Jean Y. Moon

Warfarin Monitoring in Antiphospholipid Syndrome and Lupus Anticoagulant

Objective: To review the available literature on international normalized ratio (INR) and chromogenic factor X (CFX) monitoring in patients with antiphospholipid syndrome (APS), specifically lupus anticoagulant (LA), and furthermore, to identify benefits of one monitoring test compared with the other in the presence of LA. Data Sources: A literature search was conducted through MEDLINE (1946-May 2014) utilizing the following MeSH terms chromogenic compounds, anticoagulants, and factor X. Further articles were identified from original literature citations. Study Selection: All English-language studies were included that involved INR and/or CFX monitoring in APS patients that focused on a therapeutic anticoagulation level with warfarin therapy. Data Synthesis: A total of 55 articles were identified, of which nine are referenced because of their relevance for this review: three articles focus on the efficacy of utilizing INR monitoring in patients with APS, five focus on CFX compared with INR for therapeutic warfarin dosing, and one compares different thromboplastins utilizing both INR and CFX monitoring. INR monitoring in patients with APS, specifically LA, was not found to be reliable because thromboplastin reagents are sensitive to LA. Furthermore, when INR was compared to CFX, patients with LA had supratherapeutic INRs despite having CFX within goal range. Conclusions: In a subgroup of APS patients, INR monitoring may not be safe for determining the dose of warfarin because their INR values can be falsely elevated. Although CFX monitoring is more accurate, it too comes with its own downsides. Managing warfarin therapy in the APS population needs to be individualized.

Entrustable Professional Activities for Pharmacy Practice

The profession of pharmacy is facing a shifting health system context that holds both opportunity and risk. If the profession of pharmacy is to advance, pharmacists must be recognized as a consistent member of the health care team in all clinical settings, contributing at the fullest extent of licensure and education. One part of achieving this broad goal is to implement a new way of defining and assessing pharmacy practice skills, such as entrustable professional activities (EPA). Assessment of professional tasks and practice activities with EPAs has been successfully implemented in medical education for assessing trainee preparation for practice. This EPA model is being applied to pharmacy education to develop an assessment framework across the advanced pharmacy practice experience (APPE) curriculum. The APPE course directors, practice faculty members, and the Office of Experiential Education collaboratively defined a set of universal EPAs critical for pharmacists in any practice setting and would be assessed in all practice experience types.

Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences

Objective. To determine if the amount of exposure to patient encounters and clinical skills correlates to student clinical competency on ambulatory care advanced pharmacy practice experiences (APPEs). Design. Students in ambulatory care APPEs tracked the number of patients encountered by medical condition and the number of patient care skills performed. At the end of the APPE, preceptors evaluated students’ competency for each medical condition and skill, referencing the Dreyfus model for skill acquisition. Assessment. Data was collected from September 2012 through August 2014. Forty-six responses from a student tracking tool were matched to preceptor ratings. Students rated as competent saw more patients and performed more skills overall. Preceptors noted minimal impact on workload. Conclusions. Increased exposure to patient encounters and skills performed had a positive association with higher Dreyfus stage, which may represent a starting point in the conversation for more thoughtful design of ambulatory care APPEs.

Supporting formative peer review of clinical teaching through a focus on process

BACKGROUND The professional need for development of clinical faculty is clear. Previous scholarship provides insight into the formative potential of peer review in both didactic and experiential settings. Less information exists on a comprehensive peer review process (PRP) designed to support faculty change. EDUCATIONAL ACTIVITY AND SETTING A clinical faculty PRP was developed and implemented based on input from the literature, stakeholders, and field experts. The process included: 1) self-reflective pre-work, 2) a peer-observation component, 3) self-reflective post-work, and 4) creation of a specific action plan via meeting with an educational expert. The process was assessed by collecting evaluative data from peer reviewer and clinical faculty participants. FINDINGS Eight of 26 faculty members participated in a pilot of the PRP and formed four clinical faculty-peer dyads. When surveyed, all participants unanimously reported that they would participate in the PRP again. Aspects perceived among most helpful to clinical teaching included peer observation, self-reflection, and meeting with an educational expert. Challenges related to the process included anxiety of peer observation, burden of pre-work, and logistics of scheduling meetings. DISCUSSION While instruments are important in guiding and documenting the evaluation of clinical teaching during an observation period, this initiative focused on the process supporting the observation and evaluation, in order to optimize the formative feedback received by participating faculty and encourage professional development actions. SUMMARY A PRP that incorporates preparation, reflective practice, and a meeting with an educational expert may support meaningful faculty development in the area of clinical teaching.

