19.2 Interprofessional Education & Clinical Teaching Strategies

19.2 Interprofessional Education & Clinical Teaching Strategies

The Board-Certified Pediatric Pharmacy Specialist (BCPPS) fulfills a vital dual role within modern academic health systems: serving as a clinical pharmacotherapy expert and as a frontline educator. Beyond traditional pharmacy students and residents, pediatric specialists educate a wide interprofessional audience including medical students, pediatric residents, subspecialty fellows, attending physicians, bedside pediatric nurses, and respiratory therapists. Delivering high-yield, context-specific clinical teaching during high-acuity pediatric rounds requires structured pedagogical frameworks that maximize learning without compromising workflow.

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Interprofessional Clinical Rounding & Bedside Education

Multidisciplinary bedside rounds in pediatric intensive care units (PICU), neonatal intensive care units (NICU), and pediatric medical wards represent the nexus of team-based clinical learning. The participation of a dedicated clinical pharmacist on pediatric rounds is proven to reduce preventable adverse drug events (pADEs) by 60% to 80%.

Interprofessional Pediatric Rounding Interface & Core Teaching Touchpoints:

             ┌────────────────────────────────────────────────────────┐
             │        Attending Physician & Subspecialty Fellows      │
             └───────────────────────────┬────────────────────────────┘
                                         │
                                         ▼
┌──────────────────────────┐  Interprofessional  ┌───────────────────────────┐
│ Pediatric Resident / Med │ ◄─────────────────► │ BCPPS Clinical Specialist │
│ Student (Trainee)        │  Clinical Teaching  │ (Pharmacotherapy Lead)    │
└──────────────────────────┘      & Safety       └───────────────────────────┘
                                         ▲
                                         │
             ┌───────────────────────────┴────────────────────────────┐
             │        Bedside Pediatric Nurse & Respiratory Team      │
             └────────────────────────────────────────────────────────┘

Core Clinical Pharmacist Teaching Domains:
• Weight-based calculation safety & adult dosing caps
• Organ maturation pharmacokinetics (CYP450, GFR, protein binding)
• Antimicrobial stewardship (vancomycin AUC/MIC, time-dependent beta-lactams)
• Parenteral nutrition osmolarity, calcium-phosphate solubility, and trace elements
• Smart pump DERS limits & vascular access compatibility

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Validated Clinical Teaching Models

When educating medical trainees, residents, and pharmacy students during bedside patient care, clinical preceptors must avoid two common teaching failures: delivering long, unprompted didactic monologues that delay rounds, or passively providing the answer without probing learner comprehension.

1. The One-Minute Preceptor (OMP / Neher's Five Microskills)

Originally formulated by Neher and colleagues, the One-Minute Preceptor (OMP) model organizes clinical instruction into five sequential "microskills" that allow the preceptor to assess knowledge, impart clinical wisdom, and provide actionable feedback in less than two to three minutes.

The Five Microskills of the One-Minute Preceptor (OMP):

┌─────────────────────────────┐
│ 1. Get a Commitment         │ ──► "What empiric antibiotic regimen do you recommend for this infant?"
└──────────────┬──────────────┘
               ▼
┌─────────────────────────────┐
│ 2. Probe for Evidence       │ ──► "What patient factors led you to choose ampicillin and cefotaxime?"
└──────────────┬──────────────┘
               ▼
┌─────────────────────────────┐
│ 3. Teach General Rules      │ ──► "In neonates <28 days, Listeria and Group B Strep dictate coverage."
└──────────────┬──────────────┘
               ▼
┌─────────────────────────────┐
│ 4. Reinforce What Was Done  │ ──► "You correctly avoided ceftriaxone to prevent bilirubin displacement."
└──────────────┬──────────────┘
               ▼
┌─────────────────────────────┐
│ 5. Correct Mistakes & Gaps  │ ──► "Remember to adjust the ampicillin interval for post-menstrual age."
└─────────────────────────────┘

