Is a Pharmacy Student the Customer or the Product?

INTRODUCTION

Faculty members at colleges and schools of pharmacy often experience episodes of uncivil and unprofessional behavior by the millennial generation in the classroom. Behaviors include surfing the Web, studying for other courses, texting, social media use, chronic absenteeism, arriving late to class or leaving early, not completing pre-class assignments, and shirking responsibilities in team assignments. Most faculty members can recount anecdotes of unprofessional behavior in students. Academic entitlement has been suggested as a significant contributing factor to this behavior.^1,2

Academic entitlement is defined as the tendency of students to expect academic success without taking personal responsibility for achieving that success. It has been associated with externalized responsibility for success (eg, “My professor did not give me what I needed to achieve an 'A' in this class.”) and entitled expectations (eg, “I cannot believe that my professor gave me a bad grade on the assignment. I deserve a better grade because I worked really hard on it!”).¹ It has also been described as revolving around several related student perceptions including (1) knowledge is a right more than a privilege; (2) educators are responsible for student learning, not the student; (3) effort, not performance, should be rewarded in grading; and (4) open or passive aggressive behavior toward faculty members is acceptable if student expectations are not met.³ Academic entitlement likely occurs in only a small proportion of students in institutions, but this vocal minority can sow discontent throughout the educational system.

Academic entitlement can occur in any student. Even the most accomplished students, those with stellar grades and positions as class leaders, can develop expectations that they deserve special treatment. In fact, they may even have earned it because of exceptional contributions to the school. The problem occurs when demands for special treatment cross the line into unprofessional behavior toward others and disrespect for the educational process. Moreover, the problem is compounded when students and pharmacy educators disagree on specific behaviors that are inappropriate. Compare student and faculty responses about the acceptability of skipping class to study for a test, surfing the Web during a presentation by a guest speaker, anonymously castigating a professor's performance on a course evaluation, or almost any other controversial behavior, and major disagreements will emerge. It seems that educators and students are often working from a different script about what it means to be a professional.

Although it might be tempting to blame the millennials, their parents, and society, academia should share a portion of the blame. Entitlement is encouraged by faculty members who give high grades for mediocre work, thereby reinforcing students' inflated perceptions of their performance and expectations for high grades in the future.⁴ Grade inflation is further encouraged by school administrators who emphasize student course evaluations when assessing faculty performance, especially as students are more likely to reward faculty members who are lenient over ones who are rigorous.⁵

Students may use academic entitlement as a mechanism for coping with the pressures and disappointments of the educational process.⁶ In pharmacy education, many conflicts between professors and students are seen over grades. Conflicts can be aggravated by the dissonance students feel when they realize the strategies that once made them successful in undergraduate settings no longer translate to success in pharmacy school. Faced with a pharmacy school classroom of high achievers, students frequently find that efforts that once resulted in A grades in prepharmacy curricula now yield B’s and C’s. When disappointed, academically entitled students are more likely to blame external causes (eg, their professor) rather than accept personal responsibility⁶ and, consequently, act out their frustration with unprofessional and uncivil behavior.²

Student consumerism has been associated with academic entitlement.² Student consumerism is defined as the perception by students that because they pay for their education, they deserve to be treated as customers.⁷ This means that educators are there to serve and satisfy them. In pharmacy education, some educators may contribute to the “student as customer” perspective out of pressure to attract and retain academically competitive students.

However, indulging student consumerism and feelings of academic entitlement can damage the educational process. It may hurt the education of good students by causing schools to lower academic expectations, thereby making the students less prepared and competitive for postgraduate experiences like residencies and fellowships. For students who struggle, however, it might tempt colleges and schools to keep them in order to meet ACPE benchmarks for student progression through the program and to achieve enrollment targets established by university or college administration. Thus, marginal students are allowed to progress through the program, barely passing courses. To ensure that these marginal students can pass the North American Pharmacist Licensure Examination (NAPLEX) and receive a license, colleges and schools may offer board preparation classes or other remediation measures. Then, when their graduates receive a license, these schools congratulate themselves on the success of their students, highlight their board-passing rates in promotional materials, and tell themselves that they are doing a good job, even if some of the graduates are unemployable as pharmacists.

But where is the patient in this process? How does the patient fare in a system that places student satisfaction first? Will indulging students be in the best interests of the patients they are trained to serve? Are students really the primary customer of pharmacy education?

THE STUDENT AS THE PRIMARY CUSTOMER

A reasonable argument can be made that professional education is a service; thus, service-marketing strategies can improve the quality of educational programs.^8-10 The problem with academic entitlement and student consumerism is not the use of marketing strategies in education. Rather, it is that colleges and schools misidentify their primary customers and the products they offer. In marketing, a customer is an individual or group whose needs and wants are served by the product, and a product is something of value which is designed to meet the needs and wants of customers.¹¹ How educators define their product and their customers determines their approach to education.

This paper argues that the idea of student consumerism is based upon a fundamental misunderstanding of the primary customer of pharmacy education. Pharmacy colleges and schools serve multiple customers -- students, alumni, funding agencies, college or university administration, employees and faculty members, employers of graduates, the community, and patients. These customer groups often have competing demands and priorities which require prioritization by educators. The primary customer should take precedence over all other customers.