Preceptor and resident perceptions of entrustable professional activities for postgraduate pharmacy training

BACKGROUND Following the development and implementation of entrustable professional activities (EPAs) as a collective graduation standard for pharmacy students, the University of Minnesotas multi-site post-graduate year one pharmacy residency program made a similar transition. EDUCATIONAL ACTIVITY AND SETTING An electronic survey was distributed to program preceptors and residents to describe the perceptions of using EPAs to assess performance. FINDINGS Residents (66.7%) and preceptors (78.3%) found the EPA framework to be more helpful than the traditional progression ratings model, but both groups also described EPAs as less beneficial for some objectives. Sixteen (69.6%) preceptors felt the residency graduation standard for attainment should be an entrustment level 4 or 5. Preceptors found the EPA scale to be more descriptive, more objective, and easier to understand; however, it did not always apply to all skills and was more challenging to provide residents information regarding what they needed to improve upon. Residents commented that the EPA scale was more descriptive, had better clarity, and gave them a better idea of where their progression was at on a continuum. Residents also commented that regardless of the rating scale, specific, day-to-day feedback is more helpful. SUMMARY Residents and preceptors perceive the EPA framework to be more helpful than traditional rating scales when evaluating learning objectives. Preceptors were less certain of what the EPAs entrustment level should be to consider a learning objective or skill achieved for residency. Both found some learning objectives to be more challenging for EPA use.

Expanding Ambulatory Care Pharmacy Residency Education Through a Multisite University-Affiliated Model

Introduction: As the health-care system evolves and shifts to value-based payment systems, there is a recognized need to increase the number of ambulatory care trained pharmacists. Objective: The objective of this article is to describe the administrative structure of the University of Minnesota Postgraduate Year 1 (PGY1) Pharmacy Residency program and to encourage adoption of similar models nationally in order to expand ambulatory care residency training opportunities and meet the demand for pharmacist practitioners. Program Structure: The University of Minnesota PGY1 Pharmacy Residency program is a multisite program centered on the practice of pharmaceutical care and provision of comprehensive medication management (CMM) services in ambulatory care settings. The centralized administration of a multisite academic-affiliated training model creates efficiency in the administration process, while allowing sites to focus on clinical training. This model also offers many innovative and unique opportunities to residents. Conclusion: A multisite university-affiliated ambulatory care residency training model provides efficiency in program administration, while successfully accelerating the growth of quality ambulatory care residency training and supporting innovative delivery of shared core learning experiences. Consequently, practice sites grow in their service delivery capacity and quality of care.

Supporting quality in experiential education through enhanced faculty engagement

INTRODUCTION There are ongoing assessment and improvement activities related to strategies to improve the quality of education in the complex and resource-intensive area of experiential education (EE). One undescribed approach for design and delivery of EE programs for schools and colleges, with reliance on volunteer preceptors, is to utilize clinical practice faculty in formal partnerships with EE leadership to enhance curriculum and assessment. COMMENTARY AND IMPLICATIONS Clinical practice faculty, who possess practice setting expertise, can serve as course directors for advanced pharmacy practice experience (APPE) rotations. In this role, they can collaborate with EE faculty and staff to create more course-specific expectations, learning objectives, and criteria for APPE rotation experiences. This model could increase consistency for students and preceptors, using an approach that is analogous to content experts serving as course directors in didactic curriculum. This commentary explores the potential of this strategy to increase quality and consistency in EE.