Friday, April 27, 2018

Statistics: The Cause Of, And Solution To All Medical Problems

In pharmacy school, there were times where mountains of material coincided with a flurry of exams. Such extreme circumstances called for masterclass test taking skills. For example, when a hundred page packet would account for 10 questions on an exam, and a 20 page packet also accounting for 10 questions, the logical studying strategy would focus on maximizing the number of points from the lower quantity material. Fast forward a decade after these exams and I found myself in the same situation. The BCPS exam is not so different from a test taking perspective.

When you consider that the BCPS exam content breakdown consists of 55% patient specific pharmacotherapy - that is a little over half of the exam pulls from ALL OF MEDICINE. Where 45% of the exam is based on a relatively small amount of content: statistics, regulatory issues and system based questions (P&T issues, MTM, etc.). An astute test taker is going to save time by not studying the various mesalamine formulations and their corresponding niches and spend that time knowing stats cold.

Through my years of practice, reading journals, and conducting my own research, I’ve become relatively familiar with stats. One could say I’ve got a pretty good working knowledge. So when the time came to recertify for BCPS, I wasn’t going to take any chances. With so many points on the table for this relatively small subject, I took every opportunity to brush up and learn something new.

Much of my preparation consisted of self-directed reading and learning, but I was falling short on what I expected of myself when studying. With my partnership with High-Yield MED Reviews, I had the opportunity to broaden my biostatistics knowledge from an expert in the field, Dr. Busti. When it comes to statistics, learning from a professional with experience from the likes of the Cochrane collaboration is as good as it gets. High-Yield Med Reviews (HYMR) offers a live webinar for biostatistics, which I was able to participate in.

The webinar itself could have been a difficult presentation to get through, since biostatistics are not exactly the most exciting thing on the planet. But I quickly realized that Dr. Busti wasn’t going to bore anyone by reviewing the application of a Student’s t-test vs and ANOVA- he tied everything back to real world practice. Each learning objective used real examples from existing articles (most of which were landmark studies- another good review), and was presented in a way that each concept was built upon from the previous one. In making the content relatable and applicable, the concepts became easier to grasp.  Grasping the concepts is they key, as Dr. Busti pointed out. The BCPS exam isn’t going to as straight-forward questions; it’s testing your knowledge in application of concepts.

The webinar itself was an excellent compliment to the biostatistic modules. But starting from my level of experience, I was able to jump right onto the webinar content. For a new graduate or young professional, you really need to spend some time reviewing biostatistic concepts before the webinar. Without preparing adequately, key points will fly over your head. Unlike the online module content, the webinar cannot be paused or rewinded. Although you can ask questions, in order to maximize the effectiveness of the webinar, one must be prepared beforehand.

While other professional organization review courses require dedication of your time and resources to travel and attend, the HYMR is 100% online. This allows you to be able to participate from the comfort of your home. However, it’s not brief. The webinar runs about 3-4 hours. Personally, my attention span is not that long. Particularly when a 10 month old is crawling around my ankles. Although long, it is worth it. The time invested here is well spent, especially compared to either traveling to a live review, or attempting to structure a similarly effective program yourself.  

Although my bias is towards recommending HYMR given our partnership, I truly feel it is beneficial. The famous “Stats Table” seen in many study guides will help with BCPS preparation, it will only get you so far, and won’t truly contribute to you becoming a better pharmacist. Since I’m already putting in the effort to study and pass the exam, why not also improve my biostatistic skills at the same time? The benefits extend beyond test preparation into one’s own practice, and improve either your study design skills or at minimum, your literature analysis skills. Furthermore, for residency programs, these modules would be a good investment of the program to provide a didactic element of biostatistics.

