Diverse Universe

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Pharmacy schools are taking steps to address cultural competency by preparing future pharmacists to be inclusive and ensure that everyone receives the care they need.

By Jane E. Rooney

Diversity has long been a buzzword in workplaces, in politics, on college campuses, in the entertainment industry—virtually all corners of society. But for health professionals, including pharmacists, recognizing diversity goes beyond simply acknowledging that patients represent different backgrounds. Truly understanding people’s differences and cultures can be a vital part of providing quality patient care. Cultural competency is defined as “a set of congruent behaviors, attitudes and policies that comes together in a system, agency or among professionals, and enable that system, agency or those professions to work effectively in cross-cultural situations.”

Obstacles to health can lead to health disparities, which stem from characteristics historically linked to discrimination or exclusion such as race or ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation or geographic location. Ideally, when health providers recognize cultural differences and work to minimize health disparities, they can achieve health equity. According to the Centers for Disease Control and Prevention, health equity occurs when all people have the opportunity to attain their full health potential and no one is disadvantaged from achieving this potential because of their social position or other socially determined circumstance. Addressing these issues is a priority for institutions as well as the Academy as a whole.

“The conditions in which people are born, live, learn, work, play, worship, intersect with culture and affect a wide range of health functioning and outcomes,” said Carla White, assistant dean, Innovative Leadership and Diversity, University of North Carolina at Chapel Hill Eshelman School of Pharmacy. “A diverse workforce and culturally skilled clinicians and scientists are a societal need.” White is chair of a special Taskforce on Diversifying Our Investment in Human Capital, which was appointed for the period of 2015–2017 by AACP Past President Cynthia J. Boyle based on recommendations from the Argus Commission. The Taskforce was charged with identifying barriers that inhibit the diversification of human capital in college and schools of pharmacy; finding “game changers” in professional education, healthcare or related areas where substantial improvements have been achieved; and recommending strategies, vetted through the AACP councils for input, for short- and long-term solutions. The AACP Board of Directors asked the Taskforce to develop and propose a diversity statement to guide the Association’s work. The board adopted the following statement in November 2016: AACP affirms its commitment to foster an inclusive community and leverage diversity of thought, background, perspective and experience to advance pharmacy education and improve health.

“Health equity and health disparities are the why to cultural competence and inclusion,” White noted. “When clinicians and researchers are not prepared, they are not asking the right questions, not equipped to consider the patient’s primary concerns and often lack self-awareness and may come across as judgmental. These experiences lead to suboptimal or no care and the lack of diversity in clinical trials.”

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White said that the Taskforce has been productive. “A representation and diversity statement was developed, topics were presented on unconscious bias and the infrastructure needed for accelerating diversity and inclusion, and a white paper, to be published this fall, offers best practices, articles and other resources. Additionally, the Taskforce helped develop a statement on testing for people with cognitive and physical disabilities. The overarching goal is to demonstrate a commitment to key stakeholders (member institutions, corporate and other partners, and public) that we are preparing a workforce ready to care for the world.

“AACP has done a tremendous job recognizing that we have an opportunity here,” White continued. Next steps, she said, include focusing on programmatic and assessment strategy.

For Dr. Nancy Borja-Hart, associate professor, The University of Tennessee Health Science Center College of Pharmacy, cultural competency is about awareness and taking the time to get to know patients beyond their medical issues. “It’s about being inclusive and thinking about what’s important to that patient,” said Borja-Hart, who is chair-elect of the Health Disparities and Cultural Competency SIG. “You don’t have to overhaul a case. Just knowing more about your patient can help you tweak care.”

Through its programming—including webinars on topics such as health literacy, limited English proficiency and religious issues—the SIG had recently focused on incorporating culture into patient cases. Borja-Hart recalled Dr. Yolanda Hardy’s presentation at the AACP Annual Meeting, providing an example: “This is a patient who is this age and has these labs and you need to think about what medications to start. But there’s more—we need to think about other issues, such as if the patient has Medicaid, or if the patient is Muslim and it’s Ramadan and how you would adjust insulin therapy for the patient during that time.” She said the speaker challenged the audience to consider how a pharmacist’s planned course of action might change once he or she weighed these additional factors.

We talk a lot about innovation in this field. As practitioners and researchers, we don’t innovate at the levels we can without diversity and inclusion.

