Mentorship and leadership for doctor of pharmacy students in an international undergraduate program

Current challenges in healthcare require pharmacists to have strong leadership skills, including good communication ability (Kerr et al., 2021), broad knowledge of various aspects of pharmacy, and an appreciation of issues in global health (Bailey et al., 2016). These elements are all included in an International Student Summer Program (ISSP) offered by the University of Southern California (USC) School of Pharmacy and designed for international undergraduate pharmacy students. A key element in this program is the recruitment of USC Doctor of Pharmacy (PharmD) students to serve as course assistants. In working with these students in two ISSP offerings (online in 2021 and on campus in 2022), it became apparent that the program offered strong mentoring opportunities for PharmD students, both as mentors to undergraduate students and as mentees working with course faculty. The PharmD course assistants developed leadership experience by preparing content and guiding learning. This work required anticipation and overcoming of technological and communication challenges caused by language and cultural barriers. In this article, we focus on the mentoring relationships of faculty with the course assistants and the opportunities for leadership in the professional development of the course assistants. These activities contribute to improvements in awareness of issues around global health in education of healthcare students and future healthcare professionals. Since the 2021 and 2022 programs were offered online and on campus, respectively, we also take the opportunity to describe the effectiveness of our mentorship approach in these two environments. Our mentorship model is similar to the layered learning approach used in experiential pharmacy education (Bates et al., 2016; Pinelli et al., 2016; Loy et al., 2017). The layered learning practice model (LLPM) was adapted from medical training for experiential pharmacy education to meet increasing demand for preceptors to educate larger numbers of learners at different levels (Bates et al., 2016; Loy et al., 2017). In the LLPM, a primary preceptor oversees the training of both senior and junior learners, typically residents and students, respectively (Loy et al., 2017). The preceptor maintains oversight of the entire learning experience, while mentoring the senior learner in teaching and providing feedback to the junior learners (Bates et al., 2016; Loy et al., 2017). The LLPM has been shown to expand patient care service, improve workflow efficiency, and promote collaborative problem-solving (Bates et al., 2016; Prescott, et al., 2020). Senior learners develop increased confidence and precepting skills, while junior learners experience a more comfortable learning environment that promotes open discussion (Kasper & Brownfield, 2018). Both junior and senior learners report increased readiness for the next stage in their learning (Kasper & Brownfield, 2018). The 2021 program enrolled 173 international students from nine countries in a 2-week online program, whereas the 2022 program enrolled 51 international students from four countries in a 4-week on-campus program. Each course was designed as an integrated delivery of four “focus areas” of pharmacy: clinical pharmacy, pharmacology, regulatory science, and health economics (marketing) (Kim et al., 2022a). Each undergraduate student was assigned to a focus area. The students were also assembled into groups that contained representatives from each focus area. There were 20 course assistants from the PharmD and Masters programs in ISSP 2021, and 12 from the PharmD program in ISSP 2022. The approaches the course assistants applied were developed through regular mentoring meetings with faculty before and during the program. Leadership opportunities for course assistants were centered on the facilitation of discussions and reinforcement of learning within an assigned group of eight or nine undergraduate students. The course assistants also provided feedback to the group by evaluating their progress and making sure that deadlines were met. Thus, the assistants had to coordinate a group and adjust the educational approach based on the needs of the group. This included making course content accessible to students with an English language barrier to ensure that all students had a positive learning experience. An overview of the two courses and the time spent on each course activity is shown in Table 1. After an introductory day (day 1), the early part of the course (days 2–4 in 2021, days 2–7 in 2022) was devoted to separate teaching of the focus areas. The second part of each course (days 5–7 in 2021, days 8–10 in 2022) included sessions designed to integrate material from pairs of focus areas. This was followed by a final period (days 8–9 in 2021, days 11–13 in 2022) of integration of all four focus areas. ISSP 2021 was taught in nine 3-hour daily periods (total teaching time 27 h), while ISSP 2022 was taught in 13 4-h (2 × 2-h) daily periods (total teaching time 52 h). The total teaching times are the sum of the times for interaction of faculty and course assistants with undergraduate students (Table 1). By necessity, this is a brief description of the course and some days that did not have formal teaching or mentoring elements are excluded in Table 1. In ISSP 2022 there were many other social and academic activities, which are not included in Table 1. The social activities involved course assistants and undergraduates, and served to strengthen interpersonal relationships. In the on-campus environment, the line between academic and social activities was more blurred than in the more formal online environment. The times spent on activities in the course are broken down in Table 1 into mentoring interactions of faculty with course assistants, mentoring interactions of course assistants with undergraduates, and teaching of undergraduates by faculty. We note that these times represent a relatively formal description of these activities, and there were many other opportunities for interactions, particularly in 2022 on campus. However, broadly, the extent of formal mentoring