Sunday, April 1, 2018

BCPS Recertification- High-Yield Med Reviews

I’ve always been a huge fan of stand up comedy. For the longest time, I admired the ability of comedians to be able to speak so conversationally, and naturally while being hilarious. Over time, I’ve come to learn that some of my favorite comedians (Jerry Seinfeld, Jim Gaffigan, Tom Papa) extensively plan out every minute detail of their jokes, practice like crazy and never stop trying to improve. The grand illusion that most professional comedians natural abilities that don’t require much effort to maintain translates into what it takes to be a pharmacist.  I think many would be surprised at the amount of effort I put in to try to continuously improve (I’d guess the same holds true with folks like Bryan and Nadia). So when the time came to recertify BCPS, I had to find a strategy that would match the level of effort I needed to exert.

Since my initial certification, I’ve become entrenched in all things emergency medicine. I started to spend more time reading what I enjoyed and had interest in, with little interest or effort put into other topics. While I suppose you could say, an emergency medicine pharmacist should know Nutrition (TPN and the like) inside out, I had zero interest in reading or staying up to date on it. Nutrition to an EM pharmacist consists of turkey sandwiches and graham crackers. So when it came to deciding whether to elect to sit for BCPS recertification or 120 hours of PSAP, the choice was easy.

What wasn’t easy was trying to establish an effective way to prepare for the exam. Through professional connections, I was lucky enough to have been connected with Dr. Anthony Busti, who created High-Yield Med Reviews. Dr. Busti is one of many educators who provide online education and exam preparation. I must say that I’ve partnered with Dr. Busti who is sponsoring the EMPharmD blog, but had nothing to do with this post or me reviewing the program at all. Plus Dr. Busti isn’t just anybody, as you’ll find out later. Nevertheless, I went with the BCPS Premium plan which fit my learning style with a self-directed learning model, online lectures, and many many practice questions.

Before diving into the content and structure of High-Yield Med Reviews, it’s critical to know where (or from whom) the content is coming from. Online pharmacy education can be pretty hit or miss. If you’ve tried to watch pharmacology and pharmacotherapy lectures on YouTube, they’re almost all horrible: somewhere on the spectrum of inaccurate to unwatchable. What stood out to me with High-Yield Med Reviews BCPS preparation and why I’ve been using it for my recertification is the credibility Dr. Busti brings to the online content. Although Dr. Busti is an EM attending physician at UT Southwestern Medical Center in Dallas, he is also a nurse, and a pharmacist. Not only was he a nurse, but an critical care and emergency medicine nurse. Not only was he a pharmacist, but a residency trained clinical pharmacist, faculty at Texas Tech University and residency program director. As if he needed any more credibility, he’s now pursuing a MSc in Evidence-Based Health Care at Oxford University. Needless to say, the online lectures, provided content and practice questions are high quality, effective and reliable.

The structure of High-Yield Med Reviews fits with my learning style and my teaching philosophy. I like to picture medical/pharmacy education as a spiral (Kolb spiral): Experience with structure, Reflection/Refinement, Meta-cognition/abstract concepts, Testing. Visualized as a spiral, rather than a circle, is significant because since each cycle where new knowledge is gained builds upon what was previously known by assimilating new information with prior knowledge.  However, since different people have varying levels of prior knowledge, the knowledge they can gain from a given lesson is limited by their “zone of proximal development.” For example, because of my practice, my knowledge level of acute coronary syndrome (ACS) pharmacotherapy is high, so I would easily be able to learn advanced topics. On the flip side, my knowledge of TPNs and nutrition is pretty basic, so I would require a number of sequential lessons to reach the same level of knowledge as with ACS. High-Yield Med Reviews online lectures compliments this learning method by providing > 100 different lectures to build knowledge.

Clinical practice is the best way to gain experience. But experience can also be acquired through lectures, as long as their effective. Effective lectures that not only provide knowledge, but also context. In the online lectures by Dr. Busti, his lecture style effectively provides this context either through the case based teaching or building upon basic concepts in sequential lectures. There are several lectures ranging from basic pharmacology to detailed evidence based medicine discussions. For example, rather than just a 60-90 minute lecture on hypertension guidelines, High-Yield Med Reviews has 16 lectures on hypertension, each around 10-20 minutes in length covering topics ranging from specific drug classes to guidelines to special populations like hypertension in pregnancy. So I can spend less than an hour on reviewing updates in guidelines rather than have to start with the basic pharmacology. Whereas a new pharmacist would benefit from the pharmacology lectures in order to build up to the guideline reviews. Since I’m a pharmacology geek, I watched the pharmacology lectures anyways - Dr Busti and I share the same attitude towards beta-blockers in the management of hypertension.