Dr. Carla White

One of the SIG’s goals is improving students’ knowledge of these cultural issues and helping them understand that some populations struggle with the healthcare system, whether it’s due to a language barrier or a lack of financial resources. Borja-Hart has also talked about patient interaction with her students and paying attention to whether they are saying things that are inappropriate or culturally insensitive without even realizing it. “I encourage members to publish what they’re doing in the classroom and with their patients in relation to cultural competence and health disparities,” Borja-Hart noted. “The other piece is to get faculty to try things in the classroom and give it the effort. It’s really just about the desire to learn more and a willingness to incorporate it into everyday practice.”

Similarly, White said the Taskforce wanted to “provide resources and examples so member institutions could understand how they can approach this work and that key stakeholders understand on a national level that we are contemporary in our thinking and we are connected to the issues and prepared to address them.” She wants schools to be able to build on the infrastructure in terms of curriculum and workforce development. Pharmacy students “will be faced with situations and nuances and we want to make sure they get an education that is relevant and realistic,” she added. “They deserve to be prepared and equipped to work at the very top of their training. We talk a lot about innovation in this field. As practitioners and researchers, we don’t innovate at the levels we can without diversity and inclusion.”

Seeing Patients as People

Institutions are trying various approaches to fulfill Standard 3 of Standards 2016, Approach to Practice and Care, and incorporate it into curricula. Cultural sensitivity is an element within this standard. Since its foundation in 2006, St. John Fisher College Wegmans School of Pharmacy has offered a diversity course to first-year students. The course addresses numerous different patient populations including: elderly, veterans, HIV positive, LGBT, end-of-life, refugee, Muslim, patients with a disability, and mental health. When the course first began, training around basic LGBT terminology was included, said Dr. Amy Parkhill, associate professor and interim chair, Department of Pharmaceutical Sciences, but once students began asking more questions specifically about transgender patients, the school decided to collaborate with the Out Alliance (formally Gay Alliance of Genesee Valley) to create a panel discussion with transgender individuals from the community.

“We didn’t want the discussion to be too clinically focused,” Parkhill noted. “We wanted students to think of the panelists as people and not as a condition. The panelists do start off by talking about their own stories and also talk about any experiences they’ve had in pharmacy, good and bad. After that it’s open for questions. A lot of students do ask about hormone therapy, but for the most part it is getting-to-know-you types of questions. The panelists are very open—no question is off limits. We want students to think about asking questions that will make them better pharmacists.”

Parkhill said student feedback on the transgender panel discussion has been overwhelmingly positive. Students comment on how the discussion helps clear up misconceptions and changes their viewpoints about how they will interact with transgender patients going forward. Still, she admitted that it is challenging to integrate LGBT healthcare into the entire curriculum. “It’s hard to fit in with all the other required topics we need to fit in. We have some work to do to intentionally include LGBT patients within all our courses and making it just a normal part of the courses activities.”

Parkhill said the biggest benefit the first-year diversity course offers is that “students are able to interact with different patient populations and clear up any preconceived notions in a safe environment. That interaction takes away any fear and hesitancy they might have in interacting with diverse patients. So when they have to interact as an intern or pharmacist, they are a lot more confident. Several patients from diverse populations have had negative interactions with the healthcare system. Since pharmacists play such a key role in healthcare, I think it’s important to teach students to be both open-minded and empathetic in order to be a good resource to all of their patients.”

Addressing cultural sensitivity in general has always been a big priority at the school and significant efforts have been made to include many diverse populations in many of our didactic required and elective courses, our early and advanced experiential experiences, and our co-curricular experiences. For example, as part of the school’s requirements, all first to third year students are required to complete 10 hours in a diverse setting. Additionally, the school’s diversity committee develops events to allow students to keep up with diversity topics. The committee schedules speakers who have discussed topics including HIV, refugee health, Amish healthcare, and working with patients on the autism spectrum. The school also offers several international medical service summer trips and 4th year rotations—where students can put their cultural competence training into action. Lastly, the school has created continuing education programs on diverse patient populations that are available to both students, faculty, preceptors, and regional pharmacists.

