Layered Learning Experiences From The APPE Student Perspective

ShifkoCarlee Shifko, Pharm.D.'21 (Candidate)

This past summer, I completed Advanced Pharmacy Practice Experience (APPE) rotations at Allegheny General Hospital in the Emergency Department and Solid Organ Transplant Clinic with Dr. Caitlin Reardon and Dr. Nicole Persun, respectively. During that time, I had the pleasure of learning from not only these clinically-specialized pharmacists, but also present PGY1 and PGY2 residents that, like me, were rotating through the units. I have heard this referred to as the "layered learning practice model (LLPM)," whereas learners in different points in training strive for correspondingly different expectations, but a sense of community is promoted amongst all levels.1 While AGH, to my understanding, does not currently mandate this structure into its educational programming, I am excited to share my perceived benefits of the general approach of LLPM.

First, I affirm that learning from and alongside the resident builds confidence and comradery. Part of LLPM derives from Lave and Wenger's theory on the community of practice (COP), where identity amongst a community plays a role in clinical and professional development.2 I found every preceptor I have had to be knowledgeable, approachable, and supportive, but working with the resident further eases the pressure to impress. After all, residents share the closer temporal proximity to my current position; many can recall the struggles they had as an APPE student and what, specifically, they did to improve.

As one example, my patient presentations in the beginning of transplant rotation were disorganized and shaky. I had done this type of brief verbal plan of care before, on earlier rotations, but transplant in practice is an art form that can easily overwhelm the naive APPE student. One morning before rounds, the PGY1 resident, Dr. Aoife Iaria, and I practiced patient presentations over and over until I improved. After rounds, Dr. Persun noted a significant improvement. I do not mean to detract from the power of coaching directly from the preceptor; I have found these connections to be equally meaningful and fruitful. Still, the accessible nature of the resident minimized feelings of embarrassment during the extensive practice I needed, and it felt fantastic to unveil the upgraded product to my preceptor.

Another benefit of LLPM is the bonus problem-solving perspectives awarded to the least experienced learner. An inevitable, wonderful aspect of being human is that two folks can land at the same resolution while having arrived via unique routes. I found in the ED that pharmacist recommendations were quite similar, whether derived from the PGY2 resident, Dr. Mareena Shuster, or one of the clinical specialists, but the identity of the sender never overshadowed my interest in their thought process. LLPM allows eager APPE students, like me, to optimize our academically-spongey nature by shadowing as many gifted pharmacists as possible.

Like transplant, emergency medicine involves a touch of magic that is difficult to learn in the classroom alone. Dr. Reardon always made a priority of debriefing both Dr. Shuster and I following fast-paced cardiac arrests or unique cases. Many times, during these debriefs or topic discussions, Dr. Shuster introduced intriguing questions that were more advanced than I would have devised. This allowed me, from the APPE student side, to absorb as much pertinent information as I could from discussion and later research concepts that remained vague.

Finally, LLPM also benefits residents through additional teaching experience. APPE students have higher health literacy than most patients will, but they serve as a more forgiving audience than grand rounds, as an example. Still, these small opportunities to quiz another person or explain the "why" of the intervention reflect a strong, eloquent practitioner. Additionally, as much as I hoped to respect their time, I know that having a student required time management skills. Just like I feel challenged to meet the levels of Dr. Iaria and Dr. Shuster someday, I like to think they feel like better pharmacists because they developed their practice teaching students like me.

In conclusion, I would not change anything about my experiences with layered learning structures. The value it provides through mutually-energizing relationships and conceptual variety greatly fostered my professional development. I thank Dr. Reardon and Dr. Persun for not only their dedication to my learning and their tremendous encouragement, but also for their open-mindedness in sponsoring an open dynamic between me and the residents.


1Bates JS, Buie LW, Lyons K, et al. A Study of Layered Learning in Oncology. Am J Pharm Educ. 2016 May 25; 80(4): 68.
2Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. 1st ed, New York, NY: Cambridge University Press; 1991.

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