time from faculty to PharmD students did not change from 2021 to 2022. There was an increase in teaching time for faculty interactions with undergraduates, and most notably a large increase in the time course assistants spent mentoring undergraduates (10 h online in 2021 to 28 h on-campus in 2022). This change was a consequence of the greater time available in the on-campus course and was designed to promote social and cultural interactions. Such an arrangement in near-peer mentoring has been found to be effective for psychosocial and academic support (Zaniewski & Reinholz, 2016). This change may be reflected in the survey data in the “Post-Program Survey” section. The LLPM recommends a four-step approach of (1) orientation of faculty and senior learners, (2) pre-experience planning with faculty and senior learners, (3) implementation of the layered learning model with senior learners providing evaluation and feedback to junior learners, and (4) post-experience evaluation by senior and junior learners (Loy et al., 2017). We follow the same general approach with our adaptation of the LLPM for didactic learning: (1) course faculty orient course assistants (PharmD students) to the course plan and expectations for facilitation; (2) course faculty and course assistants adjust course materials and expectations for course activities; (3) course assistants are assigned to small groups of undergraduate students for the duration of the course so that they can facilitate group discussions and provide regular feedback on course assignments; and (4) a post-class survey of course assistants is conducted. In the didactic setting, the use of the layered learning model expands the scope of the course, rather than expanding the clinical practice. The course assistants develop teaching skills while providing timely feedback to undergraduate learners. We view this process as mentorship through layered learning. The relationship of our layered learning implementation with the course activities and the effects on the career development of the course assistants are summarized in Table 2. We refer to this table in the following sections while discussing our view of the layered mentoring interactions. We define “Content,” “Transfer,” and “Interpersonal” components, for which we believe that course assistants play a critical role in “bridging” between faculty and undergraduates (Figure 1). Most importantly, mentorship and leadership opportunities emerge through these interactions and provide a transformative environment that may influence the career choices of a PharmD student (Table 2). Development of knowledge Communication with senior colleagues Planning a detailed approach to a project Anticipating difficulties and considering solutions Enhancement of critical thinking Ability to adjust to unexpected events Formative feedback to senior colleagues Immediate self-reflection on performance Team and relationship building, conflict management Provision of positive, but critical, feedback Decision-making under pressure Internationalization and exposure to different cultures Critical self-evaluation Scholarship and improvement of CV Long-term reflection Application of experiences in interviews Subject area knowledge is clearly the domain of the program faculty (Figure 1). In preparing for and offering the programs, faculty had multiple pre-program meetings with course assistants at which content was discussed. The key to these interactions was to allow course assistants to focus on relatively narrow areas (specifically, one or two drug formulations) while listening to the broader context presented by faculty. Thus, faculty provide the “breadth,” course assistants focus on the “detail,” and this bridges the gap to what is likely to be still relatively “fragmentary” understanding among undergraduates. Placing detail into context during the mentorship of undergraduates is an important learning experience for course assistants. The pre-program meetings are the first step of the layered learning approach (Table 2). At these meetings, mentorship of course assistants by faculty involved discussion of a project that was similar to that to be performed by the undergraduates in the program. In fact, the course assistants performed the project as a group and provided in-person and written feedback on the project to faculty. In addition to knowledge development, the course assistants gained experience in conveying their ideas to faculty, understanding the need for forward planning, and anticipating difficulties that might arise in facilitating the project work in the program. These meetings were also used to advise course assistants on the appropriate approach to running a group session, including how to solicit opinions from group members through persuasion. The meetings were informal but served as a basis for learning highly transferrable skills for career development. In terms of the approach to delivery (transfer) of material (Figure 1), the faculty-course assistant mentoring is characterized by a transfer of faculty “experience” in this delivery. However, such experience may not always be positive, in that frequent delivery of the same material may tend to lose its edge. Course assistants can build on this experience, but also have the flexibility to show “originality” in their mentorship of undergraduates. That is, course assistants can choose to adjust their method of delivery after mentorship in this area from faculty. This became necessary in preparation of material for the project, once the strengths and weaknesses of the undergraduates became more apparent to each course assistant. This creates a good environment for leadership decisions and a space in which course assistants can develop their teaching and communication skills. Progress meetings (Table 1) between faculty and course assistants were used mainly to support step 2 of our layered learning implementation, which was focused on adjustment of material once the program began. At these meetings, course assistants provided “real-time” feedback to faculty on progression of each group project, and adjustments to the program were made based on this feedback. The conversation centered around what was a “normal” event