Another group that has not always been included in health professions education is people with disabilities. The overall percentage of people with disabilities in the U.S. is about 12 percent, according to Dr. W. Thomas Smith, dean of pharmacy programs and professor of pharmaceutical sciences, Manchester University College of Pharmacy, Natural & Health Sciences. “As our population ages, more and more people will have cognitive as well as physical challenges and will be in need of care from pharmacists,” Smith pointed out. While he said that cultural competence is a high hurdle to clear, cultural sensitivity is something we can and should expect from pharmacists. Pharmacists who are culturally sensitive “won’t make assumptions in dealing with patients from a given minority culture and will know the kinds of questions they need to ask and the questions they may need to avoid when speaking with persons from a particular culture. It’s important to expand our sense of culture beyond just race and gender and look at culture a bit more broadly to encompass other minority populations, including persons with disabilities.”

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As a person with a disability, Smith said it’s been important to him to get students to expand the notion of culture to include persons with disabilities. He has not seen conversations around disabilities and health disparities happening enough in health professions. “I have done some workshops with AACP and faculty from other institutions who were incorporating disability issues in their discussions, but I have not seen that take off in a widespread way,” he said. “There weren’t others really leading that charge in the Academy. There are people incorporating disability issues in their work but not leading the charge to advance the curriculum.”

Smith created an assessment tool a few years ago to look at student comfort level in their interactions with persons with disabilities. “We found that the students weren’t all that comfortable interacting with patients with disabilities but also didn’t have a lot of experience in interacting with them, certainly in the classroom as well as in the experiential curriculum,” he noted. “It was a patient population that many students identified as not having enough experience with. As demographics evolve, we expect to see more individuals with disabilities as people age.”

At Manchester, cultural sensitivity is woven into the curriculum, beginning with an Introduction to Pharmacy class that looks at what it means to be a culturally-sensitive practitioner. “In those discussions we talk about the definition of culture in a broader sense to include populations beyond the traditional thinking of race and gender,” Smith explained. “We also talk about it in our Professional Communications course. Students work in teams and are assigned a particular culture to learn more about and the team is asked to give a presentation about the particular culture to the rest of the class. There are some exercises in our Pharmacy Skills Lab that incorporate culturally sensitive communications, such as counseling to members of a particular culture. A stand-alone elective course centers on medically-underserved individuals. We offer some experiential opportunities for students to work in underserved areas in our community. Students are asked to do IPPEs that involve the student going out to a clinic in the Fort Wayne area that works with vulnerable and underserved patients.”

Smith said all of this is geared toward getting students to think about reducing barriers to quality care. “We can’t do much as colleges and schools of pharmacy in mitigating payment barriers, but we can help mitigate cultural barriers,” he acknowledged. “We can educate pharmacy students about the various kinds of patients they are likely to encounter in a community and really get them to treat all patients with respect, provide them with the dignity they’re owed, not make assumptions and invest in patients as human beings. It helps to tear down those barriers caused by fear and lack of understanding. Starting with the person first is never bad advice to give to student pharmacists. That’s where we can do a better job in helping to reduce those barriers for future practitioners.”

Serving All Populations

Colleges of pharmacy want students to be prepared to handle patient interactions with empathy and be cognizant of health disparities, which is why many colleges are committed to research and service devoted to ensuring that all community members have equal access to care. The U.S. Census Bureau predicts that by 2043, the United States will become a majority-minority nation. Demographic changes will necessitate changes to the healthcare delivery system, according to Dr. Margarita Echeverri, associate professor, educational coordinator in health disparities, cultural competence and diversity, Xavier University of Louisiana College of Pharmacy. “Research has found that healthcare professionals’ biases and stereotypes combined with patients’ diversity characteristics have an impact in treatments, healthcare practices and health outcomes,” she said. “The Healthy People 2020 Initiative to eliminate health disparities includes new indicators to measure the percentages of medical, dental, nursing and pharmacy programs providing training in cultural diversity. The goal is to develop educational interventions to make current and future healthcare providers, including pharmacists, aware that disparities in healthcare exist and to prepare them to face all the challenges.”

Part of the university’s mission, she continued, is to promote a more just and humane society, which is addressed through community service and scholarly work. For student pharmacists, that means focusing on eliminating disparities and promoting equal access to care. Accordingly, the college created community clinical practice experiences focused on providing integrated culturally competent and interprofessional healthcare services to underserved populations in New Orleans.

