankful for the contributions of the PREA recipients (program, preceptor, and new preceptor) for their involvement in this book and for serving as role models in advancing our profession. We want to express our sincere gratitude to Ruth Bloom, Daniel Cobaugh, Elaine Jimenez, and their colleagues in ASHP Publishing for their expertise and patience while developing this book.

TABLE OF CONTENTS

Foreword.................................................................................................................................................... v Barbara B. Nussbaum, BS Pharm, PhD and Janet A. Silvester, PharmD, MBA, FASHP

Preface..................................................................................................................................................... viii

Letters Nicole M. Acquisto, PharmD, FCCP, BCCCP....................................................................1 Margaret Chrymko, BS, PharmD, MA, RPh, FASHP................................................... 7 Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP..............................................13 Stephen F. Eckel, PharmD, MHA, BCPS.........................................................................19 Joshua J. Elder, PharmD, BCPS, BCOP..........................................................................25 Brian L. Erstad, PharmD, BCPS, FASHP .......................................................................31 Rachel M.F. Heilmann, PharmD, BCPS.......................................................................... 37 Emily Kosirog, PharmD, BCACP......................................................................................43 Robert J. Kuhn, BA, BS, PharmD, FKSHP, FPPAG, FCCP, FASHP..........................49 Dorothy McCoy, PharmD, BCPS AQ-ID......................................................................... 53 Eric W. Mueller, PharmD, FCCP, FCCM......................................................................... 57 Jennifer M. Namba, PharmD, BCPS................................................................................63 Elizabeth Anne Neuner, PharmD, BCPS, BCIDP.........................................................69 Beth Bryles Phillips, PharmD, BCPS, BCACP, FCCP, FASHP................................... 75 Jane M. Pruemer, PharmD, BCOP, FASHP.................................................................. 81 Joshua N. Raub, PharmD, BCPS...................................................................................... 87 Carol J. Rollins, MS, RD, PharmD, BCNSP, FASPEN, FASHP..................................93 Arthur A. Schuna, MS, FASHP ........................................................................................99 Emmanuelle Schwartzman, PharmD, APh, BCACP, CDE...................................... 105 Amy L. Seybert, PharmD, FASHP, FCCP, CHSE...........................................................111 John Valgus, PharmD, MHA, BCOP............................................................................... 117 Lisa Hall Zimmerman, PharmD, FCCM, BCPS, BCNSP, BCCCP.......................... 123

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FOREWORD Barbara B. Nussbaum, BS Pharm, PhD and Janet A. Silvester, PharmD, MBA, FASHP

Pharmacy Residency: Past and Future The contributions of residency training to advancing pharmacy practice have been significant and are considered to be foundational to strong pharmacy patient care across all healthcare settings. Residency program accreditation began more than 50 years ago, but residency training in the form of internships began in the 1930s.1 During the early years of residency training, pharmacy practice and, therefore, residency training, focused largely on the preparation and distribution of pharmaceuticals. Healthcare delivery and systems evolved over the decades, as did the profession of pharmacy. Today and into the future, the need for pharmacy specialists is critical due to the complexity of medication therapy, care delivery across the continuum of practice settings, and increasing involvement of pharmacists in optimizing care outcomes. The ASHP House of Delegates passed a policy that by 2020, all new pharmacy graduates should be required to complete a postgraduate year (PGY) 1 residency to provide direct patient care. To meet this goal, ASHP and the profession have expanded the number of accredited residency programs and the number of residents per program. The ASHP Foundation began funding residency expansion grants in 2011 through the support of donors. All of these efforts are showing results with a 43% expansion in programs in the past 5 years. ASHP currently accredits nearly 2,500 pharmacy residency programs, including 26 different PGY2 specialty areas of practice. PGY1 programs now exist in hospitals, clinics, community pharmacy, and managed care practice settings. PGY1, PGY2, and combined programs continue to grow. Although the demand continues to surpass the supply of residency positions, we are getting closer as almost 5,100 residents are expected to graduate in 2020. PGY2 program growth has outpaced PGY1 growth, supporting the market demand for pharmacists with advanced training to fill critical roles on the patient care team. Comparing 2019 to 2009, overall positions and programs have increased by 128%. PGY1 programs have grown by 92%, and positions have grown by 105%. PGY2 programs have grown by a staggering 222% and positions by 241%, all in the last decade. We have seen the addition of novel practice areas emerge as new PGY2 specialty programs, including pharmacogenomics and healthcare outcomes and analytics. These new training programs will prepare pharmacists for practice in areas such as precision medicine and decision support guided by artificial intelligence. Residency training continues to advance the preparation of pharmacists for practice today and tomorrow.

Pharmacy Residency Excellence Awards Leaders from practice, education, industry, ASHP, and the ASHP Foundation acted on a shared vision that residency training is one of the most important factors in advancing the profession of pharmacy and that recognizing excellence can serve as a catalyst to spread best practices. Since the first offering in 2006, the Pharmacy Residency Excellence Awards program has been administered by the ASHP Foundation and was made possible through continuous support from Amgen, Inc. No other national program recognizes excellence and leadership in the training and mentoring of pharmacy residents. ASHP-accredited programs meet rigorous standards to ensure that residency training prepares pharmacists to achieve professional competence in the delivery of patient-centered care and general pharmacy services and for PGY2 programs, competence in a specialized practice area. Preceptors are critical factors for success. The Residency Excellence Awards recognize excellence in programs and preceptors. New and established preceptors are recognized in separate categories, with the latter demonstrating sustained contributions to residency training. Like the residency accreditation process, submitting an application for the awards’ program provides an opportunity to assess, reflect, learn, v

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and celebrate. Recipients are selected annually in the three categories by an external panel of past award recipients using established criteria. Since 2006, 39 preceptors, new preceptors, and programs have been recognized for their excellence. Their best practices have been shared with thousands of healthcare providers through webinars, articles, educational sessions at ASHP meetings, and letters in this book. Preceptorship is central to the training of pharmacy residents.

In the Words of Residents Going above and beyond their primary precepting roles of instructing, modeling, coaching, and facilitating, preceptors are leaders in health systems, communities, and the profession with a record of service and achievement in practice, research, scholarship, and advocacy. A deeper understanding of a preceptor’s excellence shines through in the words of their residents whose letters of support accompany each submission. The word cloud shown below was created with NVivo 12 using a sample of resident letters analyzed for similar words and themes. The alignment of preceptors with what they do has had a profound and enduring influence on their residents, colleagues, programs, and our profession. Their legacy of excellence is sure to play a pivotal role as residency training expands to meet the complex needs of patients and advance the profession of pharmacy.

Reference 1.

Zellmer WA. Creation of the ASHP residency accreditation program: the choices of early leaders. Am J Health-Syst Pharm. 2014; 71:1183–9.

Pharmacy Residency Excellence Recipients Year

Preceptor

New Preceptor

2006

Brian L. Erstad, PharmD, BCPS, FASHP

John Valgus, PharmD, MHA, BCOP

2007

Arthur A. Schuna, MS, FASHP

Eric W. Mueller, PharmD, FCCP, FCCM

2008

Cindy J. Wordell, BS, PharmD, BCPS, FASHP

Susan L. Davis, PharmD

2009

Amy L. Seybert, PharmD, FASHP, FCCP, CHSE

Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP

2010

Beth Bryles Phillips, PharmD, BCPS, BCACP, FCCP, FASHP

Jennifer M. Namba, PharmD, BCPS

2011

Margaret Chrymko, BS, PharmD, MA, RPh, FASHP

Dorothy McCoy, PharmD, BCPS AQ-ID

2012

Carol J. Rollins, MS, RD, PharmD, BCNSP, FASPEN, FASHP

Elizabeth Anne Neuner, PharmD, BCPS, BCIDP

2013

Jane M. Pruemer, PharmD, BCOP, FASHP

Nicole M. Acquisto, PharmD, FCCP, BCCCP

2014

Robert J. Kuhn, BA, BS, PharmD, FKSHP, FPPAG, FCCP, FASHP

Rachel M.F. Heilmann, PharmD, BCPS

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LETTERS FROM PHARMACY PRECEPTORS: PEARLS FOR SUCCESS

2015

Stephen F. Eckel, PharmD, MHA, BCPS

Suprat Saely Wilson, PharmD, BCPS

2016

Sandra Kane-Gill, PharmD, MS, FCCM, FCCP

Joshua N. Raub, PharmD, BCPS

2017

Emmanuelle Schwartzman, PharmD, APh, BCACP, CDE

Joshua J. Elder, PharmD, BCPS, BCOP

2018

Lisa Hall Zimmerman, PharmD, FCCM, BCPS, BCNSP, BCCCP

Emily Kosirog, PharmD, BCACP

Program Recipients Year

Residency Program Director

Program and Institution

2006

Steve S. Rough, MS, RPh, FASHP

University of Wisconsin Hospital and Clinics PGY1/PGY2 Health System Pharmacy Practice Administration Madison, Wisconsin

2007

Kelly M. Smith, PharmD, FCCP, FASHP

University of Kentucky HealthCare PGY1 Pharmacy Lexington, Kentucky

2008

Dominic Ragucci, PharmD

Medical University of South Carolina and College of Pharmacy PGY1 Pharmacy Charleston, South Carolina

2009

Rick H. Couldry, MS, RPh, FASHP

The University of Kansas Hospital PGY1/PGY2 Health System Pharmacy Practice Administration Kansas City, Kansas

2010

John S. Clark, PharmD, MS, BCPS, FASHP

University of Michigan Hospitals and Health Centers and College of Pharmacy PGY1 Pharmacy Ann Arbor, Michigan

2011

Shantel M. Mullin, PharmD, BCPS

University of Utah Hospitals and Clinics PGY1 Pharmacy Salt Lake City, Utah

2012

Joanne S. Heil, PharmD, BCPS

Thomas Jefferson University Hospital PGY1 Pharmacy Philadelphia, Pennsylvania

2013

Denise K. Lowe, PharmD, BCPS

Virginia Commonwealth University Health System PGY1 Pharmacy Richmond, Virginia

2014

Elizabeth A. Chester, PharmD, MPH, FCCP, BCPS

Kaiser Permanente Colorado PGY2 Ambulatory Care Pharmacy Denver, Colorado

2015

Steven C. Stoner, PharmD, BCPP

Providence Health & Services, Oregon Region PGY2 Ambulatory Care Pharmacy Portland, Oregon

2016

Patrick D. Fuller, PharmD, BCPS, FASHP

Nebraska Medicine PGY1 Pharmacy Omaha, Nebraska

2017

Michelle W. McCarthy, PharmD, FASHP

University of Virginia Health System PGY1 Pharmacy Charlottesville, Virginia

2018

Jennifer D. Twilla, PharmD, BCPS

Methodist University Hospital PGY1 Pharmacy Memphis, Tennessee

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PREFACE

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receptorship is both an art and a science, but like any skilled professional it is crucial to have the right tools to master the trade. Currently, ASHP has standards in place for the minimum requirements to serve as a pharmacy resident preceptor. Along with these standards, residency programs are required to provide and monitor programs aiding in preceptor development. Executing the role as a preceptor, however, requires a diverse set of skills and an adaptive teaching philosophy. In our roles as preceptors and program directors, we—as editors—understand the vital role of preceptors in residency training. They are the core of the program. The successful mastery of residency goals and objectives are instructed, modeled, coached, and facilitated through the eyes of a preceptor. We rely on their expertise, patience, and assessment of our residents as they navigate the challenging pathway of pharmacy residency training. This book is intended to help guide both new and tenured preceptors to further develop their skills as pharmacy educators. Its conception was the result of Joshua Raub identifying a void in the literature for precepting pearls and a professional need to share best practices. When selecting our authors, we chose previous recipients of the ASHP Foundation’s Pharmacy Residency Excellence Award: Preceptor and New Preceptor recipients. Their peers have recognized these individuals as leading role models for precepting in the profession of pharmacy. The application process for these awards is competitive, requiring applicants to provide an intimate description of their teaching style, approach to precepting, and residency contributions. Each recipient demonstrates a unique skill that has aided in his or her role as a preceptor. These skills provided the impetus for this book. You will discover a collection of precepting pearls from individuals recognized as experts in the art and skill of precepting. Their advice and stories are derived from years of precepting pharmacy students and residents. This compilation of precepting pearls is derived from the collective experience of precepting 2,148 residents. Topics include: • • • • • • • • • • •

Socratic teaching Creating a teaching philosophy Interdisciplinary involvement of learners Importance of accreditation Avoiding burnout Precepting Millennials Preceptor development plans Simulator training Mentorship Coaching Involving residents in academic courses

Letters from Pharmacy Preceptors joins the ASHP series of personal letters books created to inspire pharmacists through all stages of their professional journey: Letters to a Young Pharmacist: Sage Advice on Life & Career from Extraordinary Pharmacists; Letters from Rising Pharmacy Stars: Advice on Creating and Advancing Your Career in a Changing Profession; Letters from Pharmacy Residents: Navigating Your Career; and Letters from Women in Pharmacy: Stories on Integrating Life and Career. The editors were chosen based on their sustained contribution to residency training. Joshua N. Raub, a PREA New Preceptor recipient (2016) has served as PGY1 Residency Coordinator, Assistant Program Director, and Program Director at the Detroit Medical Center to nearly 100 residents. Cathy L. Walker currently serves as the PGY1 Program Director and Assistant Director of Education at The Johns Hopkins Hospital. Her career has focused on the training and development of scores of pharmacy residents. Sara J. viii



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White has directly precepted over 100 residents during her career in addition to serving as ASHP President (1996) and receiving the Harvey A.K. Whitney Award (2006). These pearls describe methods to improve precepting across the entire continuum of pharmacy training and apply to both students and residents. We believe that being an excellent preceptor requires lifelong learning while appreciating and adopting best practices from our colleagues. We are excited to share these precepting pearls with you and hope they aid in your continued development as a pharmacy preceptor. Respectfully, Joshua N. Raub, Cathy L. Walker, and Sara J. White

Nicole M. Acquisto PharmD, FCCP, BCCCP Interdisciplinary Involvement of Residents Nicole believes that building interdisciplinary relationships leads to interdisciplinary resident education opportunities. She is currently an Emergency Medicine (EM) Clinical Pharmacy Specialist and Associate Professor in the Department of Emergency Medicine at the University of Rochester Medical Center (URMC) in Rochester, New York. Nicole has been the Primary Preceptor or Residency Program Director for the postgraduate year (PGY) 2 EM pharmacy residency programs for 11 years and has precepted approximately 20 PGY1 (pharmacy practice and pediatrics) and 27 PGY2 residents (EM, infectious diseases, oncology) in addition to many pharmacy students, medical students and residents, and paramedic students on clinical and research learning experiences. She also mentors a team of EM pharmacists. In 2013, Nicole was the recipient of the ASHP Pharmacy Residency Excellence New Preceptor Award. Nicole received her PharmD from the State University of New York at Buffalo, School of Pharmacy and Pharmaceutical Sciences. She completed a PGY1 pharmacy practice residency at Kaleida Health in Buffalo, New York, and a PGY2 EM/ critical care pharmacy residency at URMC. Nicole’s precepting advice is: Create interdisciplinary opportunities for your residents by building interdisciplinary relationships yourself. Interdisciplinary team members are key stakeholders in your residency’s success. Although building these relationships takes time and effort, it is essential to foster interdisciplinary teamwork, which is an important model for both education and delivery of patient care.

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 LETTERS FROM PHARMACY PRECEPTORS: PEARLS FOR SUCCESS

Dear Colleague, The first objective in the competency areas, goals, and objectives for many ASHP-accredited residency programs is “interacting effectively with healthcare teams to manage patients’ medication therapy.” During any residency training program, the resident will interact and collaborate with team members from several specialty services (e.g., medicine, EM, critical care, infectious diseases) and disciplines (e.g., physicians, advanced practice providers, nurses). Traditionally, this happens during interdisciplinary patient care rounds in the inpatient setting; but building an opportunity for additional interdisciplinary learning experiences for residents beyond the bedside starts with YOU, the preceptor. When I think of the interdisciplinary educational opportunities that were available to our residents early on—compared to today—and reflect on how they were developed, I continue to land on one theme: relationship building with team members outside of the pharmacy department. Linearly, as my relationship as a clinician grew with my team, so did the interdisciplinary educational opportunities for our trainees. The EM practice setting is also unique for relationship building in that you are not just building relationships with the EM team but also with every team that sees patients in the emergency department (e.g., trauma, critical care, neurology, cardiology, orthopedics, infectious diseases). Below are the attributes that I believe will help you build successful interdisciplinary relationships to take your residency training program to the next level. Be… ▧▧

Adventurous—you don’t have to climb a mountain to be adventurous; get out of your comfort zone and network with nonpharmacists in the workplace. Introduce yourself; make sure people know who you are, what you do, and what you can do.

▧▧

Approachable—ALL members of the interdisciplinary team should feel comfortable asking you questions.

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Humble—it’s OK to say “I don’t know”; this can be an opportunity to find out the answer together with your colleagues.

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Open-minded—consider new ideas or practice changes that your colleagues discuss with you. If the idea and rationale seem feasible (considering evidence, efficacy, safety, and cost), try it.

▧▧

A Do’er—don’t just listen to ideas or concerns but act, follow through, and make change. This builds credibility with your team.



▧▧

NICOLE M. ACQUISTO

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Available—be accessible in person or by phone or email so your team always feels your support. Suggest meeting in person to work through departmental clinical decisions or issues to have more face-to-face time with members of the interdisciplinary team.

▧▧

Visible—be seen during the work day AND during nonclinical times. Seek out professional opportunities such as staff, committee, and town hall meetings in addition to departmental events like holiday parties and other social gatherings. If your clinical service has a medical residency program, participate in open opportunities such as weekly didactic conferences, journal club, simulation, graduation, or other social events. Because there may be only one or a few pharmacists for an entire service line, staying visible in all of these places helps to keep the pharmacist as an interdisciplinary team member at the forefront.

How does preceptor−interdisciplinary relationship building lead to interdisciplinary opportunities for residents? There are two main connections: 1.

Being more involved and visible helps you recognize what opportunities may be available.

2. Quid pro quo or this for that. First, presence is important to inclusion. The more involved and visible you are, the easier it is for you to identify opportunities. Getting involved begins with building relationships! Many times, when interdisciplinary education is developed, pharmacy involvement may be unintentionally overlooked. Whether we like it or not, compared to the clinician and nurse groups, we are smaller in number. Also, other disciplines may not recognize the nontraditional roles for pharmacy in some activities (e.g., simulation). As preceptors, we need to continue to advocate for pharmacy as a crucial component of the interdisciplinary team. I have found that having a seat at the table during service line meetings and being inquisitive about potential interdisciplinary opportunities is an impactful way to do this. Some examples are the trauma service seeking volunteers for medical student naloxone and stop the bleed training, the stroke team implementing interdisciplinary stroke simulation, and the emergency department (ED) nursing team promoting a trauma nursing skills day. I would not have known about these educational activities unless I was at our trauma council, stroke quality, and EM nurse staff meetings, respectively. Given the relationship that I’ve built with these team members, I’ve had the confidence to advocate for pharmacy resident participation. Over time, as we’ve developed these relationships and demonstrated competency, our colleagues began to

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 LETTERS FROM PHARMACY PRECEPTORS: PEARLS FOR SUCCESS

reach out for pharmacy and pharmacy resident involvement in participant and educator roles. Secondly, if you say “yes” and follow through, your colleagues will also feel inclined to do so. In my experience, most opportunities that I said “yes” to have ultimately opened up more doors. I said “yes” to many requests for education and guideline/protocol/document development or input. I went out of my way to be available even if it was not convenient and volunteered when others have not. Specifically, I advised a medical resident research project for a resident at-risk for graduation (because my physician colleagues knew I would get it done), built dummy medications for simulation at the last minute, filled in EM department conference holes with pharmacy education for late cancellations, was available early/late hours for educational activities for colleagues who work evenings or overnights, provided pharmacy clinical rotation opportunities to medical residents and paramedics, and was an active EM faculty member at department presentations and journal clubs. I know that sometimes these yes responses seem trivial and go unnoticed, but the cumulative effect definitely does not. Those who I’ve helped out have been inclined to say “yes” in return. I recognize that the more I acted like a team member, the more I was seen as a team member. This led to my expanded involvement in the EM department and many interdisciplinary opportunities for our pharmacy residents. Through long-term relationship building, I’ve been able to align our pharmacy residents with educational opportunities embedded in the EM medical residency program. They participate in a weekly EM medical resident’s conference including a fire, rescue, and hazmat day as well as wilderness conference day; EM department journal club and EM simulation (with physicians and nurses) that focus on pediatric resuscitation, trauma resuscitation, and drug shortage simulation; other interdisciplinary simulation activities with medical residents, nurses, and respiratory therapists; cadaver skills laboratory to learn procedures; and a 2-week prehospital medicine rotation. These opportunities did not occur overnight and were cultivated over many years. I have been able to find allies in our EM medical residency leadership by saying “yes” often and providing clinical pharmacy support to the medical residency program in the roles of clinical practice, education, and scholarly activity. Eventually, we created a relationship where the EM pharmacy residents were immediately aligned with the EM medical interns starting with educational opportunities during orientation. In my position as the EM Clinical Pharmacy Specialist, I collaborate with several service lines through committee and quality improvement work and



NICOLE M. ACQUISTO

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have been able to leverage my relationships with many services for our residents to participate in non-EM department interdisciplinary activities. Examples include critical care resident and fellows journal clubs and lectures, adult and pediatric trauma and medical simulation, and nursing skills days. Pharmacy resident visibility at these activities further builds a personal relationship with interdisciplinary team members, teaches the importance of relationship building, and improves effectiveness during bedside clinical practice. Why are interdisciplinary opportunities so important? Medicine is a team sport, and understanding your colleagues’ role and their perspectives is invaluable in creating/furthering your own. By participating in interdisciplinary educational opportunities, you appreciate what your colleagues find as the most important points in a topic and what they focus on through the questions they ask. This allows you to anticipate clinical practice needs at the bedside and gain advanced critical thinking to solve problems and also to develop education directed at the needs of your colleagues. This is an important skill for your trainees to learn, and they do so by collaborating at the bedside with members of the team and by participating in educational opportunities targeted at different specialty services and disciplines. Our pharmacy residents participate in many interdisciplinary educational opportunities that may seem diverse and not pharmacy related; however, in my career, I found that understanding the continuum of care from the perspective of all disciplines, from pre-hospital practice to critical care, is necessary to be a successful clinician. These activities teach residents important non-pharmacy knowledge and skills to improve their practice. For instance, by understanding how a confined space rescue is managed, what medications are available to prehospital providers, the limitations of using certain medications in the back of an ambulance, and the current prehospital treatment protocols, they have an understanding of how the patient may have already been treated and can anticipate pharmacotherapy management when the patient arrives in the ED. By understanding electrocardiogram interpretation, they are able to follow the bedside discussion and contribute to and anticipate pharmacotherapy decisions. By having knowledge of different administration access lines, they are more suited to field medication administration questions from nurses. Submersing themselves in these interdisciplinary educational opportunities also helps pharmacy residents learn what is important to other specialty services and disciplines to be better team educators. For example, nurses are likely more interested in a brief understanding of the pharmacology and a greater focus on administration, side effect profile, and monitoring of the

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 LETTERS FROM PHARMACY PRECEPTORS: PEARLS FOR SUCCESS

patient; physicians are more interested in the relevant primary literature, placement in therapy, and dose; and advanced practice providers appreciate a more practical understanding of treatment management at their particular institution. In my opinion, interdisciplinary teamwork is the most important aspect of residency training and a successful clinical practice. Embedding pharmacy residents in interdisciplinary experiences builds their relationships with fellow team members, improves their approachability, and provides additional opportunity to contribute pharmacotherapy expertise. These opportunities promote their ultimate success as a clinical pharmacist at the bedside and also provide credibility in more formalized education to other specialty services and disciplines. As preceptors, we need to spend time building relationships with interdisciplinary colleagues as this is the cornerstone for identifying educational opportunities and advocating for pharmacy resident involvement. In turn, pharmacy resident involvement expands the pharmacy footprint overall and furthers our relationship development with other specialties and disciplines as a pharmacy team.

Sincerely, Nicole

Margaret Chrymko BS, PharmD, MA, RPh, FASHP Promoting Resident Well-Being Margaret has been active in clinical pharmacy practice and residency training for over 30 years and has a number of publications. She is currently a Clinical Pharmacy Specialist at the Erie Veterans Affairs Medical Center where she started the postgraduate year (PGY) 1 residency in 2002. She holds an appointment as an Adjunct Clinical Professor at Lake Erie College of Medicine School of Pharmacy. In 2011, she received the ASHP Research and Education Foundation Pharmacy Residency Excellence Award for Preceptors. She is a member of several professional organizations and has served as the President of the Pennsylvania Society of Health-System Pharmacists and on several ASHP committees, including the ASHP Commission on Credentialing, a guest surveyor for residency accreditation, and as faculty for the RLS/RPDC workshops. Margaret received her BS and PharmD degrees from the State University of New York at Buffalo and completed her residency at the Erie County Medical Center in Buffalo. She also completed a MA in Pastoral Studies at Gannon University. Margaret’s precepting advice is: Treat residents’ well-being as a top priority. Teach work−life balance and coping skills. Know and encourage the use of available resources for stress management and burnout prevention.

Note: The author has written this work in her personal capacity. The views expressed are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. The author wishes to acknowledge and thank William N. Jones, MS, RPh, FASHP for his review and input.