1. Microskill 1: Get a Commitment
   • Instead of immediately giving the solution, the preceptor asks the learner to state their diagnostic impression or pharmacotherapeutic plan.
     Script: "Based on this 3-year-old child's presentation with septic shock, what fluid bolus volume and what initial empiric broad-spectrum antibiotic regimen would you order right now?"
   • Educational Value: Forces the learner to process data and commit to an active decision rather than remaining a passive observer.
2. Microskill 2: Probe for Supporting Evidence
   • The preceptor asks the learner to justify their decision.
     Script: "Why did you choose cefepime at 50 mg/kg every 8 hours instead of ceftriaxone at 50 mg/kg every 24 hours for this oncology patient?"
   • Educational Value: Distinguishes whether the learner made a well-reasoned deduction or a lucky guess, identifying specific knowledge deficits or misconceptions.
3. Microskill 3: Teach General Rules
   • The preceptor provides a concise, high-yield clinical principle (1–2 sentences) that the learner can generalize to future clinical encounters.
     Script: "In pediatric febrile neutropenia, Pseudomonas aeruginosa is an aggressive pathogen capable of causing fatal bacteremic shock within hours; therefore, empiric monotherapy requires an antipseudomonal beta-lactam dosed at high-frequency intervals to optimize time above MIC ($T > \text{MIC}$)."
4. Microskill 4: Reinforce What Was Done Well
   • Provide specific, timely praise for positive behaviors or accurate clinical reasoning.
     Script: "You did an excellent job verifying the patient's absolute neutrophil count ($ANC < 500/\text{mm}^3$) and calculating the weight-based cefepime dose using the child's exact metric scale weight rather than an estimate."
5. Microskill 5: Correct Mistakes and Gaps
   • Constructively address errors or omissions and guide the learner toward the correct practice.
     Script: "Notice that you wrote for cefepime every 12 hours. In pediatric patients with normal renal function, cefepime clearance is significantly higher than in adults, so an 8-hour interval is required to prevent subtherapeutic troughs in pseudomonal sepsis."

2. The SNAPPS Model (Learner-Centered Clinical Presentations)

While the OMP model is preceptor-driven, the SNAPPS model is an active, learner-driven framework specifically designed for clinical case presentations in outpatient clinics or morning work rounds:

• S — Summarize: The learner concisely presents the patient's history, physical examination, and pertinent laboratory findings (limited to <2–3 minutes).
• N — Narrow: The learner narrows the differential diagnosis to the two or three most likely or critical possibilities.
• A — Analyze: The learner compares and contrasts the clinical features and pharmacotherapeutic options across the differential diagnoses.
• P — Probe the Preceptor: The learner initiates a discussion by asking the preceptor questions about areas of uncertainty, management dilemmas, or conflicting evidence (e.g., "I am uncertain whether this neonate's respiratory distress warrants early surfactant therapy or continued CPAP alone—how do you weigh the chest radiograph findings against the oxygenation index?").
• P — Plan Management: The learner formulates a comprehensive management and monitoring plan for the patient.
• S — Select Self-Directed Learning: The learner identifies an unresolved clinical question or knowledge gap from the encounter to investigate independently and report back to the team the following day.

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Precepting Trainees: ASHP Accreditation Standards & The Four Preceptor Roles

The American Society of Health-System Pharmacists (ASHP) accreditation standards for PGY1 pharmacy and PGY2 pediatric pharmacy residencies define four progressive preceptor teaching roles that must be utilized systematically across learning experiences:

Evolution of ASHP Preceptor Teaching Roles Across Residency Rotations:

  1. DIRECT INSTRUCTION   ──► Preceptor teaches core concepts didactically (Lectures/Topic Discussions)
            │
            ▼
  2. MODELING             ──► Preceptor demonstrates clinical task; Learner silently observes
            │
            ▼
  3. COACHING             ──► Learner performs clinical task; Preceptor observes and coaches
            │
            ▼
  4. FACILITATING         ──► Learner practices independently; Preceptor debriefs retrospectively

1. Direct Instruction: The preceptor delivers foundational didactic instruction on pediatric pharmacotherapy concepts (e.g., conducting a formal topic discussion on developmental pharmacokinetics, aminoglycoside extended-interval dosing, or pediatric advanced life support protocols).
2. Modeling: The preceptor performs the clinical activity while the learner observes. The preceptor explicitly models professional behaviors, patient workups, therapeutic drug monitoring calculations, and multidisciplinary communication (e.g., the preceptor leads rounds while the resident observes the pharmacist's interaction style and bedside intervention techniques).
3. Coaching: The learner performs the clinical activity while the preceptor directly observes in real time. The preceptor provides active support, prompts when necessary, and conducts an immediate debriefing following the encounter (e.g., the resident presents pharmacokinetic consults on rounds while the preceptor stands by, stepping in only if patient safety is compromised).
4. Facilitating: The learner functions independently as the primary clinical pharmacist for the patient care unit. The preceptor provides distant supervision, reviewing orders, consults, and notes retrospectively and facilitating high-level discussions (e.g., the PGY2 resident manages the entire PICU satellite independently, discussing complex cases with the preceptor during afternoon debriefs).

Formative vs. Summative Evaluations

• Formative Evaluation: Ongoing, informal or structured, day-to-day feedback provided during learning activities. Formative feedback highlights real-time strengths and immediate areas for growth without carrying a formal grade (e.g., daily rounding debriefs, mid-point rotation reviews).
• Summative Evaluation: Formal, documented assessment conducted at the conclusion of a discrete learning experience or rotation (e.g., via PharmAcademic). Summative evaluations rate trainee performance against specific ASHP educational goals and objectives (e.g., Needs Improvement [NI], Satisfactory Progress [SP], Achieved [ACH], or Achieved with Distinction [ACH-D]).

