Incorporating LGBT Instruction into Pharmacy Curricula

by Elizabeth Hearn, Pharm.D., PGY-1 Community Pharmacy Resident, University of Mississippi School of Pharmacy, Jackson, Mississippi

While only 4.5% of adults in the United States identify themselves as lesbian, gay, bisexual, or transgender (LGBT), this population faces some significant health problems.¹ HealthyPeople2020 reports that LGBT youth are more likely to be homeless and are up to 3 times more likely to attempt suicide when compared to heterosexual, cis-gendered youth. They also have significantly higher rates of illicit drug, tobacco, and alcohol use.² Transgender individuals are more likely to suffer from mental health disorders such as depression, post-traumatic stress disorder, and suicidality as well as HIV/AIDS and other sexually transmitted infections.^2,3 Perhaps one of the most shocking data for healthcare providers to digest is that LGBT individuals report feeling isolated and a lack of social support due to culturally incompetent healthcare providers.²

HealthyPeople2020 set nationwide goals for improving the health, safety, and well-being of the LGBT community. One of the metrics is to provide, “medical students with training to increase provision of culturally competent care.”² However, healthcare providers across multiple healthcare disciplines – not just physicians – have reported limited knowledge and confidence in treating transgender patients.³ Are we doing enough to equip pharmacy students with the knowledge and confidence needed to address the healthcare disparities experienced by the LGBT community? Or are we leaving them ill-prepared?

A recent cross-sectional survey of 142 schools of pharmacy in the United States found a wide variety of transgender-related instructional activities. However, only 53% (35, n=66) of surveyed schools reported purposely implementing instruction regarding transgender care in their curriculum. Of those schools who have transgender-related care coursework, only 14 of 35 provided 2 hours or less of student experience with this patient population. Moreover, only 15 schools had plans to further develop or implement transgender-related care in their curricula within the next 3 years. When schools were asked to rate graduating pharmacy students’ confidence level for providing competent care to transgender patients, only 2 schools felt students would have a high level of confidence.³ With these data in mind, there is room for improvement with regard to transgender-related care in American pharmacy schools.

Instruction regarding LGBT health-related issues can be taught in several ways. In a 2017 study, didactic instruction about transgender-related care improved pharmacy students’ scores on knowledge-based assessments and self-reported confidence in decision making. Third-year Doctor of Pharmacy students received a 2-hour lecture about transgender-related care. When compared to 4th-year students who did not receive the lecture, 3rd-year students scored significantly higher on both a knowledge-based assessment (63.4% vs. 72.5%) and a self-confidence assessment (60.6% vs. 76.8%).⁴

In another study, lecture-based instruction about LGBT healthcare was shown to improve students’ understanding of the role of a pharmacist in transgender care. Pre- and post-lecture surveys showed a marked increase in student pharmacists’ understanding of their role in caring for transgender patients (30.6% vs. 96.5%).⁵ Amongst the schools of pharmacy who have already incorporated instruction about transgender-related care into their curricula, didactic lectures and discussions are by far the most prevalent instructional methods.³

Some schools of pharmacy report offering Introductory and Advanced Pharmacy Practice Experience (IPPE and APPE) opportunities for students to interact with LGBT patients. Utilizing IPPEs and APPEs for this purpose may seem ideal, as educators have reported they perceive that there is not enough time in the didactic curricula to include additional lectures, discussions, or care-based activities. Designated IPPE and APPE sites could be LGBT-specific clinics or locations that have a higher-than-average percent of their patient population who identifies as LGBT (such as an HIV clinic). However, these IPPE and APPE experiences are uncommon, with only 12 (out of 63) schools providing an experience where students can interact with LGBT patients. Due to limited availability and potential site-to-site variability, these types of IPPEs and APPEs may be best suited as elective experiences.³

Researchers at two schools of pharmacy in Washington and New Mexico took a creative approach to their instructional methods. Students were exposed to 3 hours of content about cultural, empathetic, and medical considerations for patients with diverse gender identities. Interestingly, the educators used a variety of mediums, namely: a pre-recorded video lecture; a list of frequently-asked-questions and answers; a game-show-style game; a patient video; a gender identity exploration exercise; role-playing scenarios; and a panel discussion with gender-diverse patients. The gender-exploration activity, which was adapted from Lavender Health’s Gender Role Socialization activity, was rated least helpful by students in the post-class surveys. However, more than half of the students found the remaining exercises to be very informative — the panel discussion with gender-diverse patients was considered by students to be most helpful. A panel session with individuals who identify as LGBT appears to be an effective way to include LGBT instruction in pharmacy curricula.⁶