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 LETTERS FROM PHARMACY PRECEPTORS: PEARLS FOR SUCCESS

Dear Colleague, After I completed my education, my residency, and was practicing, I thought I knew what I had signed up for. I loved teaching and coaching residents, but I didn’t have a clue that I would need to address their well-being. I had no training or experience for this, but the importance of their well-being was clear. I frequently see articles on suicide or burnout, and I ask myself “Why?” The answer seems multi-faceted. Expectations are high; the world is complex and fast moving; social support systems aren’t always in place; we are constantly connected to our devices; and social media influencers are prevalent. Yet, identifying all of this doesn’t address a resident’s well-being. Where do we start? I encourage residents to reflect on who they are as well as their values, goals, and priorities. Seeing the big picture early in the program can build a good foundation. Periodic review of their insights is also important. This may help them put things in perspective and reframe situations. Once they have defined their goals, what else should be addressed? I try to remember that I am dealing with trainees who were very successful prior to starting the residency. They are accustomed to getting positive reinforcement and being at the top of the class. Now they are at a new level where there may be less positive reinforcement. They get more criticism than they have previously received. Some handle this well, while others may be frustrated or even devastated. I need to orient residents to realistic expectations regarding performance and feedback to minimize their frustration. I also need to ensure that other preceptors do not have unrealistic expectations. While orienting the residents, I introduce them to a self-monitoring approach for their performance. We also discuss signs of depression, anxiety, and burnout, and the resources available to help with these issues. Withdrawal, decrease in performance, lack of interest or engagement, avoidance, irritability, lack of sleep, and lack of self-care may be indicators of larger problems that may need immediate attention and referral. Residents have to recognize these signs in themselves, patients, or colleagues. They need to monitor their own mental health and stress and develop coping skills. Numerous factors contribute to stress. Many of our pharmacy trainees are perfectionists, which can be good, but it can paralyze residents to the point that they waste time and can’t complete anything. Helping them understand that I expect them to do their best but I don’t expect perfection, and neither should they, may be liberating for them. It is helpful to talk about accuracy versus perfection. We need to be as accurate as possible, especially when dealing with



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drug therapy; but, when dealing with all the literature that we can possibly review before answering a question, endless editing before finishing a project, etc., we need to find a reasonable end point. Often, residents are very hard on themselves. I encourage positive “self-talk” and suggest that they treat themselves as compassionately as they would treat a dear friend. Their contributions to patient care and process improvement should be recognized and reinforced. When asked to compare their current skills to their abilities a year ago, most will acknowledge that they have grown significantly. Lack of control can create stress. Residents need to learn that they can’t control everything. They should control what they can and not stress about what is beyond their control. If they are stressed about their performance, how could they do it differently the next time? I try to teach residents to learn from experiences and then let go of previous “errors.” Keep the focus on the present and not regret the past or worry about the future. The only time that they can address is the present. Of course, planning for the future is still appropriate. Some residents may be away from their families for the first time. They may lack a local support system. Establishing a new support system may be more challenging if the residents don’t feel compatible with one another. Even when compatibility is not an issue, establishing a support system takes time and energy. Listening to residents’ perceptions can be revealing. One of the most valuable tools that I have encountered over my career was a counseling course using the approach of Carl Rogers. We had to counsel one another as part of our class assignments. When my assigned partner told me about her traumatic life experiences, I was scared that I didn’t have the skills to deal with her issues. I approached the professor to express my fear. He pointed out that, using the Rogerian approach, my job was to do reflective listening. He suggested that I might start with “That sounds like it was really traumatic for you,” and then listen for her to go further into the issue. To really listen compassionately without judgment, not interrupt, and then express what I heard is a skill that has helped me in many circumstances. The goal is for the person to solve his or her own problems. By no means did this single, basic course make me a qualified counselor, but it significantly helped me to become a better listener. When we listen reflectively to residents’ perceptions of their stresses, they may experience some relief. The residents’ perceptions are their reality. It is very tempting to interrupt and defend expectations of the program from my perspective, but this is often counter-productive. I really try to listen to

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 LETTERS FROM PHARMACY PRECEPTORS: PEARLS FOR SUCCESS

the content and the emotions that residents express. As appropriate, I try to elicit the resident’s problem-solving skills to address the issues. For example, I might ask, “What do you think you should do?” or “How else might you approach this?” Sometimes, listening allows me to reassess the requirements and reframe the situation, adjust timelines/expectations, or consider a leave of absence if the situation warrants. As a Residency Program Director (RPD), I am always focused on the completion of residency requirements, but I never want these expectations to take precedence over a resident’s well-being. If I see any signs of mental health issues, I refer the resident to our employee assistance program (EAP). If I see any potential signs, I want the resident to see someone qualified to do a professional assessment. I share examples of how EAPs help residents or employees by assisting with prioritization, time management, limiting distractions, and good self-care, not just major mental health issues. I encourage residents to self-refer to EAP or similar resources as needed. If my assessment doesn’t reveal issues beyond time management or project management skills, I set up regular meetings to increase accountability and create a plan to help the resident accomplish tasks in a timely fashion. I need to meet residents where they are. Sometimes, dissecting the situation reveals that more modeling, coaching, or feedback is needed. I ask the residents what they think is happening and what they think they need. Did they understand what was required? Were they being too creative? Were they afraid to be creative, afraid to take a risk, afraid they would make a “mistake”? Were they wasting time on unnecessary steps? Were they totally overwhelmed with no idea where to begin? I like to see what they can do on their own, but I don’t want them to waste huge amounts of time trying to get started. Often, poor time management is an underlying cause of problems that residents experience. Time management strategies are addressed early in the year during our weekly topic discussions. I also schedule routine meetings individually every 2 weeks to discuss their workload and progress. This gives me some insight into their time management skills and an opportunity to help residents set priorities and redirect or prevent them from digging themselves into a hole. I want them to resolve issues themselves, but there isn’t time for them to make major mistakes managing their time. To address time management issues, I help residents divide projects into smaller sections and create work plans with timelines. If residents can see that they accomplished a portion of a project, they may experience a feeling of success. I refer to the old joke, “How do you eat an elephant? One bite at



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a time.” They can take “one bite” at a time. Timely feedback can help them achieve small successes. Each success can help them see that they can manage the work; it may prevent feelings of failure and lack of confidence. When I don’t get the outcome that I am looking for, in addition to providing timely feedback, I ask myself how I could have been clearer. Communication using the residents’ learning styles may be key. Perhaps I need to communicate both verbally and in writing. Maybe the residents need to repeat what they think they have been asked to do, just as I would ask a patient to explain how he or she understood the medication regimen. Sometimes another preceptor might help by listening to you and the resident, and then offering another perspective or explaining the requirements in another way. I need to be humble and appreciative of anyone who helps increase success. Are there additional issues outside the residency like family health, financial, or personal issues that require extra attention? Although these may be totally beyond my control, I want to be supportive and encourage residents to seek the appropriate support and guidance for these external issues. Although I can address some sources of stress, I can’t eliminate all of it. Therefore, I need to help residents learn to manage stress. Encouraging good self-care—including the basics of eating well, exercising, healthy relationships, socializing, relaxing, and getting enough sleep—is critical. I don’t know anyone who manages this perfectly, but even small improvements in self-care make a difference. Understanding their goals may help them keep things in perspective. Faith can be a source of strength for those who have religious beliefs. Sometimes they just need to pause and take some deep breaths. This alone can decrease immediate stress and anxiety. Techniques for relaxation, like meditation or yoga, may be useful. Occasionally, residents may need to take a day away from the residency to do something they enjoy. Residents might say they don’t have time to take care of themselves. I am reminded of the safety announcement on a plane: “Put on your own oxygen mask before helping others.” Residents need to take care of themselves if they are to be successful. We need to model healthy habits and give residents permission to address their own needs. Helping residents keep things in perspective is critical. It is useful to return to a discussion of their overall values, goals, and priorities. I also ask them to reflect on their growth over the last year. Thinking about what they are grateful for may be beneficial. All of this can help them reframe situations. If they can’t identify anything to be grateful for or if they express hopelessness, I need to refer them for additional help as these may be signs of mental health issues. Hopelessness can be a sign of suicidality. I had to learn that it was

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okay to ask about suicidal ideation. There is a misperception that asking about suicidal ideation increases the chance of suicide. To the contrary, getting help for suicidal ideation is much more likely to decrease the risk of suicide than avoiding the question. We can ensure that residents are aware of potential warning signs of burnout or mental health issues, monitor for them, and listen attentively and reflectively. We also need to create an environment where they feel safe asking for help. We must take steps to reduce the stigma associated with admitting there is a mental health condition. We need to help residents improve their coping skills, set realistic expectations, and maintain a healthy perspective. If there is a sign of a crisis, we may need to ask for help. We should know the local resources, be willing to refer residents when appropriate, know the crisis help lines, and use them if needed. Address issues early and prioritize caring—Resident well-being IS a top priority.

Wishing you much success guiding residents to be resilient, Margaret

Suggested Resource ▧▧

ASHP Well-Being and Resilience Resources; https://wellbeing.ashp.org/ Resources.

Tammie Lee Demler BS, PharmD, MBA, BCGP, BCPP Carpe Diem Preceptor: The Etiquette and Art of Remaining Resilient and Avoiding Burnout Tammie Lee is currently the Director of Pharmacy Services and Pharmacy Residency Training at the New York State Office of Mental Health (OMH) at the Buffalo Psychiatric Center.  She is a dually Board-Certified Specialist in both psychiatric and geriatric pharmacy. She holds numerous adjunct academic appointments, including Clinical Associate Professor for State University of New York (SUNY) Buffalo School of Pharmacy and Pharmaceutical Sciences and SUNY School of Medicine, Department of Psychiatry; Clinical Assistant Professor, D’Youville College School of Pharmacy, University of Florida College of Pharmacy Gainesville; and Clinical Instructor for the Erie County Community College Pharmacy Technician Certification Program. She is the recipient of the 2019 Teacher of the Year Award from the SUNY School of Pharmacy and Pharmaceutical Sciences. Tammie Lee received her PharmD, MBA, and BS degrees at SUNY−Buffalo.  Tammie Lee’s precepting advice is: Be open to stepping outside of your comfort zone to grow personally and professionally, while challenging your residents to do the same. This is a key component in preventing burnout. There is nothing more rewarding than role modeling continuous PERSONAL development.

Dear Colleague, We hope to be remembered for making the world a better place through our personal and professional contributions. The last song, “Who Lives, Who Dies, 13

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 LETTERS FROM PHARMACY PRECEPTORS: PEARLS FOR SUCCESS

Who Tells Your Story,” in Lin-Manuel Miranda’s Hamilton reminded me of this “legacy effect.” The lyrics describe that it is the lives we touch during our daily encounters that will ultimately tell our story of the core values we teach. I have encountered numerous teachers on my educational journey; however, those most remembered are those who made the learning meaningful and memorable, and who fostered a love of the pursuit of a lifelong exploration of unanswered questions. These experiences solidified my personal beliefs and established core values and standards that have guided my academic journey. It is an exhilarating experience to witness new practitioners, seasoned healthcare providers, and even patients achieve a “breakthrough” moment of understanding something new. Knowing that I contributed to their newfound knowledge continues to fuel my desire to teach. Maintaining this teaching approach and philosophy can be taxing on the teacher. Nevertheless, with resilience and a structured approach to learning, you can avoid burnout.

Pursuit of Lifelong Learning Early in my career, I learned that if I declined an experience or opportunity due to not feeling confident or competent, I would lose that chance to someone else who was willing to “give it a try.” Each of us can be stunted by the imposter syndrome, where we doubt our accomplishments, skills, and abilities from fear of being criticized or exposed for not knowing everything we believe we should. The trick is that we can establish a plan for continuous professional growth that not only challenges us to move ahead, but also inspires our residents and trainees as we lead by example to develop additional competences. I have worked hard to overcome the imposter syndrome by pushing through my self-doubts and fears. After accepting my Director of Pharmacy position, I completed my MBA and sought psychiatric board certification because I felt I just didn’t have enough background to be the “best” in that position. These efforts—to improve one’s skills continuously—may seem extreme to some, and critics will argue that promoting and seeking such extremes may foster frustration by setting unattainable goals. I agree that there is no need to obtain a PhD in statistics to satisfy my interest in sharpening my skills in biostatistics. However, this is where knowing when to say NO becomes important. We must guard ourselves and our mentees from catastrophic burnout by sharing our experiences, maximizing focus on the successes, and limiting reflection on failures when considering whether to make the extra stretch. Is that extra stretch currently important enough to invest the energy?



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When deciding on the most important professional energy expenditure, I share with my residents that implementing an ongoing “wellness” check is essential. For this, one must consider short- and long-range goals that have the most appropriate payout. Each of us has an emotional bank account, which is subject to deposits of good things and withdrawals of those that are not so good. In other words, avoid issuing a $1000 check for a $1 expected payout. Is the risk worth the benefit of accomplishing that task or taking on this extra activity? Prioritize goals and incorporate them into a schedule that permits the necessary work−life balance. Revisit and re-establish professional and personal priorities PRN and on a regular, scheduled basis. These priorities can be set for daily, weekly, and even longer term for more robust outcomes. One should strive to have organized action plans with goals and task lists ready to go; however, this takes time and requires planning. Reflect on the most challenging days why you chose the profession and be guided by those principles. Remember to remain not only physically present but also emotionally invested within your current commitment while training for the next phase of practice in order to achieve your future goals.

Managing and Preventing Burnout My multitasking efforts have been described as excessive; for example, I have baked a pie while writing a research paper. Nevertheless, I advocate that we can remain enthusiastically and clinically invested, family-focused, and manage and prevent burnout while using every opportunity to avoid wasting time not otherwise already allocated to keep moving forward. Recognizing that we each have unique approaches to time management and that good time management skills must be cultivated, I routinely include this skill development in my residency training program. It allows me to monitor for, and guard against, potential frustration and residency burnout in those I mentor. Understanding my residents’ approach to time management is different from my own, I must be vigilant in monitoring for their potential burnout. Professional burnout is extreme personal and professional exhaustion that results from significant stress associated with an imbalance between expected and realistic productivity. This equation can be altered by just one factor— lessening the level of productivity that is normally achievable but due to a stressor, it temporarily becomes seemingly insurmountable. These stressors can be work-related, traumatic life events, personal or family illness, or even a significant loss. I have personally experienced intermittent burnout resulting in extremely low energy phases, lasting from a few days to a few weeks. Giving myself permission to take a break and allowing some personal slack (acknowl-

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 LETTERS FROM PHARMACY PRECEPTORS: PEARLS FOR SUCCESS

edging that I cannot do everything—or at least not all at once) helped me recover and return to baseline faster. Everyone agrees that burnout is a significant healthcare issue for our patients, clinicians, and providers. We should exercise self-awareness and know ourselves well enough to identify low energy days and when we need to authorize a prescription for a personal respite. Know when to say no. I enjoy the pursuit of seeking excellence and have built my reputation on over-delivering by avoiding the temptation to over-promise and under-deliver. As a protective measure, I build buffers into my projected timelines in case of unexpected work−life imbalances. I continually seek ways to avoid declining opportunities and have discovered that offers can be negotiated. Want to participate in a project but already have enough on your plate? I have begun the use of a “non-absolute” no—a method of expressing my interest but also realistically framing my high demand schedule as one that might not allow me to meet the initial deadline. Often, the sponsor provides more latitude or eases up the deadlines if they are interested in having me join in. Go positive, supplementing the ordinary with the extraordinary. Without a change to your routine, boredom can contribute to burnout. Teach, mentor, publish, volunteer, get involved, and don’t let fear of the unknown or not knowing something hold you back. Take the risk to learn new things (specifically non-pharmacy things) like cooking or a new language; they will broaden your impact and can create new opportunities for shared experiences and collegiality with your residents. For example, I am well known for offering an optional cultural “elective” in teaching Polish pierogi making, which has become a legend among my residents. Don’t let your current job be the sole source of your identity. Despite our positive outlook, we need to understand that dealing with difficult people can still be challenging. Other people can’t make you feel upset; we alone are in charge of how we feel. I remind my residents that a bad day at work is just “a day” and this, too, shall pass. This is not all there is—our family, friends, and mental health are anchors.

Making Things Meaningful and Memorable Ask your students what they believe could be a better way to tackle a clinical challenge or even an operational/distributional workflow issue. Use less intimidating terms that still allow growth and assessment such as “room to grow” instead of “weakness,” while still celebrating the “extra good” as another way of promoting “strengths.” I also prefer to use the term suboptimal when things are



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not going well—lessening the gloom on something otherwise not going well. I pride myself on facilitating a nonjudgmental classroom experience and encouraging students and residents to ask questions freely as a roadmap to learning. Implement the use of a “good things” folder, which offers a place to tuck thank-you notes, heartfelt e-mails, and other tangible things you have been involved with, that signify you have made a difference, and that can be presented at a job performance evaluation or at signs of burnout when a STAT boost to morale is needed. Practice what you preach is an important mentoring pearl I can also offer. Having just submitted my teaching portfolio and updated philosophy, I was struck with the similar philosophy that I described over a decade ago. Lifelong learning, coupled with challenging yourself to step outside your personal comfort zone, allows us all to strengthen our professional resiliency and precepting engagement with our mentees. One thing I missed, however, was that my early efforts to diligently self-assess and apply ongoing professional improvement blocked my own view of the extra good, and focused my energy almost entirely on the room to grow. Although my overall philosophy included the regular use of a “good things” folder, I forgot to open this on a regular basis to remind myself of the positives. I was guilty of not practicing what I preach. My message to you is: Capture, collect, and share the good things along with those that offer room to grow. Reflect on your past strengths and areas to improve concurrently so you can prevent burnout. As pharmacists, we often believe that continuous Personal development (CPD) is only about continuous professional development (CpD); however, personal development is equally, if not even more important, to your overall portfolio. Do not let fear of failure hold you back. You are the CEO of your CpD AND CPD, and you are best positioned to shamelessly self-promote all the good things you do daily. New practitioners must learn the importance of this. When shared, your life lessons can inspire fellow preceptors, residents, and future students to reflect on their own experiences and further ensure that all patient encounters are authentic, amazing, and impactful. Schedule time for creative free-thinking, planning, and goal setting for your personal and professional development. Invest in the practice of paying attention in the present moment while also balancing efforts to plan and prepare for career “evolution” working toward phase 2 while you’re still experiencing phase 1, even if phase 1 seems to be your dream at that very moment. Establish an approach of never saying never in order to avoid losing a potential once-in-alifetime opportunity.

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I hope my shared precepting pearls and personal lessons learned offer some new approaches you can take on your own precepting journey!

Wishing you all the best, Tammie Lee

Stephen F. Eckel PharmD, MHA, BCPS Perspective, Personality, Point of View: Full Immersion of Your Learner Stephen is the Associate Dean for Global Engagement at the University of North Carolina at Chapel Hill (UNC) Eshelman School of Pharmacy. He is also a Clinical Associate Professor in the Division of Practice Advancement and Clinical Education. In addition, he leads the 2-year Master of Science in Pharmaceutical Sciences with a specialization in health-system pharmacy administration. This degree is hosted at multiple sites across the United States. At the UNC Medical Center, he is Director of Pharmacy, Innovation Services, and Residency Program Director of the 2-year program in health-system pharmacy administration. Stephen’s dedication and service as a preceptor was recognized in 2015 when he received the ASHP Foundation’s PREA Preceptor of the Year Award. He has worked with almost 250 residents over his career and has been involved in residency leadership at his site for over 20 years. Stephen received his BS in Pharmacy and PharmD from the UNC Eshelman School of Pharmacy, and he earned his MHA from the UNC Gillings School of Global Public Health. He completed a pharmacy practice residency at Duke University Medical Center. Stephen’s precepting advice is: Involve learners in everything that you do, which includes personal activities. Not only will this allow the individuals to gain the full perspective of your responsibilities, they can assist in opening new doors. You will find it can lead to external support for learners and new initiatives, which might provide insights to assist in your roles. 19

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Dear Colleague, After precepting pharmacy students, postgraduate year (PGY) 1, and PGY2 residents on mostly administrative experiences over the last 20 years, I have come to appreciate that this type of learning experience is as important as a patient-focused one. Although every month is slightly different and many initiatives stem longer than the 1 month they have with me, there are universal precepting skills that I have used with learners to best prepare them for success within the profession. This approach to precepting has also benefitted my site of employment. Because my scope of responsibilities has changed over the years, I have had to adapt and amend my rotation activities, reading lists, and projects to remain meaningful and impactful. One thing I have learned through many discussions and observations is that the students and residents want to know more than just the content I teach. They want to understand my job and my various responsibilities, including all the activities with which I am involved. They want to know how I balance life and my career. They also want to know about me. Once this bridge has been crossed, it makes me much more approachable and they realize that I am no different from them (except a little more experienced). It also models my approach to balancing my various activities, where things are much more integrated than separated. After precepting in this style for many years, I have realized that there are also benefits to this approach for my workplace. The vast majority of my precepting experiences have been in the realm of pharmacy administration. I have always believed that learning experiences in this sector were complementary to the patient care side. I expose learners to the medication-use process and how this connects to the patient care experiences that they have scheduled. I also believe that if I expect my employees to be active preceptors, then I need to hold myself accountable to the same expectations. If they had to precept for 6 months of the year, then the leadership team and pharmacy administration should do the same. Finally, I also had projects and expectations placed on me from others, either to report out on how the organization was performing or new areas of growth. I could build projects around these activities that would not only be useful learning experiences but would assist me in my job responsibilities. When involving learners in your administrative responsibilities, you need to start with a foundation of trust. Just as you would expect learners to protect the privacy of the patient’s medical condition or identity, you should do the same with the learners on the administrative rotation. We start each rotation



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by discussing our confidentiality expectations. We share with them that they will learn information on the department’s future direction in the meetings they attend. They will also hear conversations that might include information about individuals they know (e.g., previous or future preceptors). We ask them not to share this information outside of the leadership team. This includes time frames that extend beyond the learning experience. This can be difficult, but it is also a necessity for the learning experience to be ideal. Although there have been rare breaches of trust in the past, we have dealt with them quickly. However, it has not stopped us from expecting confidentiality at the outset of each rotation. Once this foundation of trust has been established, this allows the learner to gain access to many meetings. We invite learners to leadership team meetings and one-on-one meetings with employees that I oversee as well as meetings with hospital administration, the school of pharmacy leadership team, and interviews for pharmacy technicians, pharmacists, and even residents. Depending on who is leading the meeting and its subject content, I will ask the learner to create an agenda, lead a portion of the discussion, participate in the interview, and take meeting minutes. I also try to brief them in advance on the content, the hope for the outcome of the meeting, and any personal dynamics or interactions that might arise. I also try to send notifications in advance so people know that learners will be attending. Besides the great exposure opportunity for the learner, this also changes the tenor of the meeting in a positive way. Most individuals, especially senior executives within the hospital, will be on their best behavior when learners are present. They are courteous, will explain the subject matter in more detail, and be appropriate in their interactions. I have found that these meetings run much more smoothly than when I run them alone. There are times when we will ask the learner to step outside of the room if sensitive materials are being discussed, but this is not as often as one might think. The other major benefit that arises from including learners in meetings outside the department of pharmacy is the image that it conveys to these executives. Because I practice at an academic medical center, it communicates to the medical staff and hospital administrators that education is important to the pharmacy department. The continual reminder is that education can occur at all places, not just at the bedside. It also continues to communicate to the pharmacy staff that the entire administrative team participates in education and training, and it is not just limited to operations or clinical. We hold ourselves to the same standards as our clinical preceptors.

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During these meetings with physicians and hospital executives, we want the learners to be active participants. This is usually accomplished by having them present on a topic on the agenda and, if possible, to sit at the same table with me. It highlights the involvement of these learners into the activities of the department and the quality of the work they do. We also regularly highlight to hospital executives all the projects, presentations, publications, and patient care impact that emanated from their work. We invite these executives to our residency graduation each year, which results in the administration having a better understanding of the value of residents and how we utilize them to expand the department’s scope. When we request through the budget process additional resident positions, we never have to educate on the value that these resources provide to the organization. Even though they are not always approved, they understand the value of residents to the medical center. There have been unexpected benefits that come from the exposure learners provide to enhance our image across the organization. Hospital administrators have requested learners’ assistance on projects outside of pharmacy; they are invited to attend meetings with the hospital executives, and on a few occasions based on their prior training or experience, can lend valuable information to the discussion. Not only do these opportunities broaden the training and exposure of the learners, but also the image of pharmacy is enhanced, and people further understand the value that we provide to the organization. What a tremendous payoff that occurs just from having learners participate in your daily meetings! Following all these meetings, I debrief with the learners. Before I share my impressions and perspectives, I want to gain their insights. This reflection helps to grow their emotional intelligence and to better understand the dynamics that are occurring. Doing this throughout the rotation, the learners’ reflection skills vastly improve. They are also able to perceive insights that I might not. This not only helps me better prepare for future meetings, but also aids in the learners’ growth and development. I would highly encourage you to build this into every meeting. My last piece of advice is to show that you are a real person who has a life outside of work. This allows learners to see that you have professional activities beyond your job (reviewing articles, giving talks), personal interests in addition to pharmacy, and a family. This can also be used as a discussion point on your method to balance work and life. By showing my life outside of work, I have found this makes me more approachable, stimulates great discussion, and develops a relationship that the learners utilize years later. I have even invited



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learners to have meals with my family, or to come to one of my kids’ athletic events. These experiences are usually fun, allow us to meet the many pressing deadlines, and ensure that the rotation is an optimal learning experience. We can also get to know each other in a different environment. These strategies have evolved over the years and have been tested through all types of learners. This is the common approach for all pharmacy administration preceptors at my medical center. We also get positive reviews from the learners, and a few have changed their career choices based on the experience. Some of these learners have become close professional colleagues since we have shared life experiences together. I would recommend that you identify the best strategy for your learning experience and involve the learner into your entire life. The rewards are tremendous, personally and professionally, and I would not trade my experiences with learners for anything.