A crucial step in the Kolb spiral is reflection and refinement. The learner needs time to reflect on what was learned, and be able to return to the content to sharpen understanding. The lectures are able to be watched as many times as you’d like in a 24 hour period (for up to 3 separate 24 hour periods) where you can pause, rewind, rewatch or fast forward. This allows you to think about the content just presented, identify points of confusion or anything that's unclear, and identify further questions you may have. Being able to rewatch lectures allows refinement of these topics.

However, if cramming for two weeks before the exam is your desired method of preparation, High-Yield Med Reviews is not for you. It’s also not a good idea anyways. As a result of the breadth of content covered on a BCPS exam, sufficient time is required to prepare - somewhere between 1-3 months for most residency trained pharmacists, and 6-12 for non residency trained pharmacists. This time is required for meta-cognition. In other words, you need time to think about thinking and identify gaps in your understanding. High-Yield Med Reviews is a subscription package of 1, 3, 6 or 12 months. Based on my experience, and the degree I stay up-to-date 1 month is right for me, but that is probably pushing it. Sure, I could probably wing it and walk into the exam without preparation, but my earlier career experience with the Dunning-Kruger effect, taught me that the amount of information I DON’T know is greatly outweighed by the information I DO know.

Finally, the last element to this learning cycle is testing and application. With more than 2000 questions to practice from High-Yield Med Reviews provides ample testing to ensure learning and compliment the lecture. The questions are in the format and level of difficulty of the BCPS exam and written by pharmacotherapy experts (including myself). To deliver not just testing and application, but supplementary learning, each question has a detailed explanation and rationale for the correct and incorrect answers, high-yield core concepts, take home points, and are referenced. By putting in the effort to review each question, you still benefit from whether you scored 100% or 20%. If you scored particularly low, or identified things you know you need to know, the questions are able to be flagged for further review at later time.

There are different modes that you can utilize with the practice questions: testing, tutorial and flashcards. Personally, I only use the testing mode. Tutorial provides answers and explanations after each question, rather than the end of your session; Flashcards provide the question with no multiple choices, which forces you to think of an answer rather than simply selecting one.

I’ve been extremely satisfied so far with High-Yield Med Reviews. But there are a few things that I would have liked to be different or improved. While the testing mode for questions tells you what percentage of people got the answer correct, there is no correlation to how you perform overall to your likelihood of passing the exam. While the difficulties of tracking down exam results of subscribers while maintaining privacy would make that sort of data challenging to collect.

Another aspect is practicing in a full length practice exam to not only become familiar with the style of the exam, but also to identify areas of weakness.  While currently, you can set up a mock exam yourself by selecting 200 questions in testing mode, there’s no guarantee the questions will be in the same proportion of the 3 exam domains. However, this will be a new feature where there will be full length mock exams in the near future.

Lastly, is the cost. FOAM (free open access medical education) has spoiled us with high quality medical education. But, as I said before, FOAM is lacking in high quality pharmacology and pharmacotherapeutic content in areas outside of emergency medicine, and anything available for free on Youtube is worth what you pay for it: nothing.  So while I am extremely cheap, and would prefer to not pay for anything, I would say the cost of High-Yield Med Reviews is fair given the quality of content and it’s actually quite a lot more affordable than other “review courses” and PSAP modules.

High-Yield Med Reviews is a high quality, modern educational platform that offers me exactly what I was looking for with BCPS exam preparation. Dr. Busti has a wealth of knowledge and experience that you can benefit from, and become a better pharmacist by securing board certification, and by simply improving your knowledge and expanding your new zone of proximal development. I’m proud to continue my partnership with Dr. Busti through the EMPharmD blog and through contributions to the content of High-Yield Med Reviews.

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