A Marathon, Not a Sprint

Be Present for Students

The planning committee selected a diverse group of six students representing various backgrounds from pharmacy schools across the country to participate in the opening panel discussion. Kyra Leonard, a P3 student pharmacist at the University of Georgia College of Pharmacy, said that a common refrain among the panelists was frustration at not being heard or being able to express their concerns, as well as the sense of impostor syndrome that can come with the territory for minorities. “Our schools can do more to get feedback from students. How else are you going to know if something is working if you don’t ask the people affected by it?” she pointed out. “As far as faculty members, they need to take an interest in the things we want to learn about. DEI has more of an emphasis now since the murder of George Floyd. Schools are trying to showcase representation but still not implementing it into lectures, so it’s kind of superficial so far.”

Fulford noted that the range of panelists’ experiences highlighted the various obstacles that minorities can encounter. “One student who is an Alaskan native discussed how people do not realize that Alaska is so set apart from the rest of the United States. So as a Native American, she experienced every day the things that oppress and divide people,” he said. “Another student mentioned working through different systems to get to where you are—that persistence. Things like language and dealing with stereotypes that stick out. Another student on the panel immigrated from Mexico and didn’t learn to speak English until she was 16. She received a GED and took a long route to pharmacy school. The committee also felt it important to include Caucasian students on the panel. As it relates to their DEI experiences, they had a different but valuable perspective. They discussed experiences that helped them recognize their privilege and how that has impacted aspects of their life. Listening to all of the students’ stories was phenomenal. Their similar experiences with recognizing power constructs and the nuances within these constructs were so important.”

Some attendees, he continued, were surprised by Kaitlin’s story, a white student from Athens, Ga., whose summer internship in the Bronx was transformative for her. “These stories made participants think, ‘maybe we should be creating experiences that challenge our students who are in the majority so they can have that ah-ha moment,’” he said. “It’s always been situations where someone who has more power and control wants to maintain that and some is direct and some is indirect. Some faculty members are surprised to hear what students have endured at their own schools. They think, ‘how could that happen at my school?’ It happens everywhere. It is about recognizing those constructs in your own space and doing something about it.”

Leonard said she has seen progress in terms of exposing students to situations that take people out of their comfort zone, but there is room for improvement, including having a more diverse faculty and taking a broader view within courses to consider diverse patient populations. “We learn that there are disparities within pharmacy specifically, but in the curriculum, the faculty mention it but don’t elaborate on disparities and ways to overcome those disparities,” she noted. “So we might read about a 45-year-old African American male and explore the clinical issues, but I wish we also focused on external social factors because in the real world we need to know how to help them overcome those. Another thing is more representation in lectures. For example, in a lecture on skin rashes, none of the pictures were of darker skin. The images gave us an idea of what a disease state looks like but only on people [with white skin]. Those are some things that could be improved. There’s a lack of education that emphasizes different disease states within different ethnic populations.”

Fulford agreed, adding, “What Kyra said is really important. When people have darker skin, some diseases can get past people’s thought. It's about how we integrate this lens of DEI in the patient care process.” EDI is a hot topic right now, he continued, but it tends to get compartmentalized when it is incorporated into the pharmacy curriculum. “At what point in the patient care process should we not consider social determinants of health and all the aspects of who they are? If you are doing clinical work then you need to be looking at things through an EDI lens. We design a curriculum and check boxes but we then don’t think about those extra pieces when so much of the process relates to social structures. Maybe we should start asking the patient questions as a building block. Who are you? What can you do? What are the barriers for you being able to heal better? And that’s ultimately what it is: helping people heal without making assumptions about who they are.”

A priority for pharmacy schools, according to Fulford, should be to treat students with respect and put them at the center of the work, just as pharmacists do with patients. “Take time to create connection. EDI work is actually simpler than people make it out to be. If you are willing to let go of superficial constructs we put in place and willing to challenge our own histories and receive people for who they are and be with them in the moment, then that’s the best thing to do,” he said. “Faculty are sometimes standing on the outside or worse, above their students. Meet students where they are. Be colleagues with them. That’s what humanity is about. If you have the privilege to be in a position to impact rules and protocols, you’ve got to let go of your ego. My job is to be here with students and sit down and talk and listen. If I’m present with students, I can feel all of their concerns and that makes me better and allows me to connect with them.”

Leonard echoed the idea that it takes humility for non-minorities to admit they may have benefited from existing social structures. “They could ask themselves, how can I alleviate the implications of that construct? How can I relate to my students? I do think there is a pride aspect. A lot of people don’t want to have those conversations.”

Said Fulford, “Kyra’s life experience includes some of these EDI issues. Getting anywhere in life is a journey and a labyrinth. If someone who knows the way can help you know where to turn in the maze, eventually you get there and you get there together. The whole concept is to be in it with them.”

Challenge Existing Norms

In the session “Bringing Authenticity to Professionalism/Professional Identity Formation,” Z Tenney (who uses they/their pronouns) explained that expectations in professional settings need to be reconsidered to be more inclusive of those with marginalized identities. Tenney, the inaugural diversity, equity and inclusion officer at The Ohio State University College of Pharmacy, noted that “professionalism has evolved to mean conforming to normative expectations in the workplace. Those norms were based upon things that are norms for people with dominant identities. Traditionally they were geared toward white folks, toward men, toward folks who are straight, who are able bodied. So we don’t always unpack where those expectations came from and instead we just expect everyone to be able and willing to meet them.” The challenge is acknowledging that norms are not the same for everyone.