We should use these examples to establish or update curricula at schools of pharmacy. When developing LGBT-related care education, consider the following learning opportunities for student pharmacists:

1. Understanding sexual and gender development
2. Discussing gender identity and how to document sexual preferences and gender identity in medical records⁴
3. Identifying barriers to access to care by LGBT people
4. Outlining drug and health-related resources for LGBT patients who are uninsured or underinsured
5. Motivational interviewing for smoking, alcohol, or drug cessation in the LGBT community⁷
6. Managing pharmacotherapy in LGBT people experiencing:
1. Mental health disorders
2. HIV and AIDS
3. Sexually transmitted infections
4. Chronic diseases
5. Gender transition ^4,7

Student pharmacists have expressed the desire to learn about this topic.⁵ Multiple exposures to LGBT-care-related issues would result in greater sensitivity, confidence, and competence.⁵ Given that health disparities for the LGBT community clearly exists and pharmacy students are willing to learn how to minimize them, it is our responsibility to step up and provide the opportunity. Incorporating LGBT instruction in our classrooms can transform a pharmacy student from a culturally incompetent healthcare provider to a well-informed, self-confident practitioner.

References

1. Williams Institute: Adult LGBT Population in the U.S. March 2019. Accessed 15 August 2019. Available from: https://bit.ly/2W2AxHB
2. HealthyPeople2020: Lesbian, Gay, Bisexual, and Transgender Health. Accessed 15 August 2019. Available from: https://bit.ly/2H939tF
3. Eckstein MA, Newsome CC, Borrego ME, et al. A Cross-sectional Survey Evaluating Transgender-Related Care Education in United States Pharmacy School Curricula. Currents in Pharmacy Teaching and Learning. 2019; 11(2019): 782-792. DOI: 10.1016/j.cptl.2019.04.005
4. Ostroff JL, Ostroff ML, Billings S, Nemec EC. Integration of Transgender Care into a Pharmacy Therapeutics Curriculum. Currents in Pharmacy Teaching and Learning. 2018; 10(2018): 463-468. DOI:10.1016/j.cptl.2017.12.016
5. Knockel LE, Ray ME, Miller ML. Incorporating LGBTQ Health Into the Curriculum: Assessment of Student Pharmacists’ Knowledge and Comfort Level in Caring for Transgender Patients. Currents in Pharmacy Teaching and Learning. 2019; DOI:10.1016/j.cptl.2019.07.001
6. Newsome C, Chen LW, Conklin J. Addition of Care for Transgender-Related Patient Care into Doctorate of Pharmacy Curriculum Implementation and Preliminary Evaluation. Pharmacy. 2018; 6(4): 107. DOI: 10.3390/pharmacy6040107
7. Mandap M, Carillo S, Youmans SL. An Evaluation of Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Education in Pharmacy School Curricula. Currents in Pharmacy Teaching and Learning. 2014; 6(2014): 752-758.  DOI:10.1016/j.cptl.2014.08.001

Patient Simulation and the Benefits to Student Pharmacists

Darby Pullen, Pharm.D., PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital, North Mississippi

Pharmacy education is continually changing and faculty should be familiar with a variety of models to teach students. During my time in Pharmacy School, patient simulation mannequins were used to demonstrate and practice hands-on techniques that I might later use in practice, such as how to give glucagon when a patient with diabetes is hypoglycemic and not responsive.

Students today are exposed to more stimuli and expect more than a typical PowerPoint presentation. Mannequins can mimic several disease states such as cardiac arrest and allergic reactions. Students can gather a variety of clinical information from a mannequin including a pulse, heartbeat, lung sounds, and other hemodynamic parameters.¹ Virtual patients are another form of simulation that can enhance student learning. Virtual patients are created in digital, computer-based environments.

Simulation is a way to bridge the foundational knowledge that is taught in the classroom to hands-on experience. Moreover, some students prefer hands-on activities in order to fully understand different disease states. Mannequins can benefit the students who are visual, kinesthetic, or auditory learners.¹ This would, in turn, enhance the pharmacy student’s knowledge, confidence, and clinical skills.¹

Simulation can enhance students’ learning process.¹ Using patient simulation requires more active student participation in a low-risk environment.¹ Students are able to have more hands-on activities that simulates real-life scenarios but without risking actual patient harm. Facilitators are usually available to correct student behavior when they are interacting with the mannequins and computer simulators can provide ongoing feedback.¹

According to the ACPE accreditation standards for pharmacy schools, “graduates must possess basic knowledge, skills, and abilities to practice pharmacy independently, at the time of graduation."² ACPE allows up to 20% of the students’ required hours of practice experience to be fulfilled using simulation.² By including more patient simulation in the classroom, it would be a win-win situation. Students would have greater access to semi-authentic learning exercises and would fulfill requirements for ACPE.