Sincerely, Stephen

Joshua J. Elder PharmD, BCPS, BCOP Preceptor Development Plans—A Clearer Path to Professional Growth and Fulfillment Josh is the Clinical Specialist for Pediatric Hematology/Oncology/Stem Cell Transplant at Norton Children’s Hospital in Louisville, Kentucky. He currently serves as the Director for the postgraduate year (PGY) 2 oncology pharmacy residency program, which is one of four oncology residency programs in the country focusing on pediatric oncology. Three residents have completed the program. Prior to serving as the Program Director for the PGY2 oncology program, he was the Program Director for four residents for the PGY1 program. Josh holds academic appointments at Sullivan University College of Pharmacy and University of Kentucky. Currently, he is the President of the Kentucky Society of HealthSystem Pharmacists. Josh completed his PharmD training at the University of Kentucky and went on to complete 2 years of residency training at Indiana University Health, specializing in pediatrics. Josh’s precepting advice is: Preceptor development plans are integral to our professional fulfillment and happiness. As a preceptor, you should be selfish in outlining your personal goals while knowing that it often takes hard work and a bit of sacrifice to attain these goals. Surround yourself with positive energy and support to make your path forward more meaningful.

Dear Colleague, Your personal preceptor development plan requires equal parts selfishness and 25

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selflessness. I would implore you to be greedy when thinking about your own development as a preceptor. Preceptor development plans are a place to define your current self and craft a future vision for yourself. These plans allow for a central location to house your strengths and opportunities for improvement as well as to help you lay the framework for both short- and long-term precepting goals. As the saying goes, “You’ve got to look out for number 1. If you don’t, who will?” No one knows better what makes you personally fulfilled, so I would challenge you to be inward looking and not make apologies. As new practitioners entering the clinical and precepting workforce, it’s impossible to evade the ubiquitous questions about your short- and long-term goals. All too often, we have canned answers for these aspirations during job interviews. However, those precepting goals can be quickly diluted or pushed to recesses of our brain when we are surrounded by challenging clinical responsibilities. Preceptor development plans are the perfect location to house and own those goals, making sure we never lose sight of personal growth in this area. Being selfish and going after what makes me professionally happy as a preceptor has contributed to a real sense of personal fulfillment. This fulfillment has been critical in allowing me to avoid true burnout even when times of stress and workload are increasing. Over the past several years, I have attained several of my short-term goals documented on my preceptor development plan that have made me a better preceptor and pharmacist. I have fulfilled my goal— the successful accreditation of a PGY2 oncology pharmacy residency program in a pediatric hospital, one of only four in the country. Achieving this goal has undoubtedly been linked to happiness in my clinical role, both pushing me to practice at the top of my game as a preceptor, while affording me constant access to a resident pharmacist hungry to push clinical initiatives forward. I have expanded my network of pediatric oncology pharmacy colleagues and made friends along the way in helping to start a national pediatric oncology residency journal club. Without owning these goals in a tangible preceptor development plan, neither of these personal wins would have come to fruition nearly as quickly as they did. A key component to a rewarding preceptor development plan is selflessness. Success often does not come to the faint of heart, and great rewards are often the result of great efforts. Growing up on a dairy farm in rural Kentucky, my father instilled a keen work ethic in me from a young age. This work ethic still serves as a blessing and a curse. My father worked daily from sun up to sun down doing hard manual labor in the hot summer sun, which always made the prospects of 80-hour workweeks during PGY1 and PGY2 residencies in a climate-controlled building seem tolerable. This same work ethic is also why



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I have clearly outlined improvement of delegation of responsibilities in my areas for improvement in my preceptor development plan. Although it’s a very fine balance to make ourselves better preceptors, we have to recognize that it is going to take hard work and a bit of sacrifice. Clinical and administrative responsibilities in our roles as pharmacists often fill up the majority of our 8-hour workday, and sometimes it will take an extra hour or two to devote to either our learners or ourselves to further hone the craft of precepting. The key with selflessness is finding initiatives and opportunities about which you are passionate and that will better you as a preceptor, so that you are willing to work harder to attain your ultimate goals. Certainly, we all know what it feels like to be in the weeds, drowning in clinical responsibilities, and knowing there isn’t enough of ourselves to spread around, both personally and professionally. Over the last 3 years, I have certainly gained a greater appreciation for this sentiment, as we’ve welcomed two beautiful daughters into this world and they continue to help me put my priorities into perspective. It becomes more apparent to me every day that grace is one of the most important gifts that you can give yourself. Grace will allow you to not beat yourself up when you fall short of your own personal expectations. Preceptor development is not something to rush, nor is the attainment of short- and long-term goals as this will certainly lead to a less-than-optimal final product. Competing responsibilities in life and at work will ebb and flow; no matter how busy this week or this month is, there will always be opportunities to work toward your preceptor development plan. You must be patient and ready to seize opportunities as they arise, but not be disappointed if it takes time for them to appear. We must realize it is also fine to pass up occasional opportunities in times of high workload, something with which I admittedly struggle. A professional support system is critical to your development as a preceptor. Every one of us needs mentors and role models to help guide our journey of self-improvement. I have been incredibly fortunate with pharmacy leaders and colleagues, who never expressed surprise when I spoke of goals to aid in my own preceptor development, such as starting a PGY2 oncology residency. These same leaders and friends were always quick to listen and provide encouragement when I was frustrated or became too impatient, forgetting to offer myself any grace. I would encourage you to surround yourself with similar mentors and colleagues who offer the same level of professional support. Drown out negative professional relationships and latch on to those colleagues with an optimistic demeanor. Positivity is an integral component

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of happiness, and it will make your journey to self-improvement and personal discovery sweeter. Remember, all of us will occasionally misstep and fall into the realm of negativity. We have to be self-aware and have the correct people surrounding us to pull us out of this funk when it sets in. Self-improvement and true growth as a preceptor will only be attained through positive relationships, actions, and intentions. From a residency leadership perspective, the implementation of preceptor development plans for your preceptor staff is crucial to advancing the skill set of your preceptors, creating a better environment for your learners, and ultimately advancing your residency program. After serving in residency leadership capacities within our institution for the past several years, we have utilized formal preceptor development plans for several reasons. These plans allow residency leadership to visualize quickly who meets the requirements of a preceptor. If a preceptor is missing a certain requirement, opportunities are then provided for that preceptor to check that box. While there are certainly several boxes to check, we’ve empowered our preceptors to self-identify areas of strength and opportunities for improvement as well as encourage them to be selfish, identifying both short- and long-term goals to work toward to become a better preceptor. This dialogue is documented directly on the preceptor development plan. It takes a village of preceptors to run a successful residency program. Mapping out the strengths and aspirations of your preceptor pool allows you to tap into strengths of this dynamic group to create a better environment for learners, as well as provide opportunities to meet your preceptor’s aspirations. Each preceptor brings something unique, and it is imperative as residency leaders to display the strengths of each individual when designing your residency. Developing each other and ourselves into better preceptors is the greatest gift we can give to both learners and patients. I encourage you to aspire to becoming a better preceptor. This journey will certainly have some detours and delays, but by giving yourself grace and putting in the time and effort, you will no doubt attain a higher level of personal satisfaction in your role as a preceptor, which ultimately will aid in preventing burnout. A strong sense of commitment to your personal preceptor development will certainly enhance your learner’s experience and serve as a model for their self-discovery as a preceptor. There is no better way to pay it forward to future generations of pharmacists and preceptors than to instill in them a drive to grow professionally. By modeling this behavior, not only do we carry these important qualities forward for future generations, we also create a more



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engaged pharmacist workforce that is able to care for their patients with a more advanced skill set, renewed energy, and compassion. When the stakes are this high, the documentation of a preceptor development plan is critical to ensure we never lose sight of these ultimate goals.

Sincerely, Josh

Brian L. Erstad PharmD, BCPS, FASHP Meeting the Needs of Individual Learners Brian has served as a Preceptor or Co-Preceptor for more than 150 postgraduate year (PGY) 1 residents, as the Residency Program Director (RPD) for 25 PGY2 critical care residents, and as the Program Director for an international critical care fellow. Brian is currently Professor and Head, The University of Arizona College of Pharmacy, Department of Pharmacy Practice and Science. Since 2005, he has served as a Co-Director of the Arizona Clinical Research Training Program. Brian has received four Educator of the Year Awards and multiple additional nominations for that award from the College of Pharmacy students. He has also received local awards from pharmacy students including the  Teaching Award (twice), an Exceptional Pharmacy Mentor Award, a Crystal Apple Award, and an Outstanding Instructor and Preceptor Award. At the state level, the Arizona Pharmacy Association recognized him with the Faculty Excellence in Pharmacy Award. Brian was also the first recipient of the ASHP Research and Education Preceptor Award that was created to recognize “a pharmacy residency preceptor who has excelled in the training of pharmacy residents.” Brian received his BS in Pharmacy from South Dakota State and his PharmD from the University of Arizona. He completed a residency at the University of Arizona. Brian’s precepting advice is: AEIOU and some time for Y. A caring attitude by the preceptor is a necessary but not a sufficient factor for successful precepting. Other keys to successful preceptorship include early orientation, which encompasses a discussion of career goals, integration of activities, ongoing assessment, utilization of a layered learning practice model, and time for yourself. 31

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Dear Colleague, I have been a preceptor for more than 40 years, beginning soon after I received my BS degree in Pharmacy from South Dakota State University and continuing after I received my PharmD and residency training at the University of Arizona College of Pharmacy. This long history of precepting means that I have made just about every mistake that a preceptor can make, but I have learned from my mistakes. Therefore, when I give presentations or write articles related to preceptorship, I use real-life examples of problems I encountered in the clinical setting and how I made changes to reduce the chances of encountering similar problems in the future. Now, it can be argued that this is just one person’s experience, or what would be considered an n-of-1 in clinical practice or research. This is the lowest level of evidence using an evidenced-based hierarchy, which has always served as the framework for my practice recommendations. However, it is important to note that there is little evidence upon which new practitioners can base their precepting skills. For example, a PubMed search using the MeSH terms “preceptorship” and “pharmacy” only yielded 280 citations in February 2019. A cursory review of the abstracts of these citations reveals little highlevel evidence that might be used to advance preceptorship skills. Therefore, for this letter, I will base my comments on my experience and provide citations for some of the limited evidence that is available. A caring attitude—There is a good deal of credentialing in pharmacy that helps to ensure our preceptors are competent to practice, but a competent practitioner is not necessarily an excellent clinical instructor or preceptor (Am J Pharm Educ. 2014;78:Article 53). In one of my early commentaries on precepting (Am J Hosp Pharm. 1993;50:434-9), I spoke of the necessity of having a caring attitude, which is the basis for all effective preceptorships. Other qualities such as enthusiasm, empathy, and interest in teaching that are associated with effective preceptorships derive from this caring attitude. Differences in these personal characteristics explain survey results that sometimes show trainees in the clinical setting perceive preceptors with less practice experience to be more effective than preceptors with more experience (Am J Health-Syst Pharm. 2016;73[suppl 3]:S94-9). Lack of time—When I have performed informal surveys of preceptors, I frequently found that the biggest impediment and frustration hindering preceptorship was lack of time. I find this to be true regardless of setting or type of institution (e.g., community hospital, academic medical center). Ideally, preceptors would be given dedicated time for preceptorship activities. Realistically, in most settings, preceptors need to collaborate with colleagues, use



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a layered approach to trainee learning, and find ways to incorporate clinical instruction into their daily practice responsibilities. With respect to collaboration, no preceptor is available 24 hours a day, 7 days a week, so there are often times when a colleague is needed to temporarily handle precepting activities. I have found that some preceptors are reluctant to have a colleague help with precepting because they are concerned that he or she does not have sufficient content expertise. The need for specific content expertise is often overstated, assuming the colleague has the essential skills of any qualified practitioner. The colleague may not be able to perform at your level in your area of expertise, but as a qualified practitioner, they should know the basics such as not responding to clinical questions until they are sure of the answer. I remember one situation in which a surgeon asked an on-call resident early in the morning to write orders for a parenteral nutrition solution so a patient could be discharged to a home setting. The resident said the leader of the nutrition support team wasn’t in the hospital yet, but that she would contact the leader as soon as possible to get the orders written. The surgeon insisted that the resident write the orders because he said the parenteral nutrition solution was needed STAT. To her credit, the resident held her ground recognizing that this was not really a STAT situation. Layered approach to learning—Using a layered approach to learning has been the focus of much discussion related to student and resident training. Although the term layered learning is relatively new jargon in the pharmacy profession, experienced preceptors have used the concept and the general principles for many years. Layered learning allows trainees who are more experienced to precept less-experienced trainees with oversight and supervision by the clinical preceptor. For example, on a critical care rotation, a PGY2 critical care resident could oversee a PGY1 general practice resident who (usually in conjunction with the PGY2 resident) could oversee a pharmacy student. Literature demonstrates that this multi-layered model has the potential to increase the number of trainees assigned to a preceptor and increase the number of patient care-related interventions while maintaining or improving the learning experiences of the trainees (Hosp Pharm 2017;52:266-72). Assuming there are different levels of trainees at your practice site, I would encourage the use of the layered model. Integration of activities—One important thing I learned early in my career is to think about integration before starting any new endeavor rather than waiting until I’m overloaded with work and trying to dig my way out of it. The heavy workload of most preceptors necessitates that they incorporate clinical instruction into their daily practice responsibilities. As a clinical faculty

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member who has precepted hundreds of students and residents, I have found that integration of activities is a necessity to be successful in the academic triad of teaching, research, and service. For example, when I was contemplating becoming an RPD for a PGY2 critical care residency, I considered how I would incorporate the PGY2 residents into my existing rotations that involved students and PGY1 residents. By using a layered model and integrating my activities, I was able to use my new PGY2 residents to expand my clinical, research, and service activities. Toward that end, I have engaged trainees as co-authors on most of the publications on my CV list. The publications cover numerous topics ranging from more classic research involving medications to articles concerning student or resident training and ones related to the justification of clinical pharmacy services. For the remainder of this letter, I am going to provide my thoughts on more specific and common problems involved in precepting, along with my suggestions about ways to prevent or ameliorate these problems. I believe that many, if not most, problems related to student and resident training are due to inadequate communication prior to and at the beginning of clinical rotations. Preliminary communication—This early communication needs to cover a variety of topics such as onboarding (e.g., software training, background checks) at the training site, expectations of the preceptor, expectations and long-term goals of the trainee, learning objectives and assessment strategies, instructions on daily activities, and introduction of key personnel at the site. As a novice preceptor, I found that I did not have enough handouts, so I began to create and provide extensive handouts to trainees. After many years, I realized that trainees were not reading my handouts because the sheer volume of materials overloaded the residents. This led me to change the orientation phase of my program so I focused on the most important items of the rotation, such as rotation objectives and daily activities. The remaining materials were given to the trainees as supplemental materials that could be reviewed as specific issues arose during the rotation. No matter how busy your rotation, it is critical that you set aside dedicated time at the beginning of the trainee’s experience to discuss issues of importance. Some of the most serious trainee problems I have encountered or other preceptors have asked about relate to inadequate two-way communication during the orientation phase of the experience. Ongoing assessments—As the rotation progresses, the preceptor has to offer ongoing assessments of the trainee so formative feedback can be provided before problems progress to the point that they can only be dealt with during the final summative evaluation (when it’s too late). This is particularly true



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for a trainee’s overall poor performance. The preceptor needs to identify and intervene early as problems arise. There should be ongoing communication about persistent problems until they have been resolved; further, the preceptor should document (in writing) the issue discussed and the stated expectations of the trainee emanating from the conversations. The summative evaluation should contain no surprises for the trainee. Lack of trainee motivation—This is a common complaint I hear from pharmacy preceptors, particularly when the rotation was assigned and not chosen by the trainee. Again, an appropriate orientation that covers issues such as the preceptor’s expectations and trainee career goals may help to prevent subsequent motivation problems by finding ways to incorporate the trainee’s interests and aspirations into the rotation experience. If this type of approach does not seem to be working, the preceptor should be candid (but not mean-spirited or threatening) that the successful completion of the rotation is necessary for graduation and that you as a preceptor want to do everything you can to ensure student success. I remember one student many years ago who was assigned to my surgery/ trauma rotation. This student had always wanted to practice in the community setting after graduation, and I knew this prior to the rotation. Additionally, this was the first hospital rotation assigned to the student. In light of this information I asked the student about her past community pharmacy experiences, what she liked about community pharmacy practice, and what types of problems were common in the patients she encountered in her community pharmacy settings. She mentioned that a number of patients came to the pharmacy with prescriptions following hospitalizations, which often included surgical procedures. I told her that this rotation would be a great opportunity to see what her patients have gone through during their hospitalization when they present at her community pharmacy. I suggested that she follow her trauma team whenever possible, not just during rounds, but when they performed procedures, when they were called to the emergency department, or when they went to surgery (with the appropriate permissions ahead of time). The student did as requested and followed her team everywhere. Because she did not have an extensive knowledge base with respect to medications commonly used in the hospital setting, she didn’t make a large number of impactful recommendations; however, the team was impressed by her desire to learn and was motivated to include her in their various activities. She worked hard, learned a lot (as indicated by a pre-posttest), and was a pleasure to work with during the rotation. To this day, whenever I see her, she tells me that the trauma rotation was the best rotation she had in college.

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Periodic motivation—Finally, it is important to consider that preceptors also are in need of periodic motivation. One of the things that can augment preceptor motivation is occasional time for yourself. All health professionals need to find the appropriate work–life integration and balance. Remember AEIOU and some time for Y. Take advantage of time off and, although I know it is difficult, try very hard not to think about work!

Brian

Rachel M.F. Heilmann PharmD, BCPS The Value of Quality over Quantity Rachel is currently the Clinical Pharmacy Manager in Specialties at Kaiser Permanente Colorado. She has almost 10 years of clinical practice experience in endocrinology and primary care as a student and resident preceptor. She is someone her students, residents, and colleagues aspire to emulate. Throughout her career, Rachel has successfully managed her many professional responsibilities while also providing exceptional learning experiences and continues to precept in her management role. In the following letter, Rachel discusses her experience using the One-Minute Preceptor approach to focus on feedback quality over quantity. Rachel’s teaching and leadership skills are widely recognized, and she has been honored as the 2014 ASHP New Preceptor of the Year, the 2013 Kaiser Permanente Colorado Teacher of the Year, and the 2016 and 2018 Kaiser Permanente Colorado Pharmacy Manager of the Year. Rachel received her PharmD from West Virginia University and completed a postgraduate year (PGY) 1 pharmacy practice residency at Cabell Huntington Hospital in Huntington, West Virginia, and a PGY2 ambulatory care residency at Kaiser Permanente Colorado in Denver, Colorado. Rachel’s precepting advice is: Focusing on quality over quantity can help all preceptors excel at providing meaningful feedback to students and residents while balancing competing priorities.

Dear Colleague, As I prepared to write this new preceptor pearl, I reflected on what I valued most 37

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from preceptors in my residency journey and how I’ve applied that to becoming a preceptor. Superficially, I highly valued preceptors who spent hours with me to sort through complex patient cases, providing clarity around inconsistent guidelines across disease states while encouraging open dialogue, or navigating important research questions. I still take this approach with residents now when it’s necessary. However, when I truly reflect on what has been the most valuable for my own growth as a practitioner and what I apply the most when I’m precepting, it is the ability to understand the approach and communication preferences of individual residents and to be able to provide concise feedback. This focus on quality over quantity is something I’ve appreciated for most of my life. My dad, a Mainer, has always said “Buy one nice sleeping bag from L.L. Bean. It’ll last you a lifetime. It’s always reasonable to invest more for quality than quantity.” In the end, this approach allows residents to recognize their gaps, appreciate their successes, and develop their own sense of confidence and autonomy to become independent clinical practitioners. The One-Minute Preceptor is a well-documented approach to precepting throughout healthcare training disciplines that provides five “micro skills” for preceptors. The five micro skills techniques are: 1.

Getting a commitment

2. Asking for supporting evidence 3. Reinforcing the positives 4. Providing guidance about gaps 5. Teaching These precepting micro skills utilize an effective method of delivering actionable feedback. I couple the One-Minute Preceptor technique with the individual resident’s specific learning, communication, and processing styles. Following this advice and leveraging these tools has allowed me to communicate on the level that is most effective for obtaining the best results of engagement and outcomes.

Utilizing the Strengths of Personality Assessments Both my PGY1 pharmacy practice residency and PGY2 ambulatory care residency employed the use of Myers-Briggs to establish a baseline resident personality overview for preceptors. This was my first exposure and adoption of exercising this type of assessment to support the communication and feedback loop. As I moved into my new career at Kaiser Permanente Colorado as a Primary Care Clinical Pharmacy Specialist, I recognized that I would need to



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provide quality feedback over the duration of the rotation versus investments of quantity of time to ensure the resident was an extension and integration of my practice. The Kaiser Permanente PGY2 ambulatory care residency already utilized the Myers-Briggs evaluation. As part of the preceptor development established within the residency program, I recognized if I had a learner with an ESFJ (extraversion, sensing, feeling, judgment) Myers-Briggs type, I needed to be gentle and more detailed in relaying positive feedback as well as areas for improvement. If I had a learner with INTJ (introverted, intuitive, thinking, and judging), I could be a little more direct, less detailed, and calmer in the approach. When my career shifted to include a leadership role and a clinical practice focused in endocrinology, Kaiser Permanente Colorado’s residency program also evolved to include a Working Styles and a Strength Finders assessment for every residency class. I’ve integrated all these assessments into providing better quality feedback for both my employees and residents. The first day of rotation, I reviewed the resident’s own “test” results with them and shared my own. (I am an ENTJ with a driving/analyzing working style and relating, learning, strategizing, deliberating, and achieving strengths.) This sets the stage for open dialogue to mitigate communication gaps that can occur between us throughout the rotation. You may think that this seems like too much work to provide one-minute of feedback! Nevertheless, how many minutes of feedback do you provide in a rotation? How many residents do you have in a year? In the end, this process establishes a sense of clarity for providing high-value, quality conversations that are tailored for residents’ improvement and are highly efficient. This is your investment in a quality sleeping bag! In addition to understanding the resident’s baseline assessment, I’ve learned to reset expectations of the individual resident by establishing a new baseline at the start of the rotation. I don’t have pretenses that every resident will excel, and I expect some may struggle in areas that are unforeseen. It’s important to not compare one resident’s strengths to another but instead to focus on: ▧▧

The individual’s strengths

▧▧

Small opportunities for improvements

▧▧

Positive reinforcement to build the confidence (or in some case reset the confidence) to move to the next rotation

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Many PGY2 residents possess strengths in the executing and relationship-building quadrants, meaning they are achievers, focused, empathetic, and harmonious. They also tend to be more “judging” in the Myers-Briggs assessment, which translates into being highly organized. I have seen a mix of sensing (detail gathers) and intuitive (big picture) preferences as well as feelers and thinkers. Each one of these combinations brings a new dynamic to the clinic as well as challenges in providing meaningful, quality, efficient feedback. For example, a rare Myers-Brigg personality in the pharmacy resident demographic is an INFP (introvert, intuitive, feeler, perceiver). In the small number of residents with this personality type, I establish basic guidelines at the beginning of the rotation for projects by clearly outlining the project’s intent, background, and deadline. For SOAP (subjective, objective, assessment, and plan) notes, I ask for as many details as possible in the objective and assessment information with a clear timeframe for check in. This will set up that quick one-minute feedback when necessary. I choose not to perseverate on the personal style of notes or of projects for most residents, especially INFPs. I also find INFPs to be particularly creative, and I do not want to hinder that strength by forcing my personal style or “right” way on them to complete a project. The most important growth opportunity is to focus on meeting deadlines in a reasonable timeframe and including enough details for others to understand their work. When check-in time comes, I can concentrate on the micro skills necessary for a quality conversation. For instance, I can ask the residents about a difficult osteoporosis case. The residents can express the patient history, laboratory test results, and recommendations. I can ask them, “Why did you lean toward treatment A over treatment B?” They have already gathered the details necessary to explain this through the expectation to provide as many details as possible in their initial note, which can be used to reinforce that they are on the right track. Finally, I can point out the value of including additional laboratory tests, such as urine calcium, and discuss how it’s important to tease out secondary causes of osteoporosis. This allows a meaningful patient-centered case experience and provides context for a later discussion around the entire disease state, which will incorporate more complex, critical thinking skills sets necessary for making future clinical decisions. This feedback loop can vary dramatically if your resident is a more achieving, driver, analytical, sensing, or judging type. Where I find this feedback particularly useful is in residency projects. This type of resident may want as many details as possible to complete a project. I often give this type of resi-



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dent a list of projects at the beginning of the rotation as I know they will strive to “mark them off the list.” The One-Minute Preceptor micro skills will come in handy in this strength type by focusing on details. Analytical or sensing residents will require more details initially as well as consistent feedback on what to keep and what is extraneous throughout the process. The resident will strive to finish the project list provided. However, they may struggle with deciding about what to include or not include. For example, if the project is to evaluate the literature around diabetes management in pharmacy-run services and to design a specific patient population intervention, the resident may spend hours gathering available literature yet struggle on important patient characteristics that would make sense for the organization. In this instance, it’s vital to provide as much context and background as possible for the resident. This can include the number of patients with diabetes, the resources available both within and outside of pharmacy, what the organization values in terms of outcomes, etc. These details can help the resident narrow the focus in the literature search and population design with you providing clear, intermediate check-ins along the way. In all feedback examples, it is relevant to consider whether the resident is a “thinker” or a “feeler.” The identification of this personality type requires the need to apply some other mechanisms of feedback that can be incorporated into the One-Minute micro skills techniques. For the feeling perceiver, the sandwich method (i.e., positive reinforcement, areas for improvement, positive reinforcement) is helpful in keeping the task on track without damaging self-confidence or the perception of the preceptor being too critical. Residents with this strength in the Myers-Briggs profile may be more prone to a sense of perfectionism. It’s important to give permission to make mistakes, but also provide the encouragement that the resident is directionally correct. Those with thinking perception types can tolerate more direct feedback, but it is still imperative to preserve a sense of achievement. In summary, the One-Minute Precepting technique combined with individual resident personality assessments can be a simple and efficient way to improve resident feedback, interactions, growth, and development. To ensure quality minutes, there must be investment up front to understand the individual resident’s strengths, personality, and communication styles. In the end, the effort made up front will provide quality minutes over quantity of minutes fostering a more independent, confident resident.