To foster a more inclusive culture, individuals who are in a position to make decisions about expectations within colleges of pharmacy can initiate conversations about when and where traditional norms are genuinely required. “Do folks truly have to be dressed certain ways or have certain hairstyles or hide their tattoos in these spaces or can we leave some of these things behind?” Tenney suggested. “Be really clear and proactive and up front about what the expectation is. For example, in pharmacy lab, there’s an expectation that someone dress professionally. But someone who is from Appalachia might show up in dark jeans because that was considered dressed up where they came from. People don’t always have clear guidelines.”

It’s essential to steer conversations in an educational direction rather than a punitive one so students aren’t punished for not knowing any unspoken rules. In discussing professional identity formation, Tenney referenced research in higher education about how learners come to be their authentic selves and carve their own pathways. “There is some research on self-authorship about how students move from being instructed and taking everything at face value versus over time maturing to be able to think critically and determine their own path. How can we as professionals help guide students as opposed to telling them what to do step by step?”

Tenney proposed thinking of a tandem bicycle—it’s easy to picture pharmacy faculty being the ones in front who are steering. However, “we should be recommending that we switch places and remember that it is the student’s learning journey and their career so they should get to steer. We can guide them and give advice from the back, but our main role is to pedal to help them get where they want to go.” The future of professionalism in pharmacy revolves around rethinking standards and supporting an increasingly diverse workforce. “How do we define [professionalism] and still meet the goals of confidence in the profession and trust from patients? Someone doing their hair a certain way is no less capable of being professional than someone else. What would it look like for us to affirm those things and increase trust in the profession from patients who are often distrustful?”

Incorporating EDI into the foundations of what pharmacy schools are doing and examining policies through that lens is the only way to effect true change. Tenney is encouraged by data from an internal survey at Ohio State revealing a shift in public opinion supporting EDI initiatives and recent momentum at other higher education institutions to devote more attention and resources to these efforts. “A lot of this has come about as a result of the murder of George Floyd. It did change a lot of hearts and minds in higher education,” Tenney noted. “That event reminded folks who might not have been paying attention to diversity issues that for many students, this is the reality they are still facing. It was a catalyst. More schools are willing to say this is a priority and we are going to put dollars behind it and have someone in the position to do something about it.”

Build Bridges to Sustain EDI Efforts

In the Institute’s closing session, “How to Be an Accomplice and Cause Good Trouble,” Dr. Regina McClinton, chief officer for diversity, equity and inclusion, University of Michigan College of Pharmacy, reflected on being the power behind EDI efforts and allowing others to take the lead. The key to making sustainable progress around equity, diversity and inclusion is to recognize that it is about building relationships, she said.

“You can have the different conversations that need to be had because you built trust and cache first,” McClinton explained. “EDI work is emotional in many ways. Here we are in these schools with pharmacists for whom things have to be perfect or a patient gets hurt. I am asking them to use different parts of their brains and beings to understand the needs of people they have not traditionally considered, or goals they have not traditionally considered.”

Attracting a more diverse student population is essential. When McClinton started doing EDI work at Michigan, “people listened because I had built the rapport and made the connections and understood where people were so I could steer them where I needed them go,” she continued. “The other thing about being an accomplice is when you do that, other people get wins in EDI. The barriers can seem so high. If you let them lead something they build their confidence, they build recognition and they begin to embrace the work because they see themselves as part of it.”

Understanding an institution’s culture, values and mission is a necessary first step before attempting to implement EDI initiatives. The leadership absolutely must be on board so you have leverage when you are making connections and making the case for change, McClinton said. “If pharmacy schools want to produce the best and brightest and be transformative but the workforce does not represent America, then you’ve failed. Those voices are not at the table. It behooves pharmacy schools to produce diverse cohorts, have diverse student populations so they represent the needs and cultures of America that are out there.” EDI efforts advance the pharmacy profession as a whole because when students understand these issues, it translates to better patient care.

“Even the students that are not from underrepresented groups need to come up to speed and understand cultural differences and values. They will hear their patients differently and will be able to better connect to those patients than those who have not received that kind of training,” she emphasized. “In particular, those who are from similar backgrounds to the populations are more relatable. I know that when I work with white clinicians, I’m thinking, ‘how am I saying this so you understand me?’ It is hard labor to have to train your clinician to understand you. When that person understands you, you trust what the clinician is saying. It isn’t that it always has to be a Black clinician treating a Black person. You just need to be aware.”

Bringing more diverse voices to these conversations will also result in richer approaches to addressing social determinants of health. “If schools are not producing well-rounded pharmacists that are able to have seats at the table in their organizations or on a larger scale in a city or a state, our ability to effectively address social determinants of health is hampered,” McClinton added. Ensuring that EDI is considered mission critical within a pharmacy school—leading from the top and listening from the bottom—will support its sustainability.

“What do you look like to the rest of the world? If you’re bringing in faculty that are people of color, they will have needs that other faculty will not. We understand that about women, so we need to understand that people of color may have additional demands on them,” she noted. “Students of color will flock to that faculty member. You might have that person on three committees. The work of EDI has to be the work of the whole college.” Within the university, it’s essential to communicate the value and importance of EDI to the president and provost so they can secure necessary funding to support outreach efforts.

An ongoing part of EDI work is to help people be comfortable with being uncomfortable and to get to know people who are not like them so they can have authentic exchanges. “For pharmacy schools to create that and model that for the students and demonstrate the value so they are equipped after they leave is part of that sustainability,” she said. “Those people become your alums. It turns those students into bridge builders in areas they would not have been without that kind of exposure.”

Finally, she added, “EDI work is a marathon, but it’s like an ultra-marathon that lasts 50 days through a hot desert. People have to understand that you might get quick wins early on, but then the real work begins. If you get off course, you have to find your way back. Build a cohort and network. Build that community of people invested enough to do that work in your organization.”

Jane E. Rooney is managing editor of Academic Pharmacy Now.