Faculty at the Universiti Teknologi MARA in Selangor, Malaysia evaluated the difference in students’ performance when they were taught using a human patient simulator compared to a problem-based learning activity.³ The investigators were teaching students about diabetic ketoacidosis and thyroid storm. This was a crossover study. Students were randomized to receive instruction using either a human patient simulator or a problem-based learning activity for one of the disease states and then crossed-over to receive instruction using the alternative instructional method for the second disease state. After each case, students were assessed using a posttest immediately after the lesson followed by a knowledge retention test 10 weeks later. The knowledge retention test included recall and application questions.

On follow-up surveys, students indicated they were more satisfied learning using the patient simulation rather than problem-based learning.³ The posttest and knowledge retention scores were significantly higher (p < 0.05) in the mannequin group (mean scores: posttest 78.5; knowledge retention 58.5) for the thyroid storm case when compared to problem-based learning group (mean scores: posttest 75.1; knowledge retention 53.5).1 This study suggests that human patient simulation may be more effective for long-term knowledge retention than problem-based learning.

In another study, investigators at Griffith University in Queensland Australia assessed the role of virtual (simulated) patients in pharmacy education. Specifically, they examined how students feel about the experience as well as how well they performance on knowledge tests and assessments of clinical skills.⁴ They performed a meta-analysis and found nine studies that compared virtual patients to traditional teaching methods. Their findings showed that the use of virtual patient to teach about therapeutic topics was not superior to traditional teaching in terms of student performance, but does improve the students’ reaction to the learning experience.⁴

Simulator mannequins are expensive. They can run anywhere from 16 to 90 thousand dollars.³ Plus there are additional costs for maintaining the mannequins and hiring qualified operators. This is a high cost for pharmacy schools to add to their budgets. However, schools can consider collaborating with other health professional schools. Nursing and medical programs often use patient mannequins. By using them for interprofessional activities, this not only improves pharmacy student knowledge but also teaches them about team member roles. By having more interprofessional interactions, medical and nursing student benefit as well.

Using mannequins and virtual patients, students must use critical thinking skills in addition to their baseline pharmacotherapy knowledge.⁴ Students can be placed into a high-stress environment but the stakes are low. You don’t want students having their first interaction with a real patient while still trying to learn about a new disease state. Students can be prepared for the experience by completing an orientation exercise and continue to repeatedly practice with the mannequins. Using virtual patients and mannequins, pharmacy students would have greater confidence when advancing into their advanced practice experiences.

There is some evidence that simulator mannequins improve students’ learning, particularly long-term knowledge retention.^4,5 Students respond favorably to learning activities involving mannequins and virtual patients because they are low risk. Traditional learning methods are still needed but simulator mannequins and virtual patients can help students build their confidence. Simulator mannequins should be considered when there is a hands-on technique that students need to master, such as working as an interprofessional team during a code or administering medications. Virtual patients can further pharmacy student’s knowledge and clinical decision-making skills.

References

1. Vyas D, Wombwell E, Russell E, et. al. High-Fidelity Patient Simulation Series to Supplement Introductory Pharmacy Practice Experiences. American Journal of Pharmaceutical Education. 2010; 74 (9) 169. DOI:10.5688/aj7409169
2. Accreditation Council for Pharmacy Education: Policies and Procedures for ACPE Accreditation of Professional Degree Programs – January 2010. Accessed 30 April 2019.
3. Chin KL, Yap YL, Lee WL, et. al. Comparing Effectiveness of High-Fidelity Human Patient Simulation vs Case-Based Learning in Pharmacy Education. Am J Pharm Educ 2014; 78 (8) Article 153. DOI:10.5688/ajpe788153 
4. Baumann-Birkbeck L, Florentina F, Karatas O, et. al. Appraising the Role of the Virtual Patient for Therapeutics Health Education. Currents in Pharmacy Teaching and Learning. 2017; 9 (5): 934-944. DOI:10.1016/j.cptl.2017.05.012
5. Seybert, AL. Patient Simulation in Pharmacy Education. Am J Pharm Educ 2011; 75 (9) Article 187. DOI:10.5688/ajpe759187