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Now, go build the future of pharmacy! Rachel

P.S. In case you were wondering, I’ve had my quality sleeping bag for 15 years. There is certainly new technology and lower temperature-graded bags, but even with the evolutions, my 15-year-old bag has provided me much warmth, comfort, and effectiveness through years of camping!

Emily Kosirog PharmD, BCACP A Millennial’s Advice on Precepting Generation WHY Emily is currently an Assistant Professor at the University of Colorado Skaggs School of Pharmacy and a Clinical Pharmacist at Salud Family Health Centers. She serves as the Residency Coordinator for the Federally Qualified Health Center Track of the postgraduate year 2 (PGY2) ambulatory care residency at the University of Colorado. As one of the first clinical pharmacists at Salud, she developed and implemented robust clinical pharmacy services that have provided care for thousands of underserved patients. She developed several collaborative drug therapy management protocols and is an active member of the Clinical Quality Team at her practice site. She is the recipient of the 2017 American College of Clinical Pharmacy New Practitioner Award and the 2018 ASHP Foundation’s New Preceptor Award. Emily received her PharmD at Butler University and completed a PGY1 pharmacy residency at Wishard Health Services (now Eskenazi Health) in Indianapolis. She moved to sunny Colorado to complete her PGY2 residency at Kaiser Permanente Colorado and hasn’t looked back. This Millennial also wants you to know she has a wonderfully supportive husband, Nate, and two adorable and crazy kids, Ben and Luke. Emily’s precepting advice is: Millennials desire a personal connection to their preceptor. Their curiousity should be approached with transparency, and their feedback should be pertinent to their progress.

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Dear Colleague, Millennials are often stereotyped as the participation trophy or special snowflake generation. In 2019, most pharmacy trainees are Millennials, and many sterotypes have crept into the educational realm. The underlying tone of most articles on mentoring Millennials has been something along the lines of “How do you solve a problem like Millennials? They are self-centered and don’t respect authority.” I’m hoping this letter strikes a different tone. As a Millennial and an educator, I feel qualified to share a few tips on how to precept pharmacy trainees in this generation. For the Millennials reading this, here is the TL;DR (for everybody else: “too long; didn’t read”): Make personal connections. Explain the why; be transparent and vulnerable. Focus on passions and strengths. Millennials by definition are the group of individuals born between the early 1980s and the late 1990s. They currently represent the largest generation in the United States and an increasingly larger proportion of the workforce. Stereotypes would suggest that Millennials only want positive feedback or “praise” (probably because of their helicopter parents), and need it instantly (they are so used to “likes” on Facebook). Research shows that most Millennials value connection—not just through social media; they are more likely than any other generation to want to live near family and friends and also contribute to their communities. They desire flexibility and creativity in their work while believing in, understanding, and supporting the purpose and values of their organization. They tend to be accepting and socially conscious. I am a Millennial. I am proud of how my generation looks out for the common good and strives to be creative in problem-solving. I fit a lot of Millennial stereotypes: I had a lot of participation ribbons from childhood gymnastics meets. (Don’t worry, they no longer spark joy, so I’ve Marie Kondo’ed them out of my life.) I can hardly remember a time without social media: I had a MySpace account in high school and Facebook in college. I’m too old for SnapChat, but I still have an Instagram account. I am passionate about social justice; I value transparency; and I really appreciate feedback. My personal and work lives both matter. Knowing these things about myself and my generation has helped me be more intentional when precepting Millennials. Although you may be uncomfortable with some of my recommendations, remember that there can be a wide variety of activities associated with each recommendation. Pick the “level” that works for you. Make personal connections. Millennials are used to being connected. Reflecting on my time as a student and resident, the preceptors who impacted me most were the ones who occasionally ate lunch with me. I did not need to



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be their friend on social media, but the simple gesture of sharing a meal and learning a little bit about my interests and family helped me gain their trust while opening the door for deeper learning. In my current role as preceptor, I try to get to know each resident on a personal level and allow them to know me. I know if I am not friendly and open, the resident is not likely to feel comfortable enough for me to be able to mentor them. Some activities I regularly employ to get to know residents better are mentoring walks and beginning-ofthe-year dinners. Mentoring walks are quick 20-minute sessions that allow the resident and me to get away from the chaos of the clinic and get to know each other a little better. This exercise provides a comfortable atmosphere to talk about expectations for the rotation. Furthermore, this helps me learn about the resident’s goals related to professional practice, and allows me to hear about other exciting things in the resident’s life. As I have expanded my confidence as a preceptor, I have been able to increase these types of activities to get to know a resident’s skill set and their personal goals. Inspired by my PGY1 residency program, I’ve held a beginning-of-the-year dinner at my house with preceptors and residents from the underserved track of the residency program. Similar to the mentoring walks, getting to know the residents’ personalities in an out-of-work setting better prepared me to mentor each of them individually. If hosting something at your house is not your style, facilitating a “welcome” happy hour at a neutral location is just as good! My PGY2 program director engaged us by hosting meals and happy hours at local restaurants. These gatherings helped us to get to know her, each other, and our new city. I know this precepting style will not work for all preceptors, but it has been one that has served me well the last several years. Explain the why. Be transparent and vulnerable. Millennials sometimes get the reputation for not respecting authority due to their persistence in asking questions and comfort in providing feedback to supervisors or preceptors. While I see how this could be perceived as disrespectful, I think it really ties to a Millennial’s desire to align themselves with the mission and values of the organizations they work for. In the same vein, it is also important for Millennials to understand how assigned tasks fit into a bigger picture. No one likes busy work if they cannot identify why it is relevant. Lately, I’ve been challenging myself with Brené Brown’s reminder, “Clear is kind. Unclear is unkind.” When I describe a project to a trainee, I ask myself: Am I clear in my instructions, but also with the scope, purpose, and intent of the assignment? Along with transparency, humility and vulnerability in a preceptor are extremely important in building a trusting relationship. I think an exceptional preceptor must be able to admit when he or she makes a mistake or feels lost,

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which I have certainly had to do! There are times when I lack discretion or communicate poorly with a resident or coworker. In these cases, I have come back to apologize to the resident and explain how I should have taken different action. This also gives residents the freedom to feel like they can express their mistakes in front of me. I have also learned to be vulnerable with residents in expressing when clinical practice activities or student situations are difficult for me to handle. For example, I remember one student whose performance was not improving despite the feedback I continued to give. The student was a smooth talker, appeared confident, and always seemed to have a legitamite reason for not completing a task or assignment. I, however, was not comfortable with the student’s frequent excuses. I expressed to my resident that I did not know what I was missing, and she astutely pointed out that this student may be really good at hiding a knowledge gap. We used a student quiz that had been redesigned by a previous resident and quickly found that this student had several major clinical knowledge gaps. We were able to work with the student to improve success on the rotation, and I was immensely grateful to the resident for helping me figure out our student’s main issues. This vulnerability provided a teaching moment for the resident and myself. Vulnerability and humility afforded me the opportunity to grow from a resident’s insight. Focus on passions and strengths. While Millennials often get criticized for only wanting positive feedback, I would challenge that stigma, and say Millennials desire pertinent feedback. Connecting your feedback to a resident’s passions and skills will go a long way to help a resident see the value of the feedback and then apply it. It is always important and pertinent to give feedback that promotes critical thinking and clinical development, but it can be even more impactful if the resident connects it to the talents they already know they possess. I am personally challenged and motivated by the Frederick Buechner quote, “The place God calls you to is the place where your deep gladness and the world’s deep hunger meet.” I am passionate about underserved patient care, Federally Qualified Health Centers, and ambulatory care. Because I had mentorship as a student and resident that helped me identify communication and medication optimization as my strengths, I followed the career path to ambulatory care pharmacy. Experiences I had during my residency at a large safety-net hospital inspired my enthusiasm for working with the underserved. I believe the success I have had in my career can be attributed to the fact that I had mentors and experiences that helped me become excited about my roles at work. My unique skill set is one that aligns well with the tasks in my position. As a preceptor, my goal is never to make residents into a mini me. My job is to facilitate growth in the areas of drug knowledge and patient-centered



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communication through timely and actionable feedback, and encourage residents to pursue areas of ambulatory pharmacy that excite them. Although no one is perfect, a good preceptor is able to mold negative qualities into something positive. For example, being aggressive can be viewed as negative, but mentoring someone to turn that into appropriate assertiveness is a definite positive! I once read a blog post (ahem, Millennial here) about the difference between teaching and mentoring. It stated “A teacher has greater knowledge than a student; a mentor has greater perspective. In this sense, a mentor is more like an editor.” I love the concept that a good mentor is more like an “editor.” To be a good editor, for example, you must know and be true to the voice of the original writer, but be skilled at refining areas of the book for clarity, and capable of helping the original writer build out ideas and concepts that already exist. I think an effective pharmacy preceptor does the same thing. A good mentor is one who knows their residents well, understands their talents and passions, and is able to refine and develop them to become the best pharmacist (and preceptor, team member, and leader) they can be. As you strive to be an excellent preceptor, remember to be open and honest with yourself and to recall (or learn) your own strengths and passions. You have what it takes! But don’t get too comfortable. Generation Z is right around the corner. 

Warmly, Emily

Robert J. Kuhn BA, BS, PharmD, FKSHP, FPPAG, FCCP, FASHP Being a Model of Professional Engagement Robert is currently the Kentucky Hospital Association Endowed Professor of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy. He holds a joint appointment as Professor in the Department of Pediatrics and as a Pediatric Clinical Specialist at Kentucky Children’s Hospital, and has worked as member of the cystic fibrosis (CF) care team since 1985. His research and clinical practice has centered on pulmonary drug delivery and drug therapy in patients with CF. Robert has participated in many clinical trials of new drug therapies, helped develop and evaluate new therapies, and has led the charge in pharmacists’ involvement in CF care. He has been the recipient of the Pharmacy Residency Excellence Award: the 2014 Preceptor Award and the University of Kentucky Pharmacy Residency Program: Preceptor of the Year. Robert served as the PGY2 Residency Program Director for 40 residents, and has precepted over 250 residents during his career. Robert received his BS Pharmacy degree from Ohio State University, and completed his PharmD at the University of Texas, Austin. He completed an ASHP pediatric pharmacotherapy fellowship at Children’s Hospital in Columbus, Ohio. Robert’s precepting advice is: Encourage learners to understand how much trust they have been given to care for patients. Set the bar at the beginning of the rotation, and move it up as the learner progresses. Be open to new opportunities, and model this for your learners. 49

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Dear Colleague, Always leave time to explore new areas or opportunities. Pharmacy has many facets as I discovered when my work life started with some exploration and change. After high school, I went to a small private Catholic college in Ohio to study for the priesthood. I lived in a seminary about 14 miles outside of town on a 1500-acre farm with nearly 50 men studying or discerning their vocation. After a long 4 years, just as I started formal seminary training, I realized I did not want to be a priest. I knew I liked to help people, but I wasn’t quite sure where I belonged. I started to think about other jobs I had while in school, hoping there would be a clue as to what I should do next. As a summer job, I had worked in a community pharmacy so I thought that might be something to explore. I always enjoyed working with the small town pharmacist whenever my schedule allowed, and the pharmacist was well respected by the entire community. After some encouragement from him and a year of chemistry, calculus, and biology courses, I was admitted to the Bachelor of Sciences program at Ohio State (OSU). Two things happened in the first 2 years: first, I got a job in a local community pharmacy and, second, I was violently threatened one Sunday morning regarding payment for a paper and magazine. I took this as a sign from God that perhaps I needed to work somewhere else. I got a job as a pharmacy technician at Riverside Hospital in Columbus; it was there that I found my home. From a technician to becoming an intern, working nearly 25 hours a week, I finally started to see the big picture. As a senior and chief intern, I was given a lot of latitude. I attended codes and trained our part-time pharmacists. These experiences even set me up for my first job. But things again changed after I took an elective course that ultimately altered my pharmacy career path—a path I have been on for the last 40 years. Because I already had my undergraduate degree, I took a few electives and graduated a bit early. I signed up for a human nutrition elective, designed to discuss the novel approach to patient care through parenteral nutrition, which was something very new in those days. The professor of the course had been working at Columbus Children’s Hospital to care for children with CF. At the end of the semester, the instructor recruited students to attend a summer camp to assist in a study for a new pancreatic enzyme product. I signed up and had my firsthand experience in a clinical study. As I quickly learned, there is simply no pretty way to measure fat excretion. The most important thing I discovered, as the only pharmacy student at camp, was how negatively the parents viewed the pharmacists. Pharmacists would often refuse to fill prescriptions for tetracycline and chloramphenicol because they thought they should not be used



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in children. But in the 1980s, these drugs were essential for patients with CF. Most prescriptions at that time were cash or charge payment, and parents were often left with a large bill. Pharmacists knew little about CF and were often a hindrance to care. I decided it needed to change. Together with other healthcare students, we set out to change the negative perception of pharmacists. Over the next few weeks, I worked with our respiratory therapists from camp to set up a service of trained volunteers who took care of the patients with CF so that their parents had a few hours to attend to other responsibilities or just take a break. As students, we would complete the chest therapy and play with the children. I saw firsthand the frustration, courage, and burden that is CF, and how pharmacy was not a part of the solution. There was one exception: one pharmacy near the hospital knew how to address CF. I decided to work with that pharmacy to take care of these kids. One of my now dear friends and mentors, Dr. Milap Nahata, helped me write a grant to test aerosols that were being compounded for these patients. We discovered some real biological contamination, and I was hooked on a career as a CF pharmacist and the importance of clinical research. I finished school at OSU and took my first job at Toledo Hospital, where I met my future wife, Jan, at a code in the cardiac care unit (CCU). After 18 months, I moved to Texas to complete a PharmD degree and residency, another growth experience for me. I originally applied to my alma mater OSU, but was not offered a position. Although I was disappointed, it allowed for tremendous growth. Texas was a demanding but invaluable experience. During my second year, I focused my training in pediatrics with the help of Dr. Rosalie Sagraves. I knew after my work at the camp, my passion would forever be in pediatrics. After finishing my training in Texas, we moved back to Columbus where I completed a fellowship. Finally my path led me to Lexington, Kentucky, to be a faculty member and clinical pharmacist at the University of Kentucky (UK) College of Pharmacy. Kentucky is the place I have called my personal and professional home for nearly 35 years. Shortly after arriving at UK, Jan gave birth to our first son, who was born premature at 35 weeks and spent 11 days in the neonatal intensive care unit (NICU). I experienced what it was like to be the parent of an ill infant. I began to understand what every CF parent goes through once they have a child admitted to the hospital. The fear and frustration parents feel for their ill child, coupled with the trust and faith of the healthcare professionals, all became real. It was about that time, while talking to a student about their lack of commitment on a pediatric rotation, that I said, “Nothing comes before the care of a sick child.”

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This statement continued to be one of my mantras during my years of clinical practice. I also adapted a phrase from one of my biochemistry professors back at OSU: “No one wants to be cared for by a mediocre pharmacist.” Together, these statements have been a driving force to educate and train students and residents, as well as to develop new clinical services at UK HealthCare. In those early days, perhaps I demanded a little too much of my residents, but it came from a deep-seated hope for them to develop into the best clinicians that they could possibly be. Now I have mellowed a bit, and I think I have learned how to do the same with less pain. I encourage all of my residents and students to understand how much trust we have been given by parents and society to care for children. We owe them our best efforts and to accept this responsibility joyfully. I set the bar at the “level” setting at the beginning of the rotation and move it up a bit each week, depending on how well the resident or student is doing. I also try to help them realize how well they have done as well as what they still need to achieve. For example, they can present the patient case concisely in half the time they could at the beginning of the week. It could be they are able to do three pharmacokinetic consults in the NICU with little assistance. Or it could be they felt comfortable talking to a parent of a new diagnosed patient with CF about starting two new medications. I have been blessed to work with some of the most talented pediatric pharmacy residents in the country, and I cherish their professional accomplishments and friendship. Finally, young preceptor, I would advise you to love what you do. In my work at UK, it seems no two days are alike, and I enjoy working with incredibly talented students and residents. I have had great mentors and now lifelong friendships with so many of my former residents. I have been credited with helping advance pharmacy’s presence as an integral member of the CF team, and many of my residents are leading the charge in the care of these patients across the country. Pharmacy has a special place for you, and I encourage you to find it. Explore your options. My code training helped me meet my wife; the rejection from OSU led me to a fantastic experience at Texas; the nutrition elective led me to CF; and my son’s illness help me truly understand the concerns and fears of parents with sick children. You will all have some important options in your ever-evolving careers. Don’t be afraid to explore new opportunities.

I wish you all the best on your journey, Robert

Dorothy McCoy PharmD, BCPS AQ-ID Nurturing Develops Achievers Dorothy is currently a medical writer at PharmaWrite Medical Communications and MedVal Scientific Information Services. She has been an Infectious Diseases/Antimicrobial Stewardship Clinical Pharmacist for over 10 years, during part of which she held an academic appointment as a Clinical Associate Professor at the Ernest Mario School of Pharmacy at Rutgers University, Piscataway, New Jersey. Her clinical practice sites have included Hackensack University Medical Center in Hackensack, New Jersey, and St. Joseph’s Health in Paterson, New Jersey. She has mentored and served as a preceptor to 32 postgraduate year (PGY) 1 residents for infectious diseases and longitudinal antimicrobial stewardship learning experiences and over 100 pharmacy students during their advanced practice experiences. Dorothy enjoys teaching and mentoring learners and inspiring them to further their education and develop their careers. Her dedication to precepting was recognized when she received the 2011 ASHP Foundation’s Pharmacy Residency Excellence New Preceptor Award and the 2017 NJSHP Preceptor of the Year Award. Dorothy earned her PharmD degree at the Ernest Mario School of Pharmacy at Rutgers University and completed her PGY1 at Hackensack University Medical Center, and her PGY2 in infectious diseases at the University of Michigan Health System in Ann Arbor, Michigan. Dorothy’s precepting advice is: Create a nurturing environment for residents that will open their eyes to new things and support them when they are willing and ready to take on new opportunities. Keep the mindset that people achieve their best when they are provided with guidance and mentorship.

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Dear Colleague, Being a preceptor is a privilege and a gift. Your life is enriched by the experiences you share with your mentees. It is a great feeling to teach others and assist them in achieving their goals. My teaching philosophy has been to foster the professional growth of residents by educating them in a nurturing environment and paying attention to them—not just as professionals, but as people. It is the preceptor’s responsibility to provide the best learning experience for each particular trainee. Residents learn best and achieve more if they are in an environment that is encouraging, motivating, and nurturing. As preceptors, it is our responsibility to maintain this type of environment to facilitate the residents’ professional and personal development. Demonstrating a vested interest for the residents’ success during your time with them and as they move on in their careers creates a lasting impact for which they will always be grateful. When they complete a learning experience with you, you can measure your success as a preceptor by the residents’ ability to think “I am a better resident, pharmacist, clinician, or person because of you.” One key component of nurturing is instilling a sense of pride in one’s work. Cultivate the residents’ ability to sharpen their critical thinking, problem solving, and time management skills using clinical and real-life scenarios to demonstrate the value of what they are learning. Show them the relationship between the information they are learning and the application of that information to a personal issue, a patient care issue, or a global issue. This is effective for residents to gain a true understanding and retention of the information, which will then allow them to impact patient care in a positive way. Initially, this may mean taking a little extra time to explain something. Or you might need to look for a different approach to demonstrate that specific scenario. However, once you catch the resident’s attention, grab hold of it and keep that momentum going to maintain their interest. Many times I would pique the resident’s interest for a specific disease state and then continue to provide examples when new cases arrived. Within time, the resident would be bringing me cases that they came across to spark discussions and continue their education on their own. Most importantly, I make sure to thank them and show my appreciation for their hard work and efforts when they help me with something. Another way to nurture is to provide feedback in an encouraging, constructive manner so that the resident is not intimidated by the critique but inspired to want to improve. Feedback is extremely important when residents are in the developmental stages of their projects or clinical responsibil-



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ities. For example, when a resident was putting together a slide deck on a new antibiotic, I made sure to provide direction and insight to set them up for an effective presentation. I tried to keep in mind that this could be his or her first time working on a presentation to deliver to an audience of physicians. I made it a point to have a discussion about why it is important to evaluate this agent for clinical practice, what information is critical to include, how to evaluate the literature to provide an objective point of view, and what questions to anticipate from the audience. This allowed the resident to see why their work on the presentation was worthwhile and that it would provide valuable education to the audience, ultimately leading to improved quality of patient care. Do not forget to provide feedback on a job well done and always pass along the feedback from others such as physicians, nurses, medical residents, pharmacy students, and medical students. In addition, encouraging self-reflection and assessment is important to promote professional and personal development. Being supportive in any situation is also necessary to maintain a nurturing atmosphere. At times we might have expectations for our residents that do necessarily match the goals they set for themselves. One is having PGY1 residents who I anticipated would pursue PGY2 residencies that decided to go directly into the workforce instead. This was sometimes surprising or unexpected news based on their excellent performance as PGY1 residents. As preceptors, it is our role to provide guidance and support for their pursuit of this next step in their career and to assist them in being successful to achieve that goal. Preceptors may have to provide support during times of the residents’ indecision about their next steps. In these situations, preceptors must be careful to mentor residents through these difficult decisions without trying to steer them in one particular direction. A good preceptor will provide them with the tools and confidence to come to a decision on their own. Demonstrating a positive attitude toward challenges further establishes a nurturing setting. Preceptors should display excitement toward problem solving and use difficult situations as learning opportunities. Be brave and bold and open new doors for your learners—whether it is taking on a new lecture, writing a paper on an unfamiliar topic, presenting at a conference, starting a new research project, or taking on a leadership role in a professional organization. If the residents approach you with “I’ve never done this before and I cannot do it,” it is your role to change the thought process to “I’ve never done this before and I can figure it out.” Show them that they have the tools needed from all of their experiences to take on new things and do them successfully. It was also my philosophy to give the residents time to have discussions, ask questions, digest information, shadow me, and practice their presentations. I

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would always maintain that the time I set aside for them was important; I let them know if I was delayed or had to reschedule our meetings. Lastly, open communication is an excellent way to foster resident development. It is important to listen and understand the residents’ needs. If the residents were not completely sure of themselves, I let them know that they could call or text me if they needed help. When they were new to my rotation I would always ask them if they felt comfortable and ready to go on rounds by themselves. When problem solving, I would ask them what they thought was the best way to handle the situation and give them a chance to figure it out on their own before providing feedback or direction. I always kept an open door policy and encouraged the residents to ask questions no matter how trivial they thought they might be. In closing, you will develop a lasting impact on those you precept if you nurture them. The tools that you provide in this respect will help them to develop into great professionals and people. Support your residents by providing them with confidence, courage, perseverance, patience, leadership, and mentorship. Never lose sight of the fact that you achieve when they achieve and that their success is your success.

Wishing you success, Dorothy

Eric W. Mueller PharmD, FCCP, FCCM Keys to Success on Rotations Eric is currently Assistant Director, Clinical Pharmacy Services and Research, and a Critical Care Clinical Pharmacy Specialist, Department of Pharmacy Services, University of Cincinnati Medical Center. He is also an Adjunct Associate Professor of Pharmacy Practice and Administration, James L. Winkle College of Pharmacy, University of Cincinnati. He has provided leadership in numerous professional organizations and specifically for the Board of Pharmaceutical Specialties (BPS), Critical Care Task Force. Eric completed a critical care/nutrition support pharmacy residency and a critical care research fellowship at the University of Tennessee Health Science Center, Regional Medical Center at Memphis. Eric completed his BS in Pharmacy and PharmD at the University of Cincinnati College of Pharmacy in Cincinnati. Eric’s precepting advice is: Your impact as a preceptor on the good habits, positive deviance, and lineage of those you precept can be as profound as, and perhaps outlast, the enthusiasm, outward appreciation, and feeling of giving back that you receive.

Dear Colleague, One of the most challenging and equally rewarding aspects of my career to-date is the dually held obligation and honor to serve as a pharmacist preceptor. As an acute care clinical pharmacist, I was raised by pharmacist preceptors who practiced under the premise that teaching is central to a clinical pharmacist’s daily responsi57

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bilities. It seems to me—evidenced by my mentors’ and preceptors’ dedication, creativity, and responsibility—that a preceptor’s essential charge is to model what is feasible, inspire what is possible, and share what is available during what will undoubtedly be a brief, albeit influential, interaction in the resident’s or learner’s career. As a resident or learner traverses the training waters to their chosen practice destination, they will encounter the good and the bad as well as the nascent habits, of many peers, colleagues, and preceptors while learning their trade. I believe that the best preceptors realize the opportunity and duty they have to individualize the resident’s or learner’s transition from asking how can they impact the care of a patient to how do they impact the life and wellbeing of another person. As a resident or learner elects to now become a preceptor, they choose consciously or subconsciously to assimilate into their professional character, values, abilities, and aspirations the traits of positive deviance (uncommon but successful behaviors and strategies that enable better solutions to problems1) that resonated most with their primary practice role. Perhaps most importantly, these traits may also become a part of their precepting practice that then are generationally refined as they are passed on through the lineages of clinical practitioners and preceptors.  In essence, there can be a sort of compounded educational interest where the positive deviance and good habits of one person are transferred to another who then further extends the trait through their unique practice or approach. When they become preceptors, the resident and learner will have the chance to incorporate them into their practice as they have refined it to affect their learners and patients and so on. I believe this is more than a simple ripple effect; rather, the trait that carries forward becomes modified and refined by the next clinician and preceptor in their context, alongside their talents, amid their opportunity, and within their application. Quite a while ago, I created a formal teaching mission statement:

As a residency preceptor, I strive to provide a meaningful, resident-specific clinical learning environment that involves direct patient care experiences, didactic teaching, and clinical presentations to enhance the learner’s abilities to become a responsible member of an interdisciplinary patient care team and provide interventional patient-specific pharmacotherapy.