When colleges and schools deem students as the primary customer, student desires become the driving force behind the educational process and its outcomes. Although they might demand a high-quality education, their demands are shaped by a limited understanding of what it takes to be a professional in a dynamic health care environment. Like consumers in any service setting, they will focus on the process of education (eg, was it delivered in a convenient, friendly manner) because of their inability to assess the educational outcome (eg, professional competence).¹²

With the student as the primary customer, the approach to pharmacy education might be captured in the customer service promise shown in Table 1. Although laughable, most educators will see some element of their policies and practices in this customer service promise. Indeed, when applied in moderation, accommodating students' lives and learning preferences is a good educational strategy that will increase student engagement and learning. When taken to the extreme, however, it can pressure faculty members to relax expectations for professionalism and academic performance and result in a general downward spiral in the quality of pharmacists graduating from schools.

THE PATIENT AS THE PRIMARY CUSTOMER

A stronger argument can be made that the patient is the primary customer of pharmacy education because without the patient, there is no reason for the profession or for pharmacy education. The patient is at the center of the definition of pharmaceutical care (“the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve the patient's quality of life,”¹³) and medication therapy management (“a distinct service or group of services that optimizes drug therapy with the intent of improved therapeutic outcomes for individual patients”¹⁴). Patients are also central to the patient-centered medical home concept. These guiding principles of pharmacy practice and medicine place the patient at the center of all things accomplished within the profession. Although important, pharmacists and pharmacy students should always take a backseat to the needs of the patient.

It might be better to see the student as the product of pharmaceutical education rather than the customer. Viewed this way, students are a means for pharmacy schools to serve their various stakeholders including patients, employers of graduates, the community, and funding agencies. With the student as the product, colleges and schools compete by serving the stakeholders with graduates who are held accountable for the highest standards of professional and ethical behavior. Students benefit, too, by being trained to serve patients and other professionals who serve patients. After graduation, these students will be more highly valued by employers and more competitive for jobs.

How educational processes differ when defining the primary customer of pharmacy education is illustrated in Table 2. When the student is the customer, educational institutions assume a transactional approach that parallels many of the major complaints lodged against higher education.^2,15,16 In a transactional approach, students tend to see every interaction with the school as a commercial exchange in which they say, “If I do 'x', I expect to get 'y' in return.” With this approach, students who pay tuition expect schools to serve them in return. If they complete an assignment, they expect an acceptable grade as compensation. However, when the patient is the primary customer, a more sophisticated relationship and approach to education results. In this educational relationship, students and faculty members collaborate to develop professional competence in students. Education is neither delivered to students, nor something to which students are entitled. Rather, value emerges by the student and school co-creating the education process. Both students and educators are responsible for the process and outcome of education. Flexibility and educational choice can be encouraged as long as they serve the ultimate goal of developing professional competence. Attention can still focus on the learner as long as the learner and the educator agree that their ultimate goal is the service of patients.

With the patient at the center of the educational process, colleges and schools only enroll students who they believe have the intelligence and enthusiasm to effectively represent both the school and profession. The profession and academy should only support the accreditation of pharmacy colleges and schools that hold students to the norms of the profession, which are generally summarized in the oath of the pharmacist:

• I promise to devote myself to a lifetime of service to others through the profession of pharmacy. In fulfilling this vow:

  • • I will consider the welfare of humanity and relief of suffering my primary concerns.

  • • I will apply my knowledge, experience, and skills to the best of my ability to assure optimal outcomes for my patients.

  • • I will respect and protect all personal and health information entrusted to me.

  • • I will accept the lifelong obligation to improve my professional knowledge and competence.

  • • I will hold myself and my colleagues to the highest principles of our profession’s moral, ethical and legal conduct.

  • • I will embrace and advocate changes that improve patient care.

  • • I will utilize my knowledge, skills, experiences, and values to prepare the next generation of pharmacists.

• I take these vows voluntarily with the full realization of the responsibility with which I am entrusted by the public.

• Reprinted with permission of the American Pharmacists Association.¹⁷

The oath emphasizes service to the patient. Students who take this oath pledge to serve the needs of the patient and develop their ability to serve those needs. The oath also insists on excellence and effort, meaning that pharmacy education demands a great deal of time and effort. Students who are not capable or willing to do what is asked of them should seek another profession.

With the patient as the primary customer, a different 8-step customer service promise emerges (Table 3). In this promise to students, pharmacy colleges and schools discourage entitlement but do so in a positive, supportive manner. Although the promise emphasizes effort and challenge, it also promises personal development and the possibility to make a difference. In addition, the message to faculty members is positive and uplifting. It encourages rigorous expectations of professionalism and academic performance and a clear guide to educational priorities. The message is that granting a degree will only happen after achieving rigorous educational outcomes established to serve the needs of patients. Doing anything less would be a disservice to the students, alumni, employers, profession, public, and most of all, the patient.

Much of the problem associated with student entitlement is one of communication. When communications are framed with the students at the center of pharmacy education (eg, we are here to serve you), student entitlement results. However, when framed with the patient at the center of pharmacy education (and backed up with actions by faculty members and administration), students start to become professionals. Students and educators need to agree that the primary purpose of pharmacy education is to prepare students to serve patients, and the privilege of pharmacy education comes with expectations delineated in professional documents like the Oath of the Pharmacist. Conversations need to be ongoing because student perceptions of entitlement and consumerism are not easily changed. Still, there is a lot of common ground because both students and educators want students to succeed. The key is to place service to the patient as a primary element of student success within the profession.

Finally, a case may need to be made within educational institutions themselves. Some educators and administrators may not understand that learner-centered and patient-centered education are compatible as long as both emphasize developing student knowledge, competency, and habits of professional behavior over pleasing students. Although student satisfaction and learning are likely to be highly correlated in an engaging, supportive environment, achieving student satisfaction must always be secondary to preparing students to meet the medication-related needs of patients.