Constructive Feedback: The Situation-Behavior-Impact (SBI) Model

Delivering critical feedback to trainees can provoke defensiveness if perceived as a personal attack. The Situation-Behavior-Impact (SBI) framework, developed by the Center for Creative Leadership, standardizes feedback delivery by focusing strictly on observable facts:

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Interprofessional Clinical Simulation & Continuing Education

High-fidelity clinical simulation has emerged as the premier modality for training interprofessional teams in high-risk, low-frequency pediatric emergencies.

1. Pediatric Advanced Life Support (PALS) & Neonatal Resuscitation Simulations

During pediatric cardiopulmonary arrest simulations, clinical pharmacists function as the resuscitation pharmacotherapy team lead, preventing lethal medication errors under chaotic, high-stress conditions:

• Weight-Based Resuscitation Dosing Rules:
  • Epinephrine in PALS: The IV/IO dose is 0.01 mg/kg (0.1 mL/kg of the 0.1 mg/mL [1:10,000] concentration) every 3 to 5 minutes (maximum single dose 1 mg). The endotracheal (ET) dose is 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL [1:1,000] concentration). Pharmacists ensure the team never administers the concentrated 1 mg/mL formulation intravenously.
  • Defibrillation Energy Dosing: Initial unsynchronized shock for ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) is 2 J/kg; the second and subsequent shocks are 4 J/kg (may escalate up to 10 J/kg or maximum adult dose of 200–360 J).
  • Synchronized Cardioversion: For unstable supraventricular tachycardia (SVT) or ventricular tachycardia with pulse: 0.5 to 1 J/kg initial dose; escalate to 2 J/kg if refractory.
  • Fluid Bolus Dosing in Pediatric Shock: 10 to 20 mL/kg of balanced isotonic crystalloid (normal saline or lactated Ringer's) infused over 5 to 20 minutes (reassess after each bolus for signs of fluid overload: hepatomegaly and crackles; reduce to 10 mL/kg in cardiogenic shock or severe malnutrition).
  • Neonatal Resuscitation Program (NRP): Intravenous epinephrine dose is 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of 0.1 mg/mL solution) via umbilical venous catheter (UVC), followed by a 0.5 to 1 mL normal saline flush. Fluid expansion: 10 mL/kg normal saline over 5 to 10 minutes.

2. Smart Pump Hands-on Training & Safety

Smart infusion pumps equipped with Dose Error Reduction Systems (DERS) are standard across pediatric facilities, yet programming errors persist if clinical staff are inadequately trained on pediatric library configurations:

• Hard Limits vs. Soft Limits:
  • Soft Limits: Advisory warning limits programmed into the drug library that alert the clinician when a programmed dose falls outside standard practice. Clinicians may override soft limits with a documented clinical rationale.
  • Hard Limits: Absolute safety boundaries that cannot be overridden under any circumstance (e.g., programming an intravenous potassium chloride infusion rate $>0.5 \text{ mEq/kg/hour}$ or $>20 \text{ mEq/hour}$; programming a neonatal fentanyl bolus $>5 \text{ mcg/kg}$). Hard stops force the nurse to stop and re-verify the order.
• Syringe Pumps for Neonatal Micro-Infusions: In neonates receiving micro-infusions (e.g., continuous regular insulin at 0.05 units/kg/hour, running at $0.1 \text{ mL/hour}$), preceptors must teach nurses and trainees about dead-space volume delays in IV tubing and carrier fluid manifolds, where therapeutic drug onset can be delayed by several hours unless lines are properly primed with the drug solution.

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Practice Pearls & BCPPS Exam Traps

• Exam Trap 1: OMP Microskill Sequence: A common question presents a learner proposing a drug regimen and asks for the preceptor's next immediate step. If the learner has already committed to a plan (Microskill 1), the preceptor must Probe for Supporting Evidence (Microskill 2), not immediately teach general rules or praise them.
• Exam Trap 2: PALS Epinephrine Concentration: Remember that IV/IO epinephrine in PALS is always 0.01 mg/kg using the 0.1 mg/mL (1:10,000) concentration. Administering the 1 mg/mL (1:1,000) formulation intravenously delivers a lethal 10-fold overdose.
• Exam Trap 3: Formative vs. Summative Distinctions: Formative feedback guides daily learning and skill refinement; summative evaluations assess milestone achievement at rotation completion. Providing feedback only at the end of a rotation on a summative form violates ASHP accreditation standards.
• Exam Trap 4: SBI Feedback Construction: Feedback questions will test your ability to identify non-judgmental, objective feedback. Statements containing character appraisals (e.g., "You are being careless" or "You lack confidence") are incorrect; compliant feedback strictly describes the Situation, the observable Behavior, and the clinical Impact.