The statement seems to have some of the usual elements of a personal or a brief teaching philosophy; however, it doesn’t contain enough operational content to answer any specific question to address “How?”.2 Early in my preceptor career, I had the fortune to return to Cincinnati while one of my student preceptor mentors Peter Yurkowski, PharmD, was



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practicing there. With his direct feedback, I expanded on my precepting philosophy using my brief precepting experiences and the rich service my preceptors at the University of Cincinnati and University of Tennessee Health Science Center in Memphis provided to me. From these, I developed and practiced the following points that I once framed as a critical care medicine preceptor as “Keys to Success on Rotation” beyond the assigned rotation activities or didactic learning. I also believe that they are points that a preceptor is obligated to introduce and allow residents or learners appropriate time and focus to begin practicing. Provide care and empathy for patients. It is easy for healthcare practitioners in the acute care environment to emphasize disease state management as the goal rather than patient-centered care or shared decision making. In essence, the patient, not the disease, should be the focus of what we do and how we do it, especially our precepting attitude and the activities of our learning experiences (e.g., even a journal club session should be framed around patient care). Provide patient care, not chart care. Somewhat of a corollary to above and perhaps truer now than ever, we should avoid providing computer or chart care at the expense of or missed opportunities to providing patient care. The availability of information within the electronic medical record coupled with the mobile or remote access to this information may take one even further from the bedside. We should emphasize the need to be in front of patients and physically in the direct patient care environment as often as possible. Although medical record documentation is an important aspect of our clinical practice (and it seems we are still catching up on routine progress note documentation in the acute care environment), we need to resist the temptation of providing chart care over patient care. Be efficient. From a patient care perspective (despite the major emphasis on pre-rounding activities), this can be applied to other practice domains. Efficiency leads to preparedness, preparedness leads to being informed, being informed leads to sound decisions (and convincing arguments), and sound decisions lead to optimal patient care. It is essential to know our resources, the most important of which being the patient: literally seeing the patient during pre-rounds, interdisciplinary rounds, and again later in the day. Although this is difficult when covering multiple teams or units, being available in the direct patient environment may help. I was trained to avoid a “home base” or otherwise comfortable place wherein chart care could be uninterrupted. Rather, it was emphasized to me that the

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more often one is in the patient care environment (e.g., nursing station, patient room, provider work area), the more likely it is you will have the opportunity to influence patient care. Understanding leads to recognition—we recognize what we understand. One teaching strategy I make a concerted effort to use is demystifying the otherwise mystic—I benefited significantly from a physician preceptor’s similar approach when learning to care for critically ill surgical patients. I once heard “even rocket science isn’t rocket science,” implying that once an individual’s understanding overcomes the barrier of assumed impossibilities (i.e., rocket science), understanding can be achieved. One approach to demystifying a topic is to find the closest root of a learner’s understanding of the subject matter, using even non-pharmacy/medical-related examples, to which they can relate. (An example is how we ventilate and oxygenate normally versus how the mechanical ventilator [that box in the corner of the room everyone else talks about] helps a person ventilate and oxygenate or car tire volume and pressure relationship versus lung volume and pressure relationship as they pertain to ventilator settings.) Demystifying one facet of a topic or principle frequently invites other elements into the overall recognition of patient care plans and goals (e.g., understanding ventilator settings as a therapeutic monitoring parameter for sedation, analgesia, neuromuscular blockade). Learn how you learn. There is a remarkable emphasis on learning styles in today’s academic environment. Although it is important for a preceptor to understand the learning style of a resident or learner, perhaps the most important reason for an individual to know their learning style is for their continued self-learning. Self-learning is an essential part of professional development and responsibility as a clinician. Because most residents and clinical pharmacists identify as lifelong learners, self-learning activities become the main curriculum post-residency and throughout one’s career. Understanding one’s own learning style can also help promote educational efficiency when time is often limited as well as the opportunity to seize understanding rather than relying on memorization. See the big picture. There is sometimes an overwhelming amount of data presented for consideration while providing patient care. The most apparent are the wealth of clinical data in the electronic medical record and at the bedside (e.g., monitors, devices), and primary evidence or tertiary resources referenced while considering clinical interventions and learning about the illness(es) at hand. In a discussion of “lumpers” versus “splitters,” it is important to emphasize that both strategies have their place during assessment. However, in the



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end, it will likely be the big picture of the patient’s illness or clinical needs that will be most important to the clinical care decision. Develop a pharmacotherapeutic plan. “What do you want to do?” is a question that should be asked at the end of every patient problem list or system list (perhaps more likely in the intensive care unit) that is presented to a preceptor. A wealth of clinical data to that point has been reviewed, collected/ abstracted in some way, and now verbalized or uncovered under your guidance. The goal now should be to have the resident or learner practice making a clinical decision and developing a plan from their assessment to communicate to their team for collaborative consideration. Communicate effectively. Even the best pharmacotherapeutic plan if not communicated well (i.e., timely, clearly, directly, collaboratively) will go unimplemented. Give your residents and learners the opportunity to practice communicating their clinical perspective and pharmacotherapeutic plan rationale. Aside from realizing the internal factors (e.g., verbal and nonverbal communication style; level of understanding, and “cool” to effectively navigate discussion) and external factors (e.g., availability, willingness, and patience of the receiving party; interpersonal interactions; communication medium), an important element to be learned—through modeling first—is when to escalate. One of my mentors frequently emphasized “diplomacy when you need something done; persistence and resolve when the patient needs something done.” This may seem misguided as all that one seeks to do could be categorized as for the patient. However, there are examples of clinical interventions that are minor or moderate refinements, albeit important, to the pharmacotherapeutic plan or process-of-care that a collaborative discussion during rounds results in staying the original course. In contrast, for instances where major patient outcomes and patient safety can be eminently affected, it is important for residents and learners to understand the duty, approach, and appropriate pathway for escalating toward resolve. One more closing thought: In my opening, I used the term pharmacist preceptor. This is the best way to describe the broader opportunity we have as healthcare educators to influence not only pharmacists-in-training but each other as interdisciplinary practitioners. For example, I consider having had numerous nonpharmacist preceptors: from the medical physiologist turned pulmonary/critical care medicine fellow in the MICU; to the internal medicine attending who modeled an evidence-based practice; to my physician and nursing colleagues in the trauma intensive care unit at the Elvis Presley Trauma Center who exemplified service to the greater good; to the trauma surgeon who

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took me under his wing to help demystify myriad nonpharmacologic aspects of taking care of complex, injured patients. This, too, can be a role for a pharmacist in the informal training and practice influence of other disciplines. As long as one has an attitude of responsibility, sufficient aptitude in the matter at hand, and noticeable availability, then the opportunity to teach others the precepts of best practices (e.g., clinical, educational, research, administrative) can extend beyond an otherwise pharmacy-centric audience. Although perhaps most often without a formal assigned role, the impact that the pharmacist can have as an educator on the interdisciplinary team is remarkable.3 Remember, your impact as a preceptor on the good habits, positive deviance, and lineage of those you precept can be as profound as, and perhaps outlast, the enthusiasm, outward appreciation, and feeling of giving back that you receive.

Sincerely, Eric

References 1.

Basic field guide to positive deviance approach. the positive deviance initiative, Tufts University. 2010. Available at www.positivedeviance.org. Accessed May 28, 2019.

2. Teaching philosophy statement. Cornell Universtiy Graduate School. Available at https://gradschool.cornell.edu/academic-progress/pathways-to-success/preparefor-your-career/take-action/teaching-philosophy-statement/. Accessed May 28, 2019. 3. Starring roles: The four preceptor roles and when to use them. ASHP. Available at http://www.ashpmedia.org/softchalk/softchalk_preceptorroles/softchalk4preceptorroles_print.html. Accessed May 28, 2019.

Jennifer M. Namba PharmD, BCPS Keep It Simple and T.E.A.C.H! Jennifer is an Associate Clinical Professor of Pharmacy and the Assistant Director of Interprofessional Education and Simulation at the University of California (UC) San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. She is a past recipient of the ASHP New Preceptor Award. She has also been recognized with the Barbara and Paul Saltman Distinguished Teaching Award at UC San Diego and Student and Pharmacy Residency Preceptor of the Year Awards at UC San Diego Health. Jennifer received her PharmD from UC San Francisco. She completed a postgraduate year (PGY) 1 pharmacy practice residency at the University of Washington and a PGY2 critical care residency at UC San Diego Health. Since beginning her clinical practice 12 years ago, she has precepted over 150 students and residents and served as the PGY2 Critical Care Residency Director at UC San Diego Health. She currently specializes in transitions of care for patients with advanced heart failure. Jennifer’s advice is: Being a preceptor is one of the ultimate rewards and challenges of being a pharmacist—learn from others to simplify what you can and make time for the ventures that excite and make you happy. My pearl for you is just T.E.A.C.H!

Dear Colleague, I can honestly say that precepting is one of my primary motivations and joys about being a clinical pharmacist, and I am extremely grateful to have this privilege. As pharmacists, we share a common desire to provide optimal patient care. For 63

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many of us, this also includes a passion for teaching others how to do the same through precepting. What makes a good preceptor? If you are like me, there is no magic switch that instantly makes you feel prepared to precept. As I transitioned from residency to my own clinical practice, I had the misconception that I would be leaving my “student life” behind. I quickly realized that precepting is an integral part of our lifelong learning as pharmacists. I hope this letter will provide some practical pearls to make the start of your precepting journey successful and rewarding. I have been fortunate to work with extremely talented pharmacists and preceptors, as I am sure you have, too. How can you use their lessons to enhance your impact as a preceptor? Although few precepting styles are the same, my most influential preceptors shared several commonalities. Integrating these themes has been extremely helpful in my practice.

PEARL #1: Keep It Simple As a new student struggling with the complexity of intensive care unit patients, Dr. Kevin Box shared a lesson that initially surprised me: “Keep it simple.” In your practice, precepting, and life, look for opportunities to simplify and standardize, so you have more time to focus on the things that excite you. Filter out extraneous distractions that bog you down or add unnecessary stress. Simplifying life as a new preceptor is easier said than done, so learn from those around you and work together.

PEARL #2: Build Your Precepting Style Around a Standard Framework = T.E.A.C.H. T: Take time to orient and teach E: Establish expectations, engage and encourage your learners A: Advance responsibilities for your learners and yourself C: Constructive feedback H: Humble and happy

Take Time to Orient and Teach Our daily practice responsibilities typically overfill our plates, and there is rarely enough time in the day to accomplish everything we would like. As preceptors, we have to make a concerted effort to carve out time for our learners.



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Take time to orient. With expanded opportunities to rotate through nontraditional settings, you may often encounter learners who are new to your practice model or institutional system. Dedicating time for a standardized orientation improves your learner’s readiness to hit the ground running. It also provides a guide for fellow preceptors to assist with orientation, so you can delegate this responsibility if needed. As Allen F. Morgenstern said, “Work smarter, not harder!” ▧▧

Clearly outline your rotation goals and expectations.

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Describe daily workflow and the learner’s roles/responsibilities.

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Discuss the learner’s rotation goals and prior experience.

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Orient to computer systems, institutional resources, and communication methods.

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Introduce learners to key people and the location—establish and endorse your learner’s role by taking time to introduce them to the team they will be working with. Accept that teaching anything takes longer than doing it yourself, but

investing the time up front will start your learner on the right track. A lesson learned from Dr. Linda Awdishu is to consistently model how you review patients with every learner. I used to assume this practice would be redundant, particularly for residents who were already familiar with the institutional setting. However, learners provide positive feedback about this approach. Integrate other components of your orientation agenda into this patient review, and if possible, let the learner navigate the system as you coach. Take time to teach. Daily teaching is the heart of any learning experience, but finding ways to make time for precepting can be a challenge. ▧▧

Schedule learning activities for the rotation and provide your preferred templates or guidelines (e.g., topic discussions, journal club, patient presentations). Learners appreciate the structure and are better prepared when they can plan for activities. Give learners advanced notice to prepare for impromptu assignments.

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Find teaching moments throughout the day to engage your learners. Good teaching doesn’t have to occur on a schedule or last for a minimum amount of time. Activities that may be routine for you are often teaching opportunities for new learners. Involve them as you make decisions or interventions during the day. Take a few minutes to quiz, teach, or request follow-up about the topic. If you are busy, this strategy keeps learners engaged while

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you address other responsibilities. Give your learners ownership by making it their responsibility to follow up with you. ▧▧

Teach in teams. Don’t feel like you have to do all of the teaching yourself. Team up with residents or preceptors so a single preceptor can teach multiple learners at once. Residents enjoy the precepting experience, and students benefit from team learning. Rotating the teaching responsibility can reduce your time burden and prevent burn-out.

Establish Expectations, Engage and Encourage Your Learners Establish your expectations as a preceptor and engage learners to define shared goals. As an ICU preceptor, I realized that not all of my students loved critical care as much as I did. You are likely to encounter learners on a career path that is vastly different from your own. Don’t shy away from the discussion. If you notice a lack of engagement, begin a dialogue early on. Explore their priorities and work together to identify and achieve skills that apply to their career goals. Readdress progress regularly, but accept that you won’t convert every student to love what you do. Reflect on lessons learned and savor the small victories! Encourage your learners! As you develop your precepting style, keep in mind that being tough and encouraging don’t have to be mutually exclusive. I teach with a smile and believe in guiding learners to find their own answers, but make it clear that expectations need to be met. Whatever your style, motivate and encourage your learners by establishing shared learning objectives.

Advance Responsibilities for Your Learners (and Yourself!) Our goal as preceptors is to help learners earn recognition as the primary pharmacist by practicing independently, effectively, and efficiently. Use your orientation to gauge each learner’s starting point and sequentially apply the four ASHP preceptor roles: instruction, modeling, coaching, and facilitating. Although it is often faster and easier to implement the plan yourself, help new practitioners establish credibility with the team by modeling and coaching them through their interventions. ▧▧

Ask learners to present their verbal recommendations to you before engaging with a provider or team. Role-play scenarios in which their recommendation is not accepted or understood. Consider being present during interventions to provide additional support.



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Proofread written communications. Asking concise questions or making recommendations via page requires practice! Facilitating is most likely achieved by residents, but if you feel a student

is ready, make the most of their independence! Precepting is a time investment, but well-trained learners can be valuable assets for completing your daily responsibilities. Maintain your work−life balance, and don’t let the responsibilities to your learners replace your own professional growth. One of the biggest challenges I faced as a new preceptor was how to balance work, teaching, research, and service. I always loved teaching, so spending extra time on precepting or projects was not initially a burden. However, a growing family shifted my work−life balance. As your work−life responsibilities change, take time to reassess your priorities. With two small children, I had to adopt more efficient precepting strategies and eventually embarked on a new path in academia. Your life as a pharmacist is likely to change more than once throughout your career, so be open to new opportunities that expand your skillset and impact on the profession. Your learners will benefit from your added experience and be inspired!

Constructive Feedback Constructive feedback is a fundamental skill for effective precepting, but no one enjoys delivering negative feedback. While it is tempting to say nothing and hope for improvement, timely feedback is vital to provide your learners with opportunities to improve. ▧▧

Make it clear to the learner that feedback is being provided. Surprisingly, many learners do not recognize when they are being given informal feedback. Preface your feedback with a simple statement like, “This is feedback.”

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Ask the learner to self-assess their performance first. Most learners recognize their weaknesses and often point them out before strengths. This approach can also identify learners who are unaware that their performance is suboptimal.

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Provide and request feedback regularly. We do a disservice to struggling learners by waiting too long to provide constructive feedback. Look for debriefing opportunities throughout the day to provide immediate feedback about specific skills, both positive and constructive. Our precepting team implemented Feedback Fridays, weekly reviews of two-way feedback to improve learner performance and the rotation experience.

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▧▧

Communicate verbal and/or written feedback among the precepting team and learner. Feedback should include concrete action items. We share a written summary with the learner and precepting team to direct future teaching activities toward the identified goals.

Humble and Happy Be humble. As a new preceptor, I felt that I had to be the expert to teach my students and residents. However, as my practice has become more specialized, I acknowledge that I don’t know it all and make mistakes. Share your miss-steps with learners to highlight best practices and the value of self-assessment. We thrive on lifelong learning, but you will get busy with less time to achieve expertise in every area. Take advantage of learning from your students, residents, and colleagues. I admit when I don’t know something and give my learners ownership to take on the teaching role. Your learners will take pride in educating you and it primes them to become the next generation of preceptors. Be happy. I sincerely hope that you find happiness and satisfaction wherever your career path takes you. There will be good and bad days in any job, even the perfect one. I challenge you to learn from the bad and don’t let negativity take over. Even on the toughest days, you can find something positive you did for a patient, colleague, learner, or even yourself. As Dr. Farivar Jahansouz advised me, “Why stress about it? It doesn’t help anything. Be happy and appreciate every day.” Learners keenly observe our attitudes and how we approach our jobs, so sharing our setbacks and coping skills can be as valuable as teaching them practice skills. Embrace the joys, challenges, and privilege of being a preceptor! When I asked my 7-year-old son what makes a good teacher, he said, “They show you where to look, but not what to see… What does that mean, Mom?” Throughout your career, you will refine and adapt your practice and precepting skills to craft your own response to my son’s question. I look forward to seeing how you will guide the next generation of learners to be the future of our amazing profession. May you find happiness in your career, learn from others, find ways to keep things simple, and maintain your passion for precepting as you T.E.A.C.H!

Wishing you all the best, Jen

Elizabeth Anne Neuner PharmD, BCPS, BCIDP Socratic Teaching – Precepting through Questions Elizabeth is currently an Infectious Diseases Clinical Coordinator and Residency Program Director for the Postgraduate Year (PGY) 2 Infectious Diseases Residency at Cleveland Clinic. Her contributions in infectious diseases and residency training have been published in numerous peer-reviewed journals. She is dual board certified in pharmacotherapy and infectious diseases. Elizabeth is also the recipient of the ASHP Foundation’s New Preceptor Award (2012). She is grateful for her mentors and colleagues at Cleveland Clinic for continuing to ask her challenging questions and tolerating her many questions in return. Elizabeth completed her pre-pharmacy coursework at St. Louis University and received her PharmD from the St. Louis College of Pharmacy (2006). She completed her PGY1 and PGY2 infectious diseases residencies at Barnes-Jewish Hospital in St. Louis, Missouri, where she had experience firsthand trying to answer the many thought-provoking questions from her preceptors. Elizabeth’s precepting advice is: Precepting through questions can be an effective strategy when preceptors are thoughtful and purposeful in their selection of questions. How Socratic have you been to your trainees?

Dear Colleague, Socrates was an ancient Greek philosopher often remembered for his use of questions to teach critical thinking. From early philosophy to pharmacy residency training, the use of questions as a precepting method has become quite commonplace. Preceptors ask questions 69

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to residents for a variety of reasons: gauge knowledge base, build confidence, illuminate concepts, model thought process, and develop critical thinking. This precepting pearl is focused on being thoughtful and impactful with the questions you ask to pharmacy residents. I often warn residents during our pre-rotation meeting that my precepting style includes asking a lot of questions. Early in the rotation, many of my questions are narrowly focused and aimed at the base of Bloom’s Taxonomy, for example: What are the adverse effects of voriconazole? What are the most common pathogens in skin and soft tissue infections? These types of questions can help the preceptor and resident determine the residents’ baseline knowledge and gauge how fast to move up on Bloom’s Taxonomy. Residents will need to have an appropriate knowledge base on the subject matter to participate in answering questions aimed at developing and building critical thinking skills. If the resident needs assistance with remembering or understanding key or basic principles, you can provide direct instruction or assign reading to provide the foundation of knowledge. When the resident has a good baseline knowledge, his or her ability to answer more focused questions can help build confidence and progress to higher level questioning.

Building Connections through Questions My favorite reason to ask questions is to help illuminate concepts for residents. Many residents have silos of knowledge, and asking questions can help establish connections, which is crucial for clinical practice. As an infectious diseases practitioner, I can’t resist the analogy of the transglycosylation and transpeptidation forming the crosslinks in the peptidoglycan structure of the bacteria cell wall. These connections often provide stronger and long-lasting retention than rote memorization. For example, if the resident can’t recall the answer to the question, “What is the spectrum of activity of ceftriaxone?” I routinely follow-up with additional questions that allow them to draw the information from another existing location. Examples of follow-up questions may include, “What order-sets do you verify ceftriaxone orders from?” The resident may answer, “The colorectal surgery prophylaxis orders.” Then follow-up with, “What can you infer about the spectrum of activity if ceftriaxone is used for this indication always in combination with metronidazole?” Hopefully you’ll see the light bulb illuminate and the resident recognize that ceftriaxone must not have good anaerobic activity. The purpose for this type of questioning is two-fold: to link concepts within their knowledge base and demonstrate a strategy for approaching a question.



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Asking questions can also be a method by which you can model your thought process to residents. I will often remind residents that they will likely never have the answers to every question, especially in the evolving field of medicine. So instead, it is important to understand the right questions to ask and how to ask them. When I’m asked a patient care question from another pharmacist or provider, rarely can I answer without asking at least two to three questions in return. I often discuss with the PGY2 residents about the importance of asking clarifying questions to ensure they are getting to the crux of the issue. For example, perhaps a pharmacist colleague is asking for your opinion on a vancomycin dose adjustment based on a level. Your answer may change based on the pathogen, indication, clinical status, trend in renal function, response to therapy, etc. Asking questions back is not an avoidance tactic, but instead a way to model all the factors one should evaluate prior to answering a question. This might also help explain why my favorite answer when residents ask me a question is, “it depends!” Sometimes—by listing all of the variables I’m considering and how they would influence my answer—by the time we get back to the original question, the residents have figured out the answer themselves. It’s also important for preceptors to acknowledge when they don’t know the answer to questions and to model “thinking out-loud” to the residents. Discuss with the residents what follow-up questions they should be asking themselves and where they are going to look to find the answers before answering the question. Providing residents with the best resources can help them become more efficient in their processes. One final reason for precepting through questions is to help residents develop critical thinking skills. As preceptors, this is often the ultimate goal for our trainees. These types of questions should be focused less on the base of Bloom’s Taxonomy (i.e., remembering the pharmacokinetics of vancomycin or understanding the role of the complement system), but instead on the higher orders of analyzing (i.e., examine the antimicrobial regimen for appropriateness), evaluating (i.e., summarize the pros and cons of using combination therapy for sepsis), and creating (i.e., design a new antiretroviral regimen taking into account patient-specific factors). Socratic questioning should be probing to ensure the residents not only have the right answer but for the right reason(s). Often there is no single correct answer, so these questions should be directed at understanding the rationale for why one therapy might be preferred over another in a specific patient. For example, ask the resident to describe the advantages and disadvantages of three different treatment regimens for disease state X in patient Y. To aid residents in making critical evaluations, consider using questions to help them apply information from previous patient

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cases to the current situation. Preceptors can be creative in the design of these sessions, for example, having residents prepare to debate which antibiotic is better for the treatment of Clostridiodes difficile infection—vancomycin or fidaxomicin?

Socratic Questioning ≠ Pimping It’s important to acknowledge that the use of Socratic questioning is not synonymous with the method of pimping, which is common in the healthcare setting. The art of pimping in medical education often traces its roots to Dr. Brancati’s editorial in 1989 in which he described pimping as a series of difficult questions from an attending, or preceptor, to a trainee.1 One of the key factors to these “essentially unanswerable” questions is the underlying motive which is “political” in nature and designed to reinforce the trainee’s place in the hierarchy of the medical team, rather than foster critical thinking skills. There are several categories of pimp questions, according to Dr. Brancati, and examples include arcane points of history (Who really discovered penicillin?), teleology and metaphysics (Why are some organs paired?), exceedingly broad questions (What is the differential diagnosis for leukocytosis?), eponyms (almost any question relating to the name of microorganisms), and finally technical points of laboratory research. Often these questions are designed more to humiliate or embarrass the trainee instead of teach. Although advocates of pimping suggest the pressure and nature of the questions help with retention, this strategy is being increasingly scrutinized. Two more recent editorials on pimping published in The Journal of the American Medical Association review the pros and cons of this approach and discuss if and how pimping should remain a prominent educational strategy in medicine.2,3 Similarly, pharmacy preceptors should be thoughtful when precepting through questions. Ensure your questions have a purpose other than demonstrating your knowledge. If you can’t resist questions about pharmacy trivia or esoteric medical knowledge, consider framing the reason why you are asking the question. For example, if the attending physician with whom the resident will be working loves to test pharmacy residents on their knowledge of the history of antimicrobials, then you are adequately preparing them for rounds. In addition to avoiding too many specific trivia questions that don’t promote critical thinking, preceptors should also avoid the read-my-mind questions. These are questions that may seem perfectly logical in a preceptor’s head, but in reality are too expansive or vague for the resident to follow along. I can usually tell when my question fails by the silence and blank looks on the resident’s face. In these instances,



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consider acknowledging that you’ve asked a less-than-optimal question and try again by rephrasing, providing additional background information, or asking a series of questions leading up to the original concept. Similar to medicine, precepting is an evolving practice, and we are always learning. The use of Socratic questioning is a powerful tool in which preceptors can promote critical thinking among their trainees using a continuous active learning environment. Fulfilling the role of Socrates as a preceptor, however, takes patience and practice; it forces you to continually assess your trainees’ knowledge with each question asked. Thanks for reading—Any questions?

Sincerely, Elizabeth

References 1.

Brancati FL. The art of pimping. JAMA. 1989;262(1):89-90.

2. Detsky AS. The art of pimping. JAMA. 2009;301(13):1379-81. 3. Reifler DR. The pedagogy of pimping: Educational rigor or mistreatment? JAMA. 2015;314(22):2355-56.

Recommended Reading Kost A, Chen FM. Socrates was not a pimp: Changing the paradigm of questioning in medical education. Acad Med. 2015;90(1):20-4. Oyler DR, Romanelli F. The fact of ignorance: Revisiting the Socratic method as a tool for teaching critical thinking. Am J Pharm Educ. 2014;78(7):1-9.

Beth Bryles Phillips PharmD, BCPS, BCACP, FCCP, FASHP Set Your Standards High … and Help Them Achieve! Beth is currently Rite Aid Professor, Clinical and Administrative Pharmacy, University of Georgia, College of Pharmacy. She has served as a Residency Program Director for over 20 years and has mentored and trained over 65 postgraduate year (PGY) 1 and PGY2 residents at the University of Iowa and University of Georgia. She is currently a Residency Program Director for the University of Georgia PGY2 Ambulatory Care Residency. She has served on and chaired the ASHP Commission on Credentialing. Beth is Associate Editor for the Journal of the American College of Clinical Pharmacy. She received her PharmD degree in 1994 at the University of Kansas and completed a pharmacy practice residency at the University of Illinois, Chicago, and her ambulatory care specialty residency at the VA Medical Center, Iowa City, Iowa. Beth’s precepting advice is: Reflect on your experiences and identify key factors that led to success in your career. Chances are those elements will help the next generation of pharmacists.

Dear Colleague, Everyone who practices in a setting where residents are trained is a preceptor in their own way, whether they are directly and

actively

providing

feedback,

or

serving as a mentor or role model. Their actions and approach to the profession (and beyond) are noticed by residents. 75

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Being a preceptor is one of the most rewarding activities to engage in within the profession. Everybody has their own story to tell, and there are many books written on this topic! I hope to share the secrets to my success I have found during my journey. Many people have contributed to my professional successes. Although too numerous to list, I know they will recognize their role in my development as a preceptor and the influence they have had on how I approach precepting. I don’t remember the details: the location—class, professional student organization event, or while working as a hospital pharmacy intern; or the year—first or second year of pharmacy school; or the person—faculty member, guest lecturer, or a respected pharmacist at work. All I know is that the first time I heard about residency training, specifically the opportunity to receive one-on-one training and mentorship while impacting patient care, I knew that’s what I had to do. I began to seek opportunities for more direct patient care experience outside of the classroom. All of the pharmacists I spoke with told me the same thing, “You need to do a residency.” I didn’t realize it at the time but these pharmacists were modeling an important element that helped shaped my career, which is mentorship. Just as what these pharmacists did for me, I wanted to give back and help others find their true passions and opportunities to excel. I obtained a summer internship in clinical pharmacy (that’s what it was called at the time, but it was really direct patient care). All of the pharmacists at the hospital were instrumental in shaping the pharmacist I am today, but there was one pharmacist in particular who really challenged me to present the best data, give the most engaging presentations, write comprehensive reviews on drug topics for newsletters, get board certified, and go for the residency—not just one, but two! I took all of that with me to residency. I brought a lot of passion and enthusiasm to residency training for patient care and “all things pharmacy.” My first-year residency preceptors harnessed that energy, made sure I collected the appropriate patient information to make the best recommendations, ensured that I found pertinent information in the chart and wrote thorough yet concise progress notes in the medical record, and were serving as role models for collaborations with the physicians and nurses. They encouraged me to dig deeper into the literature, to be the expert on a topic, and translate drug facts and study results into clinically useful information. Moving into my second-year residency, my preceptors recognized my professional passions and gave me additional opportunities to complete a robust residency research project, present at a regional professional pharmacy



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meeting, teach a class at the college of pharmacy, and publish a review article in a professional journal. They were giving me feedback along the way, such as utilizing various reports and shortcuts to help me find the best information for my patients, asking the right follow-up questions of my patients, presenting information in an organized fashion, and tailoring presentation information to the audience. Fast forward to my own career and now I’m a preceptor. In the early years, my sense of preceptorship was fueled by the excitement I had (and still have) for the profession. A major theme of pharmacy practice in those days was widespread growth of clinical pharmacy services, particularly in the ambulatory care areas for disease state management of primary care disease states but other areas as well (now known as collaborative drug therapy management or collaborative practice agreements). Much of the work that I did with residents was related to maintaining current services while growing new ones; forging relationships with new providers; and delivering high-quality, timely, and practical drug information in the form of Grand Rounds presentations, in-services, and other contributions to medical resident education, newsletters, and manuscripts for publication. It was a great training environment, and the residents excelled. I developed great relationships with the residents I mentored. They were happy and seemed to enjoy their experiences; maybe most important, they secured fulfilling positions related to their training. We followed the process and applied for accreditation of the residency as early as possible. As luck would have it, we engaged in on-site residency accreditation surveys twice in a 4-year period due to the practice of surveying programs early if needed to get all of an organization’s programs on the same accreditation cycle. I wasn’t excited about being surveyed so close together. As everyone knows, program directors, pharmacy administration, and preceptors must dedicate a lot of resources, time, and effort into putting together a pre-survey packet. Additionally, you are always “on the spot” for answering questions on behalf of the programs and take responsibility for the outcome of the survey. I was nervous that I wouldn’t represent the program well, that I wouldn’t know the answer to a question being asked, or that all of our hard work would be seen as not good enough for our residents. However, looking back on it now, I see those two surveys as being instrumental to the changes I made in my own precepting style going forward. I learned a lot about the residency standard during those years and the elements of good residency training programs. We also received feedback that made me question how I precept residents and critically evaluate our processes for helping residents grow and succeed.

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Reflecting on my own style of precepting, I began to ask myself questions. Am I giving enough feedback to residents when they are doing a “great job”? What about those residents who seem to have it all together? Are they being encouraged to take their performance to the next level? What about continuing to grow in other areas of the profession? What about residents who need feedback to improve a particular aspect of practice or performance within the profession? Was the feedback specific enough so they knew exactly what was needed to improve the performance? Was feedback given in a supportive way? Was the resident motivated to perform better? Did I provide enough modeling so that expectations were clear? I continue to ask myself these questions every year as I consider the residents I am working with, their strengths, and areas for improvement. I, too, have grown a lot over the years, and matured in my precepting style. What follows are the important lessons I have learned or improved upon over time. Many of these elements were developed straight from feedback I received from residents about what worked and, reflecting on circumstances, that I felt could have gone better. My keys to precepting success are as follows: ▧▧

Keep your standards high!

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Meet residents where they are, and help them grow from that point.

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Be transparent.

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Precept and lead by example.

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Stay organized and hold residents accountable too.

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Make residency training a priority.

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Don’t forget about personal as well as professional development. Keep your standards high: Hunter S. Thompson, a journalist, once said,

“Anything worth doing is worth doing right.” I hold myself to this standard, and I carefully consider professional opportunities. I expect the same from the residents and give them the support and feedback they need to produce high-quality work. Past residents reflecting on their experiences have commented that they appreciated the expectations for quality of their work. A few past residents told me when they have a dilemma, they often think, “What would Beth Phillips do?” Meet residents where they are: All residents come in to the program with a set of skills and characteristics that make them unique. The fun part is figuring out what those attributes are and building on them. Even those residents who seemingly have the patient care, efficiency, and organization under control still have areas for growth. The key is challenging those residents and identifying additional opportunities for them during the year.



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Be transparent: Communication is an important key to success for any training program. I always make sure to keep the residents informed of any changes that may affect the program or any updates in the practice area. Precept and lead by example: I never ask the residents to do anything that I haven’t done. We ask a lot of our residents, and it is only fair if I am in the trenches as well and staying current with issues. Likewise, how can we expect residents to become leaders within the profession if we are not active in professional organizations ourselves, are board-certified, or disseminate knowledge through publication in the literature? A colleague has a saying that the preceptor should not be busier than the residents, so while we laugh and joke with the residents, I do consider this. I always look to myself and evaluate whether I have been clear with expectations and their responsibilities. When I find that there is a gap between those two areas, I work to resolve it. Stay organized: An important component for any successful project, program, or service is organization. Knowing when deadlines occur and planning for them prevents much stress and anxiety later (not to mention missed deadlines). I expect the same of residents and ask that they organize the content for our weekly meetings. I also keep a list of discussion points and add it to the meetings. Make residency training a priority: I ensure that residents are a part of my daily and weekly routine. I balance my own scholarship, service, and professional organization activities to ensure that residents can be a part of almost everything I do. For example, research projects and invitations to serve as a journal reviewer for manuscripts become opportunities for residents to be involved and learn. Don’t forget about personal and professional development: When residents train with me, I get to know them personally as well as professionally. We tailor their projects and residency requirements to their interests and career goals. When it is time to pursue career opportunities, I help the residents make decisions based on their strengths, family priorities, and opportunities for growth. Residency training is my passion. I am so grateful for all of the opportunities I have been afforded in my career; I would not be where I am today without my residency training. Reflect on your experiences and identify key factors that led to success in your career. Chances are those elements will help the next generation of pharmacists. Good luck as you set your standards high and help residents achieve!

All the best, Beth

Jane M. Pruemer PharmD, BCOP, FASHP Residency Accreditation Accolades Jane’s career is an example of a clinical pharmacy specialist becoming involved in advancing the profession through her involvement in residency training and accreditation of residency programs. Her involvement in the advancement of oncology pharmacy services and oncology pharmacy education has given direction in her career and satisfaction in improving pharmacy services to patients with cancer. Jane is currently Professor Emerita at the James L. Winkle College of Pharmacy at the University of Cincinnati Medical Center. Jane received her BS in Pharmacy from the St. Louis College of Pharmacy, then practiced as a hospital pharmacist for the next 2 years. She completed her PharmD at the University of Kentucky, and completed an ASHP-accredited clinical pharmacy residency at the Hospital of the University of Pennsylvania. Upon completion of a research fellowship at the Philadelphia College of Pharmacy and Sciences, she began her oncology pharmacy practice at the University of Cincinnati Medical Center. A highlight of her professional activities was her service to the Commission on Credentialing at ASHP, serving as Chair in 2004. Jane’s precepting advice is: Recognize and value the significance of pharmacy residency training. A completed ASHP-accredited residency program is priceless in any pharmacy career. Set yourself head and shoulders above others by accomplishing the goals set up by your program, and you will be successful.

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Dear Colleague, Throughout my pharmacy career, I have viewed one of my most valuable experiences to be my residency training. I can recall as a pharmacy student being told that a residency would provide me with the equivalent of 5 years of pharmacy experience in 1 year. Since I was so anxious to begin a career as an oncology pharmacy specialist, I could not imagine a better start to providing pharmacy services to patients with cancer than by first completing an ASHP-accredited residency. I found out that completion of a pharmacy residency was challenging in terms of time and increasing my knowledge base, but I believe that every moment invested in my program was extremely worthwhile. In retrospect, I would never trade my residency experiences for anything else.

Values of Establishing New Programs and the Accreditation Process After completing my first 2 years of practice as an Oncology Clinical Pharmacy Specialist at the University of Cincinnati Medical Center, I developed an oncology pharmacy specialty residency in 1988. My first resident had completed her PharmD degree and a general hospital residency prior to becoming my first oncology pharmacy resident. This was before the designations postgraduate year (PGY) 1 and PGY2 were used by ASHP. My resident and I actually developed the program together, and I realized how much my first resident contributed to the success of the program. The residency was outstanding, and major projects included the design of an oncology pharmacy satellite at the newly constructed Barrett Cancer Center as well as a project assessing fluorouracil stability and compatibility with mannitol. We were very successful and published a paper on the fluorouracil project in addition to a review paper on carboplatin. We applied for ASHP accreditation at the end of that first year, and were happy to find out later that we had received accreditation. Over the next 28 years, I participated in the training of numerous oncology pharmacy residents, serving as Residency Program Director (RPD). In addition, I served as a Preceptor for the PGY1 residency program, instilling in our pharmacy residents a better understanding of the role of the clinical pharmacist in the care of cancer patients. Many of the PGY1 residents decided to do a PGY2 oncology pharmacy residency under my direction, supporting my belief that our program provided quality training for future oncology pharmacists. I can say with confidence that I have had the privilege of training some of the best oncology pharmacists in the United States. Knowing that their residency program was accredited allowed these pharmacists to move forward with their



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careers and helped them to advance oncology pharmacy services in their future positions. A few years after ASHP accredited the oncology pharmacy residency, the Accreditation Services Division of ASHP asked me to serve as a site surveyor for PGY2 oncology residency training programs. Currently, the Accreditation Services Division houses the Commission on Credentialing (COC), which is the professional body that accredits pharmacy residency training programs. Under the governance of ASHP’s Board of Directors, the COC establishes residency program standards and provides the means to review programs for accreditation. The COC consists of numerous pharmacists and other healthcare professionals who are committed to “raising the bar” of the profession by establishing the goal of training the highest quality pharmacists possible. They advise the ASHP Board of Directors on various aspects of residency program development, including identification of RPDs and residency preceptors. I readily agreed to be a guest surveyor for accreditation site visits, beginning a long relationship with the Accreditation Services Division. From the early 1990s until 2000, I served as a volunteer surveyor, visiting numerous residency programs around the country. In 2000, I was asked by the President of ASHP to serve on the COC, and eventually I served as Vice-Chair, Chair, and Past-Chair of the Commission. In total, I served 5 years on the Commission. This experience gave me great insight as to how to improve my own program and preceptor skills. I had the opportunity to assist in teaching residency training workshops and helped during the Residency Showcase at the ASHP Midyear Clinical Meeting. I presented at several National Preceptor Residency Meetings and worked with other members of the COC to revise the standards of both PGY2 and PGY1 residency programs. Most importantly, my work with the Accreditation Services Division gave my own residents an example of how to serve the profession, and I really think it inspired many of them to become more involved in residency training in their careers. Many of them are RPDs as well as residency preceptors, and some of them have served as surveyors on accreditation visits. Ask any RPD what it’s like to undergo an accreditation survey visit, and they will likely remember it as consisting of a lot of documentation! But, hopefully, they will remember conducting a careful review of their program, looking to see that they are meeting the standard set by ASHP for providing the highest quality training program possible. Over 100 aspects of the program are reviewed by the site survey team, and discussions are held about improving the program to meet very high standards. As a resident, you may be lucky enough to partic-

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ipate in an accreditation review during your residency year. I encourage you to be engaged in the review, to understand the process more completely, and to assist your RPD and preceptors in this important task. Some of you may be involved in the establishment of new pharmacy residency training programs. It may seem to be an overwhelming task to develop a new program. Let me reassure you that ASHP’s website is invaluable in providing much of the materials you will use in this endeavor. In addition to what you learn about your own residency training, visiting other programs and networking with other preceptors and RPDs provides great guidance in the establishment of a new program. Also, working with other healthcare disciplines allows for the integration of pharmacy services into those provided by physicians, nurses, and other supportive personnel. One of the most valuable training areas available to pharmacy residents is working within a multidisciplinary clinic as well as providing a real healthcare environment for the resident to interact with patients and other professionals.

Characteristics of a Quality Preceptor Identifying the characteristics of a quality preceptor is one of the most important areas within the development and continuance of an excellent pharmacy residency. Having preceptors who embrace these characteristics and instill them in their residents for future preceptor development is crucial. As I have progressed in my career, my teaching philosophy has evolved and matured. Initially, I was focused more on innate abilities and skills, and I concerned myself with delivering cutting-edge information to my trainees. Although I always knew the importance of lifelong learning, I began to appreciate it even more as the age of information technology advanced. Now, I firmly endorse a focus on developing critical thinking skills and problem-solving abilities. I believe trainees pick up on this early in their residencies, and understand the Socratic style of education and training. They appreciate being given the ability to develop their problem-solving skills, and they better understand the role of the facilitator and mentor. A successful learning situation is one in which the learner: ▧▧

Can clearly reiterate the concept to be learned

▧▧

Demonstrate the application of that concept

▧▧

Self-evaluate at the end of the learning situation We know we have been effective at teaching and mentoring when we

receive feedback from other healthcare professionals about the good job that our residents have been doing. Also, after the residents compete their residen-



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cies, a follow-up with their employers should always be a part of the training programs’ assessment. I routinely keep in touch with my former residents via telephone, email, and at professional meetings. My professional interactions with former residents allows us to continue to develop in our careers, and I am honored to be among a group of colleagues who have completed residency training.

Final Advice Residency training can provide invaluable opportunities for career advancement in the profession of pharmacy. Jump on that “residency express” and keep going! Our profession will continue advancing to care for the needs of our patients, and rightly so, through the auspices of quality pharmacy residency programs.

Best, Jane

Joshua N. Raub PharmD, BCPS Mentor or Preceptor? Be Both at the Same Time! Josh currently practices as a Clinical Pharmacist Specialist in Internal Medicine in addition to serving as the Residency Program Director for the Postgraduate Year 1 (PGY1) Pharmacy Residency at Detroit Receiving Hospital. He has precepted 46 total residents (41 PGY1, 5 PGY2) over 9 years. He also has contributed to the Letters from Pharmacy Residents: Navigating Your Career. As a clinician educator, he holds adjunct faculty positions at the Wayne State University (WSU) College of Pharmacy and School of Medicine. He is a strong advocate for advancing mentorship within residency training. His precepting efforts have been recognized from three graduating classes at WSU where he was named Preceptor of the Year. In addition, he received the ASHP Foundation’s 2016 New Preceptor of the Year Award. Josh’s research interests include interdisciplinary education, transitions of care, and pain management. As a result of collaborating with two previous pharmacy residents, Josh and his colleagues received an ASHP Best Practices Award in 2018. Josh received his PharmD degree from the Eugene Applebaum College of Pharmacy and Health Sciences at WSU and completed a PGY1 pharmacy residency at The Johns Hopkins Hospital in Baltimore, Maryland. Josh’s precepting advice is: Never underestimate your impact as a mentor while you are precepting residents. Merge the two roles and provide a unique level of personal and professional development!

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Dear Colleague, As I neared the end of my PGY1 residency, I vividly remember a conversation I had with one of my mentors who was also my preceptor at the time. We were discussing professional goals that I wanted to create for the next 5 to 10 years of my career. During the conversation, my mentor repeated a phrase I had heard several times throughout my residency. “Hold on, let me take off my preceptor hat and put on my mentor hat.” Not surprisingly, the phrase left an impression on me. From these interactions, I came to believe the roles of a mentor and a preceptor were separate. Any time I self-assess my precepting skills, I cannot help but think of my mentors. Many of these individuals helped to establish the framework of my precepting style. Their sage wisdom and sometimes unconventional methods left an imprint on my desire to precept my own students or residents. A decade has passed since I completed my role as a pharmacy resident, and the subsequent 10 years have been a continuous learning experience as I expanded on my roles as both a preceptor and clinician. Immediately following residency, I followed my passion and was able to officially put on my preceptor hat. It was also during this time that I discovered my interest in mentorship. I recognized the value that mentorship had in both personal and professional development and was able to create a formal mentorship program as part of our residency at the Detroit Medical Center. Despite the benefit that mentorship provided to residents, I saw it as a separate role from routine precepting—a separate hat to wear. In my eyes, there was a clear distinction between precepting and mentoring. Preceptor assignments were often prearranged from a program director or experiential coordinator, unlike mentor and mentee pairings that were often sought out individually. A preceptor’s primary goal is to instruct, model, coach, and facilitate knowledge and behavior, while mentorship revolves around personal and professional development. Finally, the relationship of a preceptor is often limited to 4 to 6 weeks, while mentoring can last decades. After a few years of precepting, I realized that sometimes I was mentoring residents as much or more than I was precepting them. Continually “changing hats” was a concept I was getting frustrated with. I saw myself merging the two roles together more seamlessly as I precepted more and more students and residents. I was conflicted with the approach I implemented at our system and the segregated thought process that my mentors instilled in me. The beauty of mentorship, however, is that you can disagree with your mentor. The prototypical mentor–mentee relationship of Socrates to Plato demonstrates that you can spend a lifetime of learning from someone but develop a completely different



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philosophy than that of your teacher. Fortunately, this healthy “agreeing to disagree” has been sustained for the past few millennia. As you expand on your expertise as a preceptor and continually develop your role as an educator, I want to encourage you to rethink the distinction between what is expected of you as a preceptor and a mentor. Most likely, your precepting assignments will be far more numerous than your mentor relationships. As the number of students and residents seeking further education continues to increase, you have the opportunity to sprinkle in some mentoring to your rotation. To make the most of mentoring while you precept, I want to share three important points to ensure success.

Meld Preceptor and Mentor Roles There are clear distinctions between the variables that define a preceptor and a mentor. Understanding and appreciating the differences is critical. Colleges of pharmacy and ASHP have clear expectations in executing the role as a preceptor. Objectives must be evaluated, professional skills need to be assessed and refined, and knowledge should be gained. Mentorship, however, has a minimal framework and instead relies on a unique approach to foster personal and professional development. How do you effectively wear two hats at once? I have always found precepting to be one of the most rewarding aspects of our profession. Like an apprenticeship, it provides the opportunity to have direct active learning in a one-on-one setting. It is individualized learning, it is personal, and it is always engaging. Although I appreciate any opportunity to teach whether it’s in the classroom or the bedside, precepting transcends the typical teaching role because it provides a learning experience that is both personal and part of a large group setting. From the resident’s perspective, it is their time to gain knowledge, expertise, practice, and most importantly, perspective from their preceptor. As you gain more experience as a mentor, you will realize that your perspective or opinion is often one of the most soughtafter elements from your mentee. Combining years of practical experience, trials and tribulations, triumphs, and accomplishments, your perspective is an invaluable unique resource. It is easy to check off boxes on rotation evaluation forms and state the resident is making satisfactory progress at achieving his or her goals and objectives. The middle ground where the objective requirements of a preceptor and the subjective nature in how you individualize your teaching approach is where the roles of a preceptor and mentor come together. I have discovered that effective preceptors always strive to create a personal connection with their trainee. Capturing the essence of mentorship and combining it into your precepting style makes this possible.

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Make It Impactful One of the biggest differences between your role as a preceptor and a mentor is the time frame associated with each. With most residents, precepting is limited to 1 month. Those who serve as mentors, however, know that there isn’t necessarily a time frame associated with their mentee. Personally, I have mentees who I have remained close with since the start of my career; similarly, I have mentors who I looked up to while in pharmacy school that I continue to seek advice from. These relationships span years and may last decades. How do you take that type of relationship and cram it into 4 weeks? Mentoring advice is often sought when you least expect it. I found having an open-door policy helps to facilitate the fact that when my mentees need my advice, they are always welcome. As a preceptor, your door is essentially open all day, whether for pre-rounds, clinical questions, topic discussions, lunch, and whatever else the rotation throws at you. Despite the clinical responsibilities that residents are completing, the million other issues surrounding their life and residency are also concurrently swarming their conscience. The interactions and advice you give may be part of some crucial decisions that affect their residency and career. The truth is, major life decisions are unpredictable. While fulfilling your role as their preceptor, you may be called on to provide wisdom to a situation in which a decision could alter their entire career. A few years ago in the spring, one of my former PGY1 residents who had completed her residency 3 years prior emailed me unexpectedly, with one sentence: Major life decision, can we chat? We spoke later that same day. This individual had already established herself as a clinical specialist close to her hometown, but was weighing the decision of moving cross-country for an excellent job opportunity for her spouse, out of her comfort zone, and removed from her budding career into the unknown. We talked a great deal about potential opportunities in this new area. I gave perspective from my past experience of leaving home and those closest to me to pursue my residency, and I spoke of colleagues whom I could open my network to. Most importantly, we discussed the challenge this would be both personally and professionally. Major life changes such as moving and new job possibilities are common times when mentors are asked for advice. At the same time, I was precepting a PGY1 resident who was contemplating his next move following residency. The following week, he was confronted with a very similar predicament to my previous resident. Despite my primary role as their preceptor, this was a situation in which the resident needed mentor-



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ship. I was able to build on my own experience with the resident’s story from the previous week, and help this resident navigate a difficult life decision as well. Although I had been a mentor to the former resident for over 3 years and had only served as a preceptor to the latter resident for 3 weeks, it is unpredictable when you will be called upon to serve in the role of a mentor. No matter the relationship, make your advice impactful.

Leave Your Legacy One of the most valuable aspects of mentorship is passing on successful teaching habits or skills to your mentee. Successful mentorship is almost evolutionary in the sense that productive and sustaining traits are taught and eventually adopted by the mentee. Success begets more success. During the first few years as a new preceptor, I routinely found myself asking what my past mentors would do. What would Dan Ashby say here? How would Annette Rowden pimp this resident? How would Dennis Parker illustrate this teaching point? I discovered how much my mentors were impacting my role as a preceptor. Just as I found myself asking these questions, I was able to witness one of my past residents doing the same. The subject of pharmacology and drug action is one of my areas of interest. I routinely tell my residents that the phrase, “The mechanism for this medication is not known” is forbidden. We are experts in medications and pharmacotherapy, and it is our job to understand what is difficult surrounding the tenets of pharmacology. When I overheard a past resident whom I precepted for only 1 month during their PGY1 say that previous statement to a student he was precepting, I laughed but also realized the impact that I could have during 1 month of training. In the span of 1 to 2 years, our residents interact with dozens of preceptors as part of their training. Residency represents a unique time where the mentor’s influence can have a lasting impact on a career. Mentors can provide clarity and direction during a time of confusion and stress. We should never pass on the opportunity to mentor our residents, even while we are precepting them as part of their training. Just because the resident doesn’t view you as their sole mentor, it doesn’t preclude you from mentoring them in the moment. You can serve both roles concurrently! Mentorship within our profession is vitally important for both personal and professional development. Throughout my career I have observed pharmacists at every level of our profession acknowledge the support of their mentors, and as a result demonstrate the importance of mentoring others on their

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career path. Even pillars of our profession, such as Paul Pierpaoli, have noted the benefit of mentorship, considering it one of the highest callings within our professional ranks. As you continue your role as a preceptor and train the future of our profession, I challenge you to blur the lines between what it is to be a mentor and a preceptor to your trainee. Wear two hats at once and personalize your teaching style as much as possible.

Respectfully, Josh

Carol J. Rollins MS, RD, PharmD, BCNSP, FASPEN, FASHP The Preceptor Educator: Going Beyond the Modeling, Coaching, and Facilitating Roles Carol currently practices as a Clinical Professor at the University of Arizona, College of Pharmacy. She has held numerous roles within the University of Arizona’s Medical Center, including Coordinator of the parenteral nutrition team covering both in-patient and home care patients from neonatal intensive care unit (NICU) to geriatrics for 30 years. Carol’s experience as a pharmacy preceptor is unrivaled with over 200 residents precepted during her career. She is the recipient of the ASHP Foundation’s Preceptor Award in 2012. Carol received her BS in Pharmacy and PharmD from the University of Arizona. She completed a nutrition support pharmacy practice residency at University Medical Center in Tucson, Arizona. Carol received her MS in Food Science and Nutrition from Purdue University, West Lafayette, Indiana, and her initial Bachelor’s degree from Concordia College, Moorhead, Minnesota. Carol’s precepting advice is: Believe in your residents and help them find a way around the obstacles to change the trajectory for a struggling resident. Taking time to listen and offer empathy and compassion to help develop your future colleagues into caring professionals is worth your investment of time.

Dear Colleague, For many years, I have said that working with residents is one of the highlights of 93

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my job. Residents are the reason I selected the option of coming back per diem when requested time off without pay was denied, rather than the two alternate options offered: leaving my job of more than 30 years or not taking requested time. The latter was not an option; the time off was to help my 90(+) year-old parents, who lived nearly 1600 miles from me, move from their home of 67 years. The decision allowed me to continue working with the pharmacy residents while also providing help to my parents. It is always exciting to welcome the fledgling residents who are excited to fill their role on the healthcare team and apply all that they have learned through pharmacy school. Then, reality hits; they are overwhelmed by the responsibilities of residency, by dealing with emotions evoked by patients who deteriorate, by the physicians who ignore their recommendations, and by realizing they still have a huge skill deficit for practicing in pharmacy. For some residents, further challenges are added by life events, either good or bad. Concerns of not being able to finish the residency encroach upon the resident’s thoughts, and self-doubt sets in. Some lose faith in themselves, and hopes for their future in pharmacy begin to fade. Families are generally supportive but often do not understand the stresses of residency and consequences of failure in a residency. The observant preceptor has an opportunity to change the trajectory for a resident who is struggling. Providing an empathetic ear, taking the time to really listen, providing encouragement, and giving support and helping find a way around an obstacle can make a difference in the resident’s success. At times it may require going beyond the traditional modeling, coaching, and facilitating that focus on knowledge and skills for pharmacy practice. It’s not striving to be the resident’s best friend; it’s showing that you believe in them, and providing an environment in which they can safely express their doubts and uncertainties without fear of being judged as incapable of handling the demands of a residency. In many respects, it’s more like being a parent at a professional level. Adopting this precepting style requires vigilance to changes in the demeanor of residents; it means continuous self-reflection of your beliefs and commitments as well as investing extra time in training residents. In writing this letter, I did some soul searching to understand how I came to my approach toward precepting. My approach was seeded at a young age, and it was due to many contributing factors. My parents laid a solid foundation based on a strong work ethic and provided key principles that have guided me in life. They provided a loving environment and taught me to do the best that I could regardless of the circumstances—an approach I applied throughout my career as a preceptor. My parents were farmers who barely made enough money



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to pay for expenses, and they hoped for something better for their children. My parents had never traveled far from their birthplace, and they were not college educated, nor were any of my aunts, uncles, or cousins. Educators built on the foundation that was established by my parents. Both my parents and the educators in my life believed in me and pushed me to reach for something better. The teachers who displayed compassion beyond their title of a teacher left a permanent impression on me as educators. They provided possibilities and pathways, ways around the obstacles that were outside the abilities of my parents to negotiate. A college education was not something I thought of early in my school years. In fact, I barely made it from first to second grade. I was one of what many called “dumb” farm kids. However, my first-grade teacher saw something different in me and the handful of other students in my class who were struggling. She was my first encounter with an educator. Patience was a strength for her; she took extra time with our small group to review materials in different ways so that all of our senses could be used in learning. She imparted a feeling of worth to each student and reinforced “doing the best that I could do,” regardless of where I was compared to others, as long as I kept moving ahead. When I’m precepting, I try to do the same. Like my first-grade teacher, when a resident is not grasping a concept, I try to simplify the concept (make it “bare-bones”), build on what they know, and use different approaches (diagram or pictures as well as words) rather than just repeating what I said previously or having them read the articles again. As a preceptor, you need to be attuned to whether residents are grasping the concepts because they may not tell you that they are lost. When you sense they do not understand, find a way to help them comprehend the concept. The reward for the time and patience required in this precepting style is seeing the delight, and relief, on the resident’s face when they finally reach the “I’ve got it” moment. Even better is when you see the resident using those same techniques to teach that difficult concept to a student on rotation. A second encounter with an educator occurred in high school. I had become a top student in my class but had no aspirations of college. I had watched my older sister spend a year trying to find funding for college; in the end, she joined the Navy to follow her goal of a nursing degree. It was my teacher for an elective course in advanced biology who stepped beyond his role as teacher to be an advocate for me when he learned I was not applying to college. He said I should apply based on my performance in class. He listened to why I was not pursuing college; then he took the time for the extra steps that made a difference. He talked with the school counselors and set up a meeting with my parents, and he started me thinking that college was possible.

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This experience taught me a valuable lesson that I adopted to my precepting style. Investing personal time, above what is required of a normal teaching role, can change the course of an individual’s career path and ultimately their future. Residents are often hesitant to talk with the program director for fear of being labeled as whining or struggling, the preceptor may be seen as too busy or unapproachable, or maybe the resident doesn’t want to show any weaknesses because they are hoping for a PGY2 residency or job at the current facility. When you notice that a resident seems to be struggling with daily activities and becomes withdrawn, give him or her an open invitation to talk with you; let the resident know you will take time to listen. “You seem to be struggling a bit on this rotation. My door is open; stop by if you want to chat.” Obviously, you need to have worked with the resident for this to be effective. If the resident takes the offer to talk, follow up if it is reasonable to do so. Work within your system and the flexibility it offers. Talk with the program director to see if changing the rotation schedule is possible, if that is what is needed based on your observations of the resident. My rotation in nutrition support allows me to give the resident more one-on-one attention, and the resident has less direct student responsibility than on many other rotations. If a resident needs more direct preceptor guidance, I discuss this with the program director to see if the resident could be scheduled for my rotation next. Each step in my journey fostered my growth as an educator. While at Concordia, I was taught that professionals have an obligation to give back to their profession and that time and commitment were among the most valued items you can give to a trainee. After several years of following my husband’s government contract jobs, we moved back to the United States from the Marshall Islands, still with no family of our own. It was time for me to pursue what pharmacy had to offer. I completed my BS in Pharmacy, with one transfer of schools due to my husband’s job. Then, I pursued a PharmD degree because I relished what I had learned in the BS program and didn’t want to come back to school in another 10 years, again. Residency training at the University of Arizona Medical Center followed. When I finished my residency, I accepted a position as a pharmacy specialist at the University Medical Center, with adjunct appointment to the College of Pharmacy, and immediately began working with residents. It was a long circuitous route to my pharmacy career, but I was highly engaged in patient care, building total parenteral nutrition and home care services, and precepting students and residents. I fulfilled the preceptor role that included modeling, coaching, and facilitating acquisition of pharmacy skills, but I wanted to go beyond that. My goal with students and residents was to emulate the educators who had believed in me and pushed me forward, and



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made a difference in my life. I vowed to myself that I would give back to the profession by providing the valuable gift of time to the students and residents.

Make Precepting Personal I have had the pleasure of being a preceptor to pharmacy residents for nearly three decades. My past experiences, culminating from early childhood through my higher education and degrees, have shown me the impact that educators can have on the trajectory of their students. The combination of patience with willingness to give my time freely to discuss and listen to the concerns of my residents, whether pharmacy-related or life issues, has been extremely rewarding. The residency or pharmacy-related concerns are fairly easy to handle; they require listening and direction. The life issues can be more difficult. There have been many times over the years where residents came to me for help with a problem that was not related directly to the residency. I shifted my work hours and stayed beyond my scheduled hours to be available in the early evening, long after most clinical pharmacists and residents have gone for the day. This created a more comfortable environment to discuss the nonpharmacy problems. Sometimes all that is needed is to be a good listener; at other times, gentle guidance is required. Providing easier-to-grasp analogies to the situation of concern, pointing out nonverbal cues to observe, or discussing generational differences that enter into interpreting the circumstances often helps residents see a different perspective. Our experiences and advice should help guide residents in making their own decisions rather than telling them what to do. I firmly believe that taking time to help with life issues is an important component of developing competent and confident professionals. My teaching philosophy states the residents are my professional children. As such, I have an obligation and responsibility to nurture each of them as individuals while also requiring them to “stretch their wings” by taking on new and challenging roles. As you expand on your role as a preceptor and educator, I encourage you to take part in your residents’ personal journey and development. Being an educator—the one who steps outside the traditional precepting role to help residents find a way around their obstacles—is a win-win situation. It can be a source of pride and fulfillment while providing a sense of accomplishment and satisfaction despite the chaos of the work environment.

Sincerely, Carol

Arthur A. Schuna MS, FASHP Nurture Academic Affiliations, Train Pharmacy Educators, and Consider Your Professional Legacy Art has served as a Clinical Professor and preceptor for 164 residents over 33 years, having created in 1983 one of the first ASHP-accredited ambulatory care residencies and served as its Residency Program Director. Until he retired in 2016, he was the Director of the Postgraduate Year (PGY) 1 General Practice and Ambulatory Care-focus Residency and PGY2 Ambulatory Care Residency. He developed and expanded the ambulatory care services at the William S. Middleton VA Hospital in Madison, Wisconsin. Art has served as Vice Chairman and Chairman of the ASHP Primary Care Special Interest Group, Chairman of the ASHP Ambulatory Care Special Interest Group, and Member of the ASHP Commission on Credentialing doing residency site surveys. Art received his BS Pharmacy degree and MS from the University of Wisconsin School of Pharmacy, and he completed an accredited residency at the University of Wisconsin Hospital. Art’s precepting advice is: Embrace academic affiliations to strengthen your residency training program; if possible, be mindful that your impact on residents and students may be far greater than you expect, and consider your professional legacy and the impact you may have for the future of pharmacy practice.

Dear Colleague, I was hired by the Madison VA to develop ambulatory care clinical services in 1975. 99

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At the time, clinical pharmacy practice was viewed primarily as an inpatient service due to the lack of medical information in the outpatient setting. The Indian Health Service began to change that in 1972. They eliminated paper prescriptions, and drug orders were written in the patient’s medical chart. To fill or refill prescriptions, patients brought their chart to the pharmacy, which allowed pharmacist access to the patient medical record. In 1973, Richard Streit published a paper describing a therapeutic monitoring program for patients at the Cass Lake, Minnesota, Indian Reservation clinic.1 Patients presenting to the clinic for prescription refills had nursing staff perform their vital signs. Pharmacists did routine monitoring for diabetes, hypertension, obesity, heart disease, tuberculosis, and estrogen therapy. The pharmacists could order laboratory tests if they deemed it necessary. Patients were screened by pharmacists and referred to the physician staff if vital signs or laboratory tests fell outside of certain parameters for medication adjustment. I felt that if such a service could be done in Indian Health Service, it would be feasible to do something similar in a Veterans healthcare facility. Although I learned a lot in pharmacy school and in my 2-year Masters− Residency program at the University of Wisconsin, I realized there were other abilities I needed to be successful in practice. I was fortunate to have physicians who provided on-the-job training in physical assessment, taking accurate medical histories, and patient triage. At the time, most pharmacists in clinical practice served as therapeutic advisors to the healthcare providers. We developed a practice model that made the pharmacist directly responsible for prescribing and monitoring of therapy. I have always had an interest in teaching others what I know. In the second year of my Masters–Residency program, I co-taught a survey course with my faculty advisor called Therapeutic Controversies. I also had many opportunities to lead therapeutic discussion groups for students on clinical rotations. After graduating, I lectured for the School on hypertension and rheumatology, my areas of clinical practice at the VA. We had students on rotation in the clinic in their clerkships. After 8 years in practice, I wanted to develop a residency to make it easier for others to follow my career path. When ASHP approved a residency standard in ambulatory care in 1983, that desire became a reality. We obtained funding to begin a residency, and our first resident began the program that year. We were one of the first accredited residencies in that specialty in the country.



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Nurturing Academic Affiliations Given my beliefs in the importance of education, we developed important collaborations with the School of Pharmacy. Pharmacy practice faculty at the School needed to maintain a clinical practice. We were fortunate to have others join us. They developed initial clinics in anticoagulation, epilepsy, diabetes, geriatrics, congestive heart failure, psychiatry, and osteoporosis. In most cases, increased workload justified hiring additional staff funded by the VA. These clinics all became important resident rotation sites to strengthen our training program. Pharmacy students used these sites for clerkship rotations. Student exposure to clinic practice led many of them to consider residency training and is an important conduit for high-quality residency candidates. These practice sites were used for research projects for faculty and staff preceptors, residents, and students. Residents and students collaborated with faculty in project development. For students, participation in research projects and data collection helped them build their resumes and improve their ability to match with desirable residency programs. Having preceptors work with students and residents teaches them the collaborative nature of research. Projects were often designed to evaluate practice innovations. They also were used to justify expansion of services. Two of our resident projects (Increasing Access to Primary Care Using Pharmacist Providers and COPD Coordinated Access to Reduce Exacerbations) were recognized by the VA nationally for practice excellence and are being diffused to other VA clinic sites around the country. VA clinical staff provided lectures to School classes when requested. I did rheumatology and hypertension lectures while in practice at the VA. I recently talked to a former student of mine who graduated more than 40 years ago. Although he was just another face in the classroom and I did not personally interact with him, he told me I was a major influence on his career. I tried to always use a few anecdotes from practice to illustrate the key points I was trying to get across. He said I made him realize that it was possible to do more than traditional pharmacy practice activities given the right practice site and the motivation to do more. He went into critical care pharmacy practice in Milwaukee and became one of the first pharmacists to get Advanced Cardiac Life Support certified in the city. It’s easy to see your influence on residents you have for 1 or 2 years as you note their progress and they take positions using what they learn on completion of the program. However, I didn’t really think about the impact of giving a

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lecture as being career-changing. Over my time in practice, I taught more than 4500 students. I will never know how many others may have been impacted in a similar way.

Training Pharmacy Educators We also developed teaching as a resident rotation in which residents participated in therapeutics laboratory sessions with faculty as preceptors. Moreover, the School developed a teaching certificate program that had residents involved in the program lead discussions about effective teaching methods. The program gave the residents experience in using concepts learned in the seminar sessions. This experience gave residents the ability to consider faculty roles on completion of our program. Many chose this professional career path. I believe this experience also prepared residents from our program to assume roles as residency preceptors. Even for those who don’t have opportunities as faculty or preceptors, all pharmacists are teachers for patients and medical staff with whom they work. The teaching experience our residency offered made our program desirable, and most of the candidates we interviewed identified it as a reason they chose to apply to our program. Additionally, the exposure of pharmacy students to residents who were only a year or two out from graduating themselves made many students seek out residencies to further their career. A downside of the laboratory teaching experience was that it removed residents from their practice sites during teaching blocks. Also, balancing teaching and practice experiences during teaching blocks could be a challenge, but it is an experience that all those who teach and practice have to face. The benefits for the resident far outweigh any negatives. Residents also are teachers in clinic clerkships. We developed pharmacy teams with students in clerkship working directly with first- and second-year residents in the clinic. Second-year residents often provided advice and guidance to first-year residents. Pharmacy preceptors serve as attending staff, much like the medical model for clinical teaching. Residents coach students who then present patients for discussion to pharmacy attendings, and therapeutic plans are developed that the resident−student team then carry out. The resident reviews progress notes written by students and advises on changes needed to clarify and document the encounter. I almost never gave an opinion of what to do after a patient was presented. I wanted the resident or student to tell me what they wanted to do. This allowed me to better understand what the trainee knows and where he or she may



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benefit from further guidance. I always “thought out loud” in discussing pros and cons of options for therapeutic decisions. Over time, the trainee gained confidence as their knowledge and skills developed, and there were fewer disagreements between me and the resident for best approaches to treatment.

Considering Your Professional Legacy Professional legacy is not something I thought much about or appreciated until late in my pharmacy career. Your legacy is what is left behind after you no longer are in practice. The residents I trained are my legacy. They take what they learned from me and other preceptors on our team and carry that forward in their own practice. If I’ve been successful in stimulating them to be a faculty or preceptor, they carry some of what I’ve taught them forward to future generations of pharmacists. I was first made aware of my legacy when a former resident of mine, Bob, was doing a poster session at an ASHP meeting with his resident. Bob introduced me to his resident, and I felt an immediate connection. One of my first thoughts was where would this trainee be if Bob had not completed my program and then gone on to develop his own residency elsewhere. Chances are he would have done a residency somewhere else, but it is likely his career path would not have been the same. Years later I was at an ASHP meeting and was introduced to the founder of my Masters–Residency program, Winston Durant. Although I had not met him before, I felt an immediate kinship with him. Had he not had the foresight to develop a residency in 1963, I would probably not have done a residency or gone on to develop my own training program. Several of the residents he trained—David Zilz, Thomas Thielke, and David Angaran—became my mentors and role models. I sometimes now think of residents I’ve trained who go on to develop residency training programs or teach students as school of pharmacy faculty. There are now probably several generations of residents beyond the 164 residents I have trained. I have learned to appreciate the continuum of pharmacy residency training, which I had no appreciation of early in my pharmacy career. Even though I retired from practice 3 years ago, I know that some of what I taught lives on through the work of those who practice after me. My final advice to you is: ▧▧

Embrace academic affiliations to strengthen your residency training program if that is possible at your residency program. The benefits may far outweigh any perceived shortcomings.

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Be mindful that your impact on residents and students may be far greater than you expect. It includes not only those trainees under your supervision but those that they train and influence. Relatively incidental contacts with students and residents may have major influences that you can never fully appreciate.

▧▧

Consider your professional legacy and the impact you may have for the future of pharmacy practice.

Wishing you success, Art

REFERENCE 1.

Streit R. A program expanding the pharmacist’s role. JAPhA. 1973;NS13:434-443.

Emmanuelle Schwartzman PharmD, APh, BCACP, CDE Growing into Your Full Potential as a Preceptor Emmanuelle is currently an Associate Professor of Pharmacy Practice and Administration at Western University of Health Sciences (WesternU). She serves as the Director of Residency and Fellowship Training for the College of Pharmacy, overseeing program accreditations and the Research/Teaching Certificate Program. She is also the Director of a Postgraduate Year (PGY) 1 Pharmacy Residency in an ambulatory care setting. She has been precepting residents since 2008. She serves as a guest accreditor for ASHP. Emmanuelle practices at the WesternU Health Center and at a Federally Qualified Health Center in an ambulatory care setting where she works with an interprofessional team to manage chronic diseases in patients, with a focus on diabetes. Her research and teaching focus is on communication skills and diabetes. She is a Certified Diabetes Educator through the National Certification Board for Diabetes Educators, a Board Certified Ambulatory Care Pharmacist, and an Advanced Practice Pharmacist. Emmanuelle was the recipient of the ASHP Foundation 2017 Residency Preceptor of the Year Award, and has been recognized by WesternU for a Faculty Service Award and Preceptor Award. She provides precepting continuing education activities for many local and national organizations. Emmanuelle is the President-Elect for the Rho Chi National Honor Society and will serve as the Society’s President during the 2020-2022 term. Emmanuelle maintains memberships in AACP, ACCP, ADA, AADE, APhA, ASHP, CPhA, CSHP, Rho Chi, and PLS. She lives in Los Angeles with her husband, 8-year-old son, 5-year-old daughter, and her two dogs. Emmanuelle completed both her PharmD and PGY1 community pharmacy residency at the University of Southern California. 105

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Emmanuelle’s precepting advice is: Have a precepting plan and develop a personal philosophy statement. Self-reflect on your beliefs, theories, and precepting methods when developing your personal philosophy. Never stop looking for ways to develop yourself as a preceptor.

Dear Colleague, StrengthsFinder 2.0 by Tom Rath shows my number one characteristic is competitiveness. Anyone who knows me can attest that this is 100% in line with my personality. I would argue that competitiveness is highly correlated with passion—a competitive person is someone who approaches each situation with passion and zest. As a child of immigrants, I had to navigate the school system, which included attending college and earning a professional degree, without much guidance. I had to achieve, so that I could make it on my own and create a path for myself that had not been paved. This need to achieve, combined with my innate passion and competitive nature, led me to approach everything with extreme drive and perfectionism. One strategy Rath recommends for competitive people is to not only find positive lessons in loss, but to examine why you won and what can be learned from your successes. I consider the opportunities I have had to mentor students and residents as some of my biggest wins. Looking back, I see that self-awareness from each experience, even some that I may have considered a loss at the time, helped pave the road to success. My first professional setback left a profound mark on me. I was a strong student in pharmacy school; I had a well-rounded CV and had prepared extensively for residency interviews. I can still remember the gut-punch feeling I had when on Match Day I was left without a residency. Watching as my classmates rejoiced over their prospective career paths, I was facing a new reality of an uncertain future. I had never encountered an unknown such as this; I was used to planning everything out and achieving what I wanted. I had never imagined losing. Help came via a faculty member who was looking for a resident and offered me the position. This faculty member was among the first of a handful of influential mentors I would meet in my career. Beyond grateful for this opportunity, I knew that the appreciation I felt could only be expressed by paying it forward one day. I learned two important lessons from this experience: (1) The truth in the old adage of “when one door closes another door opens.” When this happens, have the courage to let go of perfection in planning your path and walk through the alternate open door. (2) To seek and accept help from others. We do not



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succeed in isolation or by ourselves; without my mentors, I could never have realized my full potential. In my experience, mentors have launched my career, acted as honest sounding boards, and helped me overcome barriers. I encourage my residents to identify a mentor (which may not always be me) with whom they can connect and who will be their professional guide. In the spirit of paying it forward, I wanted to be a preceptor and one day a mentor to residents and students seeking residency. I began precepting residents as a faculty member and eventually started my own residency program. The competitive side of me was very focused as a new director in checking the boxes to meet accreditation standards and exceeding all of the metrics. I was more focused on developing my program than I was on developing myself as a preceptor. I also made some common mistakes as a new residency preceptor as I struggled to find the balance between precepting and mentoring a resident— being too strict in my approach or too friendly in my interactions, expecting the resident to be a clone of myself, and personalizing their mistakes. I worked through these barriers and, eventually, I settled into my role as a director and preceptor. My residents were moving through my program and graduating. This, I thought, was my win—I was paying it forward, however, I also realized that as a preceptor you are never done growing. At a meeting with one of my residents, she blurted out “Dr. Schwartzman, you never tell me when I am doing a good job.” I was caught completely off-guard and at a loss on how to respond. Was it true? This led me to some deep introspection; what is my evaluation plan and goal for my residents? What other areas of development for both myself and my trainee am I missing? Am I the preceptor I had envisioned I would be? Am I nurturing my residents the way I thought I would be doing? What more should I be doing to grow as a preceptor? As I pulled myself out of the introspection, I recognized what eventually became a golden rule for me: have a precepting plan/philosophy. A philosophy provides a guideline that can act as a barometer for assessing yourself. The first thing I did was reflect on what words/statements capture the essence of who I want to be as a preceptor and what I expect from my residents. This evolved to an overarching philosophy of modeling and teaching with attitude, intention, and reflection. The goal of my precepting plan is to graduate residents who are self-directed, critical thinkers as well as lifelong learners. Attitude is one tenet of my framework because nothing succeeds without the right attitude—not even a win! Reframing my losses and viewing my wins and setbacks with the right attitude has been important for personal growth. I wanted to ensure that I was modeling and intentionally teaching all aspects

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of having the right attitude, such as showcasing empathy through reflective listening and encouraging motivation and positivity through reframing. Residents need to see this in motion as we deal with patients, especially during a stressful moment or day. They also need to have the skills to reframe challenges into opportunities. I encourage keeping a monthly reflection journal to document activities and growth for the month; we discuss setbacks the resident has had and work to reframe them. Intention is the second tenet of my framework, which is ingrained in all the activities I plan for my residents. I customize learning experiences to align the development plan with the resident’s areas of interest and need for development. The teaching strategy I utilize, “sink or swim,” is intended to deviate from passive, dependent learning, to promote autonomy and assist with the transition from student to provider. This technique has resonated with me throughout my professional career. The process of being placed in new situations where I was not comfortable has forced me to identify my own areas of weakness that need to be resolved and to seek out help from appropriate people. It is with this intention that I have my residents tackle starting a project on their own—figure out where to start, what their objectives and outcomes should be, and how they will manage it along with their other duties. Self-reflection, the third tenet of my philosophy, is also a key piece of my own precepting development. Self-reflection has helped me analyze and face my fears, deal with setbacks professionally, and examine why I succeeded in other areas. The ability to be honest with ourselves is a lifelong learning skill that helps personal growth. I feel it is important for my residents to develop their own standards that they can evaluate themselves against and selfreflect on their own performance. When my resident commented that I was not providing enough positive reinforcement, it made me realize that I had not done enough to self-reflect on my role as a preceptor and had also failed to build self-reflection activities within my residency program. I now have my residents use self-reflection tools after patient interactions, student interactions, and meetings. Self-reflection improves emotional intelligence; when added to attitude and intention, it translates to a health professional who can provide compassionate care to patients, integrate well into a healthcare team, manage stress, and grow through self-directed learning. On a personal level, self-reflection exercises have helped me temper my competitive side. Not everyone who reads this will be as competitive as I am. Most people may not be as laser-focused on particular steps down the road nor do they suffer from as much disappointment when things do not go as planned. However,



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everyone—at some point in their life—experiences the joys of winning and the frustration of losing. It is what we learn about ourselves in these wins and losses that help us develop ourselves personally and professionally. While I have learned from my fair share of setbacks, I feel that ultimately I have won from the unexpected doors that have opened and the opportunities to grow as a mentor from these setbacks. To quote Winston Churchill, “Success is not final, failure is not fatal; it is the courage to continue that counts.” If the path I had intended was smooth and uneventful, I would not have been forced out of my comfort zone to learn how to channel my passion in a positive way and to self-reflect on my weak areas. These are the lessons learned through my successes and failures that have helped me grow as a preceptor: ▧▧

Have courage to walk through an unexpected open door

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Identify your mentors and seek them out often

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Have a precepting plan and develop a personal philosophy

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Practice self-reflection No one starts as the perfect preceptor, and perhaps it is a goal that no one

can ever attain. If the prize of being a mentor is creating a space where your residents can have the very best experience to learn and grow, then winning that prize requires you to develop yourself continually as a preceptor. There is more than one formula that leads to victory, just as there are many different ways of successfully precepting. I hope the lessons I have learned help you as you develop your own path to growing as a preceptor. I wish you the best of luck on your journey.

Sincerely, Emmanuelle

Suggested Resources ▧▧

Bradberry T, Greaves J. Emotional Intelligence 2.0. San Diego, CA: TalentSmart; 2009.

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Rath T. StrengthsFinder 2.0. 6th ed. New York, NY: Gallup Press; 2007.

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Take the MBTI instrument. The Myers & Briggs Foundation website. https://www.myersbriggs.org/my-mbti-personality-type/take-the-mbti-instrument/. Accessed March 1, 2019.

Amy L. Seybert PharmD, FASHP, FCCP, CHSE Use of Simulation Training: Altering the Environment Amy is currently Chair of the Department of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy (UPMC). She also serves as the Pharmacy Residency Administrator at UPMC and the University of Pittsburgh. Prior to her role as Chair, Amy was the Clinical Pharmacy Specialist in Cardiology at UPMC for 14 years. She created and directed the Postgraduate Year (PGY) 2 Cardiology Pharmacy Residency and directed the PGY2 Critical Care Pharmacy Residency for 11 years. During her career, Amy has precepted 127 residents and has served as the Residency Program Director for 24 cardiology and critical care resident graduates. Amy is Professor of Pharmacy and Therapeutics and is a passionate advocate of pharmacy education and residency training. She has been honored with 19 teaching awards including the University of Pittsburgh Chancellor’s Distinguished Teaching Award, ASHP Foundation’s Pharmacy Residency Excellence Preceptor Award, and the AACP Lyman Award. Her areas of scholarship include simulation education, assessment, cardiovascular pharmacotherapy, and medication safety. Amy received her BS and PharmD degrees at the University of Pittsburgh School of Pharmacy and completed the cardiology/ critical care pharmacy residency at Tampa General Hospital. Amy’s precepting advice is: Take the time to get to know the learning needs of your residents. Be passionate about personalizing opportunities and be adaptable for each resident as an individual. 111

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Dear Colleague, During my residency training, I quickly learned that I must rapidly adapt to my environment to embrace every opportunity to learn and gain experience. Within the first 6 months of my training, I realized my profound passion for educating others—from pharmacy students to my interprofessional colleagues to patients. It just felt natural and energizing. I focused on learning from every aspect, which included maintaining the continuation of my own learning, identifying meaningful approaches for others to learn, and realizing that every individual learns in a different way. One of the most eye-opening moments occurred when I reflected on my learning style as my student struggled to grasp a patient care concept. I analyzed my approach very carefully and suddenly realized that the way I learned best was “hands on,” while many others do not enjoy learning in this manner. Some learners do not perform well in an active environment and do not enjoy or benefit from “hands on.”

Facing Reality of Learning Styles and Moving Forward Based on the realization of what seems to be obvious, we all learn differently and a great teacher must nimbly adapt to meet the needs of their trainees. I strive to individualize learning experiences for each resident so that they can be engaged in a challenging and enriching experience. Beyond this endeavor, three primary goals undergird all of my teaching endeavors: 1) to support residents in gaining knowledge of cardiovascular disease while developing empathy for their patients, 2) to develop teaching approaches, assignments, and assessments that promote higher levels of learning, and 3) to encourage residents to take personal responsibility for maintaining their knowledge base and assuming accountability for patient care. I have learned over the years that a rigid teaching structure is not the best method of teaching residents; mentoring is a skillful art that can aid in molding the resident into a highly skilled pharmacist. The most difficult adaptation that I have had to accomplish is how to alter the training environment to fit those individual needs.

Goals My first teaching goal is to assist residents in gaining a broad knowledge of cardiovascular disease while developing a sense of empathy and compassion for patients. Residents participate in medical rounds with me at the beginning of their program and function independently on rounds after I establish their level of knowledge and comfort. I strive to allow independence and motivation to drive the resident’s individual success. I approach daily interactions with the



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resident in a manner where our clinical discussions will stem from the patient cases from morning rounds. I require residents to treat every patient exactly the way they would treat their mother or father. Secondly, I strive to develop teaching methods, assignments, and assessments that promote higher levels of learning. It is important for pharmacists to solve drug-related problems and to communicate with patients, as well as other healthcare professionals. I strive to develop outcome assessments to better document process design and problem-solving skills early within the residency or clinical rotation. Through observation, I can objectively determine each individual resident’s clinical skills and provide immediate feedback on performance. Finally, I strongly encourage residents to take personal responsibility for maintaining their knowledge base, and assuming accountability for patient care. Our profession demands the highest level of current medication knowledge to treat our patients and community at the level that they deserve. I develop my teaching materials, assignments, and assessments to promote adult learning concepts, so that residents will learn to take an active role in their education throughout the remainder of their career.

Simulation, One Approach with Impact My incorporation of simulation-based learning into our residency and PharmD programs has accomplished this over the last 15+ years. I developed pharmacokinetic and pharmacodynamic programming in critical care medication use for patient simulation with Peter M. Winter Institute for Simulation, Education, and Research (WISER) Center and have served as the Associate Director of Pharmacy Education at WISER. Because of this collaboration with the WISER Institute, the University of Pittsburgh School of Pharmacy is able to utilize this simulator for educational purposes within our pharmacy curriculum and residency programs. When I recognize a resident with a lack of confidence or knowledge in a subject that is not commonly encountered or difficult to observe at the bedside (e.g., management of ventricular tachycardia), I use human patient simulation to allow the resident to experience the direct observation of clinical events, monitoring tools, pathophysiology, pharmacology, pharmacodynamics, pharmacokinetics, and drug administration at the bedside of the simulated patient. This method of learning has been overwhelmingly successful in terms of knowledge, confidence, and performance. I recall one situation where a resident wanted to enhance her skills in code response. As this is a difficult skill to master, the simulation environment was an ideal oppor-

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tunity for her to practice her problem-solving skills. We were able to simulate multiple code situations, prepare medications at the bedside, monitor the pharmacotherapeutics response to each medication, and adjust therapy as needed. She was able to gain a deeper level of understanding as well as confidence to use in direct patient responsibilities. Additionally, I mentor the residents to use simulation in their teaching experiences. One resident completed a patient care simulation focused on the pharmacotherapy of dysrhythmias. The simulator was an extremely useful tool for the resident to share examples of abnormal rhythms, such as atrial fibrillation or ventricular tachycardia, while allowing his students to recommend medication therapy and see the impact of that medication in real time. The resident evaluated the students’ knowledge, clinical decision making, and satisfaction with very positive results. This exploration of learning styles led to many opportunities for scholarship of teaching and learning as well as worldwide scholarship in pharmacy simulation education. I was fortunate to collaborate with my interprofessional colleagues to gain access to the simulation center. I was able to assist with programming the pharmacodynamics, pharmacokinetics, and pharmacologic responses to many medications into the simulation software for all health sciences, and this allowed our pharmacy learners to gain access to this tremendous learning environment. It was tremendously rewarding, and I believe it is more cost-effective to collaborate with your colleagues in an established simulation center compared to building a program independently. The passion for education sparked remarkable academic opportunities, but the most meaningful is when the individual trainee has that “light bulb moment” you can see on their face. What an incredible reward for a teacher!

Personalized Approach to Teaching and Assessment Mentoring pharmacy residents can be one of the most rewarding components of your career. It is my great pleasure to guide students and residents to become confident, well-rounded clinical practitioners. When I see the contributions of my past residents to pharmacy practice, I feel like a proud parent. I invest time and energy in my residents, providing guidance and support in their residency experience in addition to advice (or just a listening ear) toward their future career. Over the past 22 years of precepting and teaching residents as well as students, I have developed my skills in fostering growth and independence while addressing the learning needs of each individual resident. Coaching residents to achieve the outcomes of our program while pursuing their own personal goals has been an effective approach, but one that requires skillful assessment. I recognize that residents possess different methods of



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learning and retention, so I focus on progress assessment as well as adapting learning experiences to fit the needs of my residents. When I precept specialty residents, I first determine the residents’ baseline knowledge and comfort level through direct observation and immediate feedback. This method is successful, as it provides the residents with constructive feedback very early in the year while allowing me the opportunity to assess their level of competence. Additionally, this method successfully provides the shy or insecure resident with the comfort of knowing that I am directly involved in patient care rounds or various other tasks. After the initial, more directive and observational period (timeframe varies based on the resident), I begin to step back from clinical recommendations and educational opportunities on rounds. I measure the comfort level of the residents based on their presentation and communication skills to the interprofessional team. As a progression of mentoring, I cautiously add levels of responsibility to the residents in patient care environments and also in teaching and scholarly arenas. After the initial months of the program, residents are typically able to accept multiple tasks and begin to show their level of adaptability to the responsibilities of a clinical pharmacist. I want the residents to blossom in their own way; I do not want to sculpt the residents exactly as I practice. I believe individuals should be given the opportunity to grow without barriers and encouraged to be exceptional. My role as an educator is one of the most precious and treasured elements of my career. As you continue your journey to teaching, precepting, and mentoring, please remember why you chose your career path and those special teachers in your life. Remember that each of us may have a different approach to learning, and try to focus on how to adapt to your learner’s needs as well as to personalize your approach to training. You are making an impact that could live for generations; congratulations on choosing this career!

Respectfully, Amy

John Valgus PharmD, MHA, BCOP Reinvesting in the Future of Pharmacy John is an Assistant Director of Pharmacy at the University of North Carolina (UNC) Medical Center. He is also an Assistant Professor at the UNC Eshelman School of Pharmacy and the UNC School of Medicine. He is a member of the UNC Center for Pharmacogenomics and Individualized Therapy. His research and practice interests focus on high-quality pediatric and cancer care delivery. John’s expertise in precepting was recognized when he received the ASHP Foundation’s New Preceptor Award in 2006. During his career, he has directly precepted over 100 residents. John received his BS and PharmD degrees from the Philadelphia College of Pharmacy. He received his MHA from the UNC Gillings School of Global Public Health. John completed his pharmacy practice and hematology/oncology residencies at the University of North Carolina Hospitals and Clinics and completed a fellowship in clinical pharmacogenetics at GlaxoSmithKline. John’s precepting advice is: You play a major role in the training of future pharmacists. Make the most of your time as a preceptor and invest in the future of our profession!

Dear Colleague, In the early summer of 1998, I embarked on the much anticipated but nerveracking task of stepping into my first experiential rotation of my final year in pharmacy school. However, this was not 117

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just any rotation. I had identified early in pharmacy school that one of my areas of interest was to pursue a career as a clinical hematology/oncology pharmacist. This rotation was in a bone marrow transplant unit, and I knew it could either solidify this career path or I could be running with my tail between my legs afterward. Fortunately, the month in bone marrow transplant could not have gone better. I was with a preceptor who modeled for me how a pharmacist could practice at the top of their education. This preceptor was invested in my future and provided me with optional opportunities, which he felt would set me up to be a more qualified residency candidate. The preceptor offered career advice as well as advice on how to become a better clinician. Walking away after that month, my path was set as a future hematology/oncology pharmacist, and my preceptor played a big part in that decision. In contrast, I also remember another rotation later that same year that went very differently. It was another direct patient care rotation I was excited about. I remember seeing my preceptor much less frequently than I had seen my preceptor on my bone marrow transplant rotation. On average, I would interact with the preceptor once weekly. I recall a clinical scenario where the medical team asked me to look up a question on octreotide use. From my perspective, I did a thorough literature search and presented my conclusions to my preceptor. Without much rationale, I remember being told “that’s just not how we do it here.” The preceptor didn’t appear to have the time or interest in helping me understand why they did things the way they did. After that encounter, I did not bring up any other questions for the month. I came to rotation each day and did what was required. I probably could have been more motivated to push myself, but I felt unnecessary and possibly even a burden. It made me question my decision to be a clinical pharmacist. Each experience shaped me as a professional and a person. I strive to be the preceptor that I would have wanted to have in my early, formative years as a student and resident. For my formalized training, I sought out environments that I felt would surround me with preceptors and mentors who were engaged and committed to developing their learners. I am one of those pharmacists who was fortunate to stay on staff at the institution where I was trained. I can now directly give back to the program that gave me so much. Over the years of my training, many little things stuck with me (from each of my preceptors) that were precious nuggets of information. There was the nationally recognized preceptor who I will refer to by the fictitious name John Smith. On the first day when I greeted him as Dr. Smith, he stopped what he was doing and said, “Who is Dr Smith? My name is John.” This was a lesson



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to me that no matter how “big” I thought I made it, humility goes a long way to put people at ease. I tried to impress a different preceptor by showing up before her every day and leaving after her every day. One day she asked me why I was so inefficient and needed to spend so much time at rotation to get my work done. My take-away at that time was that it is not how much time you put in, but what you produce. My take-away now is that work−life balance is important. Another experience involved a preceptor who wanted to spend more time providing direct patient care, but her operational responsibilities often pulled her back into the pharmacy. Because this was a direct patient care rotation, she aligned my time with the right physicians to shadow and made sure throughout the month I was getting a good experience. My take-away was that even if your situation as a preceptor is not ideal, you can make a better one for someone else by putting them in the environment you wish you were in. I have no idea if any of these past preceptors of mine would remember any of these examples. This is probably because many of the moments took less than a minute of time. My take-away from all of this is if you are intentional in your precepting, even a minute of your time can make a lasting, positive impression on a learner.

Invest in Your Trainees Mentors come in many forms. One of the most common in the pharmacy profession is a preceptor. Over the course of pharmacy school, two residencies, and a fellowship, I feel like I had experienced nearly every preceptor stereotype. I was taught by the good cop, bad cop, nurturer, drill sergeant, visionary, nuts and bolts leader, and I could go on and on. With all of these different preceptor styles, I realized that personally I could be inspired by all of them. The precepting style did not matter to me. The one characteristic that meant the most to me was whether they were invested in me as a learner. Were they concerned to know what my interests were? Were they willing to have a crucial conversation with me to make sure I knew the areas where I could improve? Although I may not have appreciated their good intent in the moment, those bad cop drill sergeants—who made sure I knew every nut and bolt about managing a patient—truly cared about my future. Of course, they also make for excellent “Do you remember that rotation?” stories that my co-residents and I still talk about many years later. Being an invested preceptor is not always easy. It takes time and energy to ensure you are considering the interests of the learner and tailoring your experience to the needs of him or her. I wish I could say I was the perfectly invested

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preceptor every month I have had a learner, but I know this is not true. We have all had that month when life at work or at home pulled you away from the time and energy you would have liked to invest in the learner. It is in those moments that I remember every minute counts. I may not have the time to sit down and “run the list” for a couple hours or have time to do the in-depth topic discussion that I want to, but I always have a few minutes between meetings or other activities to reflect on the learner’s experience. I can then provide those nuggets of wisdom that I feel will help the learner to be a better pharmacist and remind him or her that I am thinking about their learning and professional development. It is also important for a preceptor to know when to take a timeout and have a crucial conversation with their learner. I remember a particular learner who would routinely be described as a “rock star.” She was highly intelligent, motivated, efficient, an excellent communicator, and determined to maximize every moment of her time with us. Over the course of the first half of the year, she acquired several “extra” projects both on a local and national level. However, by about halfway through the year, it became evident that she had overcommitted and it was negatively impacting her performance. As a preceptor and mentor, it was my responsibility to sit down with the learner to let her know what I had observed and to guide her toward decisions that would not only correct the current course but prevent it from happening in the future. After some resistance (“I can still do it all”), she realized she had taken on too much. She had to make the difficult and uncomfortable decision to back down from some of these commitments in order to prioritize others. Fast forward, and we find this same individual as a leader in our profession. She is selective in the opportunities that she takes on, prioritizes what is most important, and is a role model that I point to as an example for other learners. I often think back to that first bone marrow transplant rotation over two decades ago and wonder what if the month had not gone as well? What if the preceptor did not demonstrate genuine interest in my professional development? What if the preceptor did not model a progressive clinical practice model? What if, after our topic discussion on graft versus host disease, he didn’t tell me I did a good job picking up on the role of methotrexate in the conditioning regimen? Would I be in the same place today? I don’t know the answer, but I do know that throughout my career I have gone back to that month as well as several others where I had inspirational preceptors and used them as motivation to ensure I am reinvesting in our profession by trying to inspire the next generation of pharmacists. I feel like this is my obligation to



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continue the legacy of the many mentors who have inspired me; I encourage you to make the most of your role as a preceptor and invest in the future of our profession.

Sincerely, John

Lisa Hall Zimmerman PharmD, FCCM, BCPS, BCNSP, BCCCP Adopting a Learner-Centered Precepting Model Lisa is a Critical Care Clinical Pharmacist and has served as a Residency Program Director (RPD) for the Postgraduate Year (PGY) 2 Critical Care Pharmacy Residency at New Hanover Regional Medical Center in Wilmington, North Carolina (20162019) and Detroit Receiving Hospital in Detroit, Michigan (2004-2013). She also served as interim RPD for the PGY2 Emergency Medicine Residency at Detroit Receiving Hospital (2010-2013). As an RPD, she has graduated 12 PGY2 critical care pharmacy residents and four PGY2 emergency medicine residents. She has precepted over 60 pharmacy residents and more than 120 learners, including students in critical care-focused learning experiences. Lisa has been recognized for her precepting expertise from numerous resident classes and was the recipient of the ASHP Foundation’s 2018 Preceptor of the Year Award. She is a Fellow of Critical Care Medicine and board certified in critical care pharmacy, pharmacotherapy, and nutrition support pharmacy. Lisa remains active within the Clinical Pharmacy and Pharmacology section of the Society of Critical Care Medicine. Lisa received her BS in Pharmacy from Auburn University and her PharmD at Sanford University. She completed a PGY2 critical care pharmacy residency at the Mayo Clinic in Rochester, Minnesota. Lisa’s precepting advice is: Precepting is personal and should be individualized. Adopting a learner-centered precepting model allows the preceptor and trainee to maximize their past knowledge and experience in a new rotation.

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Dear Colleague, Our mentors teach us to share our experiences with colleagues and learners regarding mistakes we have made in precepting and teaching. Precepting is challenging because each learner has different short- and long-term professional goals. Some may be pursuing a PGY1 or PGY2 residency, whereas others may be seeking a generalist or a community pharmacy position. A preceptor quickly realizes each resident or student garners different experiences, skill sets, and knowledge based on prior learning experiences. Hence, this precepting pearl focuses on the learner-centered precepting model, which evolved from my early precepting mistakes.

Teaching and Learning During my first few years as a preceptor, I used traditional methods of clinical teaching that involved only patient cases and topic discussions. I was focused on a routine and a rotation schedule that I believed would apply to all my trainees. As such, I would expect my PGY1 pharmacy and PGY2 specialty residents to arrive very early in the morning (around 6:30 am) and work past 7:00 pm. As the preceptor, I felt I should lead the topic discussions and spend a lot of time with the residents. My expectation at that time was that the resident should learn a great deal of topics in a short amount of time during the rotation. After soliciting feedback from the residents, I realized my expectations were unattainable for most learners. Furthermore, I was expecting every resident or student to function at the level of a PGY2 critical care resident. I was not respectful of the residents’ time, and we were not using our one-on-one time efficiently. Around this period, I was fortunate to take part in a Dale Carnegie class that focused on communication skills, time management, and interpersonal dynamics. The experience was extremely rewarding, but more importantly it forced me to self-reflect on my role as a preceptor. I learned that I was very inefficient with my time professionally, as a pharmacist and educator. I realized I needed to prioritize my daily/weekly/yearly activities to be organized with time, share my own mistakes before criticizing others, and use encouragement to make a fault easy to correct. As my family grew, it became more important to manage my time productively so I could balance my personal life, teaching, and my clinical practice. I realized that my early methods of teaching were flawed, which is common among new preceptors. Since then, I have shifted from a teacher-centered to a learner-centered model. This model allows the preceptor to design the learning experience for the resident or student while tailoring to the learner’s individual goals and objectives. Utilizing this model, the residents would create their own



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unique learning experiences by selecting topics and medication concepts that they wanted to learn during the rotation. Prior to this change, I was covering a core set of topics and focused on specific patient populations without regard to their previous experience or rotations. For example, core topics for critical care include analgesia and sedation or vasopressors. Residents and students may have covered core topics on other rotations. Hence, after discussions, I modified my initial approach to the learning experience and worked with the learners to design the rotation experience based on what the residents or students wanted and needed to learn. It was a necessary change to create a positive learning environment.

Learner-Centered and DEEP-SIX On the first day of rotation, the learner and I design the rotation experience based on the residents’ needs. The residents extract topics from their required topic list that they need to cover. If a core critical care element is missing, the learner and I work collaboratively to determine if the element is needed while targeting their long-term professional goals. For example, covering a topic discussion on antibiotics is helpful for the student who might be taking a position in a community pharmacy. This approach is also a graduated learning process, taking into account past topics and experiences and applying them to the new rotation. After reflecting on my own time management, I discovered methods to improve efficiency of my learners, especially surrounding our topic discussions. I created a standardized format for the residents to present each of the topic discussions and case presentations to be more efficient with our one-on-one time. The standardized format is called DEEP-SIX, which stands for: D = diagnosis E = epidemiology E = etiology P = prognosis S = signs and symptoms I = investigations X = “extras” including management and treatment Another change I implemented with my residents is sharing the mistakes that I learned early in my career as well as best teaching practices. The learner-centered teaching model creates an open environment with the preceptor and resident, aiding in both personal and professional development during the learning experience.

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My overall teaching philosophy is to provide students and residents with a stimulating, challenging, positive, and collaborative experiential learning environment to foster their critical thinking skills and personal growth, develop evidence-based clinical problem-solving strategies, and prepare them to function as highly skilled and competent clinical pharmacy practitioners. I believe teaching needs to be learner-centered; therefore, I strive to augment the residents’ individual strengths and help enhance their areas of improvement. I accomplish this by using my expertise to provide residents with the necessary tools and resources to answer clinical questions. As such, the residents are equal partners in the learning process and are more likely to succeed. By providing the residents with a dynamic and engaging learning environment, I hope to inspire their curiosity to become self-directed, lifelong learners beyond the clinical rotation. I learn from students and residents as much as they learn from me. One of the things that has helped me in my career is realizing that I have to be a lifelong learner to keep up with the ever-changing landscape of clinical pharmacy. Because we have opportunities to learn something new every day, being a lifelong learner is one of the most important skills that I can instill in my residents as they continue in the pharmacy profession.

Feedback and Self-Improvement I also incorporate Feedback Fridays, which allow me to integrate real-time resident or student feedback to make modifications to the learning experience. If the rotational experience modifications are made, the learner and I reassess the changes to ensure we are meeting his or her goals. The learning style of the resident or student is also important to identify. Using teaching styles that address the learners’ style impacts the overall experience. For example, I employ strategies of medical images for the visual learners, sequential order of process for the sequential learning, and bedside evaluation of the critically ill patients to assist the tactile learner. In summary, the learner-centered precepting model allows a focused, individualized approach to teaching while enabling the learner to tailor his or her learning experience. Each preceptor is encouraged to evaluate what the learner needs to accomplish in the learning experience with a mutual agreement of achievable goals. Ultimately, employing a focused learner-centered precepting style, the preceptor impacts the professional trajectory of the resident or student.

Best regards, Lisa