in an educational environment and what was an “unexpected” problem. This promoted critical thinking among the course assistants and allowed them to pursue acute self-reflection on their approach to the management of the project. The course assistants were able to use these discussions to develop new strategies for interacting with their groups, often on the same or the following day. We view these meetings as preparation for situations in a working environment that require immediate decisions based on limited information (Table 2). Establishment of relationships (Figure 1) is clearly important in effective teaching. Faculty may be perceived by students to be remote, and the “confidence” of faculty in an area may be partly negative, given the “uncertainty” (lack of understanding) of undergraduates in this area. Course assistants can bridge this gap through “empathy” with undergraduates, but still grow in confidence (Loy et al., 2017) through the initial faculty mentoring. These characteristics are also consistent with layered learning creating a comfortable educational environment (Kasper & Brownfield, 2018). Disconnection of faculty is also important for summative evaluation, but not positive in connecting with undergraduate students. In contrast, formative evaluation requires the establishment of strong relationships, and these developed between course assistants and undergraduates. The assistants were integrated into the group dynamics in a way that is not possible for course faculty. Skills developed in group management were an important part of the career development aspects of step 3 of our layered learning approach (Table 2). While forming relationships with undergraduates, course assistants also had to implement deadlines and ensure that certain academic goals were met. These requirements were effective in introducing the course assistants to the challenges of a leadership position. Feedback was mainly provided synchronously, which required skills in balancing critical comments with positive encouragement. Given the nature of the programs, there were also international and cultural components to these activities, including overcoming challenges of language barriers. Faculty provided advice to course assistants for dealing with these challenges. In particular, the faculty discussed the need for balance in providing formative feedback through a combination of positive encouragement and critical (and possibly negative) evaluation. The mentoring model includes the “three Ls” of “longevity,” “leadership,” and “learning” for faculty, course assistants, and undergraduates, respectively (Figure 1). The leadership skills developed by course assistants that pertain to career development are clear in the previous sections, and this is the most important issue from the perspective of the effects of mentoring. Course assistants learned to tread the fine line between working with students and being in a position of authority. In the following section, we focus on step 4 of our layered learning implementation (Table 2) by exploring the short- and long-term effects of this activity on course assistants. However, we note that the mentoring represented in Figure 1 can also have an important influence on faculty. The new ideas of course assistants reinvigorate faculty, and this effect on longevity in teaching is important. A survey of the course assistants was performed after ISSP 2021 and ISSP 2022. The same nine questions were asked each year, with three focused on the effects of the program on leadership (Q1 to Q3), three on internationalization (Q4 to Q6), and three on the influence on career choice (Q7 to Q9) (Table 3). The nature of the questions was such that two different scales were used: a 5-point Likert scale for Q1–Q4 and Q7; and a 0–100 visual analog scale (VAS) for Q5, Q6, Q8, and Q9. The raw data are all converted into scores out of 5 in Table 3, but the comparison between the two types of questions is not valid. The program provided a unique opportunity for leadership development, and the success of this aspect of the mentoring is reflected in the answers to Q1–Q3 (Table 3). Of 83 total responses to these three questions, the rates of strongly agree and agree were 71.1% and 24.1%, respectively. There were strong positive responses for improved cross-cultural communication (Q1), teamwork (Q2), and particularly for leadership itself (Q3). We note that these items are taught in the PharmD curriculum, and thus, all course assistants had some background in these areas. There are many definitions of “leadership” (>1500 suggested by Mango (2018)). In the current context, we define leadership as the ability to guide others to achieve certain outcomes as a group, using a balance of critical feedback and positive reinforcement, with appropriate self-criticism and critical thinking (step 4, Table 2). We believe that our mentoring model of creating “independence” with a “safety net” of faculty support was particularly effective in driving the positive experience of most of the course assistants. Their work in the course represented a concrete transition from the perspective of a recipient of knowledge (a student) to that of a conveyor and manager (a leader). The international focus of the program allowed course assistants to reflect on their goals as a potential global health practitioner (Wu et al., 2020). The survey data (Q4–Q6) indicated that >70% of the course assistants developed more interest in pursuing international learning opportunities. This is an important goal in the diversification of career opportunities for PharmD students, and one that has previously been shown to be under-utilized in schools of pharmacy (Kim et al., 2020). There is an increasing emphasis on the internationalization of education, healthcare, and industry, and exposure of students to these areas is important for career development (Kim et al., 2022a, 2022b). In particular, exposure of students to different learning styles embraced by different cultures widens their scope and prepares them for future international challenges (Kim et al., 2022b). Diversification of career choices in terms of areas of pharmacy is also an important contemporary issue in pharmacy