“We have a healthcare event that targets Latino, Vietnamese and African-American populations,” Echeverri explained. “We work with doctors, dentists, social workers and pharmacists to provide clinical services to patients and partner with the community to provide screenings and referrals for free follow-up services. We collaborate with interpreters to provide integrated services. These experiences provide not only our students but also other professionals with an opportunity to serve a diverse, multicultural, multilingual population using a holistic and culturally sensitive approach.”

Echeverri said the college’s curriculum is focused on embracing diversity and improving personal interactions. “In the first year we focus more on definitions, data and implications of health and healthcare disparities,” she noted. “In the second year we spend time on knowledge of different cultures and diversity dimensions. In the third year we focus more on disparities in pharmaceutical therapies, and finally students bring it all together in the seminar and rotations in their fourth year.” Faculty created an assessment tool—the Self-Assessment of Perceived Level of Cultural Competence—to allow students to recognize their own biases and identify training needs.

As part of the college of pharmacy, in 2002 Xavier established the Center for Minority Health and Health Disparities Research and Education, which is dedicated to improving health outcomes of diverse communities disproportionately impacted by health and healthcare disparities, through community engagement and partnerships in research, education and practice. The center hosts an annual health disparities conference that looks at using multidisciplinary partnerships to achieve health equity and discusses models to eliminate health disparities. Participants include clinicians, researchers, health educators and community health leaders.

We can educate pharmacy students about the various kinds of patients they are likely to encounter in a community and really get them to treat all patients with respect, provide them with the dignity they’re owed, not make assumptions and invest in patients as human beings.

Dr. W. Thomas Smith

“We work in collaboration with the community to decrease disparities,” Echeverri said. “We focus on the main ones in Louisiana: diabetes, cancer and asthma. Most of our projects are related to research and education on prevention and early detection and barriers to care. Currently we are developing culturally competent educational interventions to address African-American and Latino populations’ lack of knowledge or misunderstandings regarding cancer prevention, screening, treatments and research.”

At the School of Pharmacy at the University of California, San Francisco, cultural awareness has been top of mind as the school redesigns its curriculum, set to begin in July 2018. “We will have a fully integrated curriculum,” said Vice Dean and Professor Dr. Sharon Youmans. “Cultural concepts will be woven throughout the curriculum. It starts with unconscious bias training so students are self-aware and understand why they think the way they do. It’s not to call out people but it’s about being aware. We want to acknowledge that we all have prejudices.” She said students will need to think about what’s driving their decision making during patient interactions and how that can impact healthcare and the way patients are treated.

When it comes to health disparities, one focus will be on communication. “We have to be more intentional in communicating with someone who has low literacy skills or speaks another language or laypeople who aren’t familiar with medical terms,” Youmans pointed out. “This is not something we’ll mention once. We need to revisit these concepts throughout the curriculum. We’re in a diverse city so we have to be able to address all healthcare needs. In the classroom and in direct patient care settings students can work on those skills, techniques, and attitudes. The goal is to provide students the tools they need to take care of patients in the real world.”

While she said these types of conversations were already happening with students, revamping the curriculum provided an opportunity to do a better job and make those discussions more intentional. “Being able to create this new curriculum allows us to take a step back and look at things with a fresh eye and think about what we’re going to talk about,” she noted. “Issues around health policy, the ACA, how insurance will be impacted...all of these are connected. These are not isolated courses. If a patient doesn’t have insurance or isn’t set up socially to carry out medication instructions, it means nothing. That’s where we want to change our focus and talk more about how to change and or improve health behaviors.”

Despite institutions’ efforts to address cultural awareness, both in terms of treating patients from diverse backgrounds and trying to recruit minority faculty and students to health professions, Xavier’s Echeverri said she thinks we’re still too focused on our differences rather than our similarities. “We need to see our patients as partners and collaborators working together for better health outcomes,” she urged. “We need to have a sincere conversation regarding our feelings, thoughts and beliefs regarding the different manifestations of diversity. I insist on talking about this with my students in class. I find that my students want to be culturally sensitive not as a means to decreasing healthcare disparities but because they want to embrace diversity and become global citizens.”

Jane E. Rooney is a freelance writer
based in Oakton, Virginia.