education (Papadopoulos et al., 2021). There were strong responses indicating that about 75% of the course assistants developed interests in areas of pharmacy that they had not previously considered (Table 3). We return to the influence of mentorship and experience in the program on career choice in the “Post-Program Effects” section. Although not the focus of this article, it is of interest to consider the impact of the on-campus (ISSP 2022) versus online (ISSP 2021) delivery on the perceived growth of the course assistants (Figure 2). Both programs were synchronous, with all teaching and mentoring performed in person (ISSP 2022) or live on Zoom (ISSP 2021). Leadership skills were developed in both programs (Table 3), but slightly more strongly in the online environment. This may reflect the additional challenge of maintaining the focus of a group of students in this environment. On the other hand, internationalization and career development seemed to be more enhanced in the on-campus environment. This may be due to the additional time for interactions with visiting international students (both actual hours spent and the longer program) and the similarly longer period of exposure to the program material in ISSP 2022. Mentoring of course assistants did not end with the completion of the program. Including our description of the earlier ISSP 2020 program (Kim et al., 2020), scholarship from the ISSPs has involved publications (Kim et al., 2020) and posters (Kim et al., 2022a; Goldenberg et al., 2021; Mojab et al., 2021) that have included 15 authorships for 10 different course assistants. The current article extends this scholarship for two-course assistants. The scholarship can be viewed as an outcome of a faculty-student mentorship collaboration (Zipp et al., 2009). This was a planned activity and data collected during the programs were used as a basis for these publications. Furthermore, preparation of publications and posters provided faculty with the opportunity to continue to build relationships with course assistants beyond the period of the program itself. The interactions required to prepare publishable material also facilitate further discussion of the academic process and the importance of communication of findings. The authorships themselves have concrete effects on career opportunities for students: they are highlights in CV preparation, they provide talking points during interviews for residencies and internships, and they are demonstrable evidence of leadership activities that are greatly valued by potential employers. The program has had a longer-term influence on course assistants, since the leadership skills developed have carried over to various areas of pharmacy, including clinical and industry-related clerkships and internships. This conclusion is based on anecdotal comments from several course assistants. In these positions, course assistants have been able to demonstrate leadership skills such as independent decision making, conflict management, relationship building, and critical thinking. As indicated in Table 2, these were deliberate goals of the mentoring program and were tied to the steps in the implemented layered learning model. The role of the course assistants in this model is similar to that of a mentor in near-peer mentoring, which has been suggested to promote personal and professional development in medical students serving as mentors (Akinla et al., 2018). A similar near-peer mentoring model used in pharmacy education was shown to improve retention of drug information among the senior learners (Rodis et al., 2014). We also believe that our layered learning and mentoring model improved retention of knowledge among course assistants in drug development, clinical treatment, regulatory science, and health economics. For example, course assistants developed the ability to select empiric drug therapy in a clinical setting based on literature-searching skills. Industry fellowships require an understanding of the journey of a drug from laboratory to market. This requires pharmaceutical insight, understanding of clinical development, and knowledge of regulatory science, such as required FDA documents, to guide the process of medical writing for approval, and health economics for understanding how a drug should be priced. Faculty mentoring of course assistants in the ISSP programs facilitated development of leadership and communication skills. In the layered learning model, these skills were expanded upon by mentoring of undergraduate students by the course assistants. The strong faculty-course assistant mentoring relationships created scholarship and have influenced the career trajectories of course assistants. These trends were apparent in the survey data and have now come to fruition upon graduation of several of the course assistants. The mentoring relationship established in the program was critical to these positive outcomes. Thus, we conclude that faculty mentoring can have short-term effects on the development of educational skills and longer-term effects on career development. We are grateful to all course assistants and faculty who contributed to ISSP 2021 and 2022. In particular, we thank Drs. Terry Church, Benson Kuo, Eunjoo Pacifici, Frances Richmond, John Stofko, and Ken Wong for their many excellent contributions to the two programs. We are also grateful to Lindsey Nokes for her management and administration of the programs. Yasi Mojab, PharmD, MS is a 2023 graduate from the University of Southern California (USC) Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA. Arghavan Zolfaghari, BS, PharmD(C) is a final year PharmD candidate at the USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA. Rory E. Kim, PharmD, MACM, BCACP is an assistant professor of Clinical Pharmacy in the Titus Family Department of Clinical Pharmacy at the USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA. Terrence F. Graham, EdD is chief international officer and associate dean for Graduate Education at the USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA. Ian S. Haworth, PhD is an associate professor of Pharmacology and Pharmaceutical Sciences at the USC Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA.