The Role of Education in Increasing Social Justice

By Bianca Lascano, PharmD, PGY2 Ambulatory Care Pharmacy Practice Resident, University of Mississippi School of Pharmacy

As healthcare professionals, we understand that social determinants of health have profound effects on health outcomes. Awareness of the health disparities they generate underscores the significance of emphasizing social justice principles in health professions education. It is important that educators help students develop the critical thinking, collaboration, and self-reflection skills necessary to foster a better society.¹ There are several courses embedded in the curriculum that must be taught as students matriculate through the didactic portion of their professional degree program. There are many opportunities to discuss social determinants of health throughout the curriculum and help students understand their implications through the lens of social justice.

Image from: https://www.promotionswest.com/health---social-equity.html

In A Practical Strategy for Infusing Multicultural Content into Any Lesson posted on the Faculty Focus website, Dr. St Germain discusses a method to integrate multicultural content into each lesson he teaches in a business communications course. Dr. St. Germain gives specific directions to guide his students to think about marginalized groups. For example, if students are developing a website for the city’s recreation department, the directions would state, “evaluate how well the website ensures people of color and how welcoming the content may be to the LGBTQ community.” Having students work at the evaluation level of Bloom’s taxonomy, greatly increases the chances that the activity will allow the students to construct new knowledge as it pertains to cultural competence and social justice.²

Professors in the health professions can emulate Dr. St. Germain by including diverse patient populations when designing patient cases within each clinical module. Including social aspects of a patient’s life that might impact health outcomes and having students explore how that could affect treatment and healthcare delivery will prompt students to create individualized plans through the lens that is different than their own. Thus social justice issues can be woven into course material that, on the surface, appears unrelated to social justice.

It is surprising that even though issues related to social justice are central to healthcare services provided to patients, they have received inadequate scholarly attention. A lot of the course material taught within the health professions curriculum can be viewed from a social justice perspective. For example, we understand the treatment of hypertension can adversely affect certain patient populations more than others. Access to treatment and follow up care is more difficult for some populations. Food insecurity and lack of transportation can be significant barriers. It is important that students begin to recognize their assumptions and implicit biases as they explore and discuss case studies.

Unfortunately, implicit bias, by definition, influences health professionals without their knowledge and despite their best intentions.⁴ A process described as implicit bias recognition and management (IBRM) is required to mitigate the negative impact of bias. Research on IBRM suggests that as health professionals begin to accept that they can never eliminate all their biases, they also confront that they are learning within an environment that reinforces and contributes to these biases.⁵  Even well-intentioned learners may find the process of discussing and reflecting on biases challenging.  Moreover, faculty may be reticent to facilitate such discussions.⁴

Sukhera, Watling, and Gonzalez propose transformative learning theory (TLT) as a guide for implementing implicit bias training in health professions education. TLT suggests that learning is a process triggered by disruption, followed by a revised interpretation of experiences that guide an individual’s actions.⁴ The process requires critical reflection, dialogue, and action. An illustrative example would be placing a health professional learner in a challenging rural or remote setting for service learning. This would facilitate cross-cultural interactions that produce dissonance, promote skill development, and require dialogue.⁴ This most certainly would be more transformative than a lecture about diabetes. Professors can assess engagement in these activities by inviting students to reflect on how their actions perpetuate the status quo. The goals of transformative learning are to increase awareness of how to construct reality and to break free of limiting structures that shape our understanding.⁴

In a recent article posted on The Edvocate website entitled Teaching Social Justice in Your Classroom, Mathew Lynch provides some activities that can be used to develop the skills necessary to advance social justice.³

These skills include:

·       Differentiating between fact and opinion to determine what is true

·       Examining diverse points of view to look at an issue from all sides

·       Developing a personal perspective based on accurate comprehension

Given that the majority of health professions students come from diverse backgrounds, these skills are not only relevant when treating patients, but also when interacting and working with classmates. Even more reason to explore social justice! Students should be able to have a healthy dialogue with persons of different ethnicities, gender, age, and religious beliefs.

In a recent article posted on the Resilient Educator website entitled Teaching Social Justice in Theory and Practice by Caitrin Blake, the author suggests using these questions  to explore potential systemic inequality in public policy … or healthcare delivery:¹

·       Who makes decisions and who is left out?

·       Who benefits and who suffers?

·       Why is a given practice fair or unfair?

·       What is required to create change?

·       What alternatives can we imagine?

Blake suggests, in order to foster social justice in the classroom, educators must first build a safe, encouraging place where students can speak about their experiences and beliefs.¹ Thought-provoking conversations can be created by encouraging students to share their ideas and respectfully respond to others without shutting the discussion down.

Social justice cannot be taught and fully understood overnight. Starting the dialogue in the classroom affords students the opportunity to engage in an authentic examination of their world and to work toward positive changes that make healthcare delivery more equitable. Providing a safe environment for students to share personal stories and opinions on different aspects of social justice is just the start. Consider how you might discuss social justice topics with your colleagues and introduce these concepts to your students.

References

1. Blake C. Teaching social justice in theory and practice. Resilient Educator [Internet]. 2015 May 13. Available from https://education.cu-portland.edu/blog/classroom-resources/teaching-social-justice/
2. Germain D St. Practical Strategy for Infusing Multicultural Content into Any Lesson. Faculty Focus [Internet]. 2019 Nov 11. Available from:  https://www.facultyfocus.com/articles/effective-teaching-strategies/infusing-multicultural-content-into-any-lesson/
3. Lynch M. Teaching Social Justice in Your Classroom. The Edvocate [Internet]. 2019 Jan 9. Available from: https://www.theedadvocate.org/teaching-social-justice-in-your-classroom/ 
4. Sukhera J, Watling CJ, Gonzalez CM. Implicit Bias in Health Professions: From Recognition to Transformation. Acad Med. 2020;95:717‐723. 
5. Van Ryn M, Hardeman R, Phelan SM, et al. Medical school experiences associated with change in implicit racial bias among 3547 students: A medical student CHANGES study report. J Gen Intern Med. 2015; 30:17

Teaching Stress Management and Coping Strategies to Students in the Health Professions

by Ganiat Animashawun, PharmD, PGY1 Pharmacy Resident G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Stress can be perceived in different ways. Stress is a complex bio-behavioral, psycho-social response to a stressor.¹ Stress can be both negative and positive.² Negative stress is labeled as distress, whereas positive stress is called eustress.³ People may assume that all stress is bad, but stress can actually be a positive thing. A stressor can be real or perceived prompted by something in the external environment or internally generated.¹ A “real” stressor is produced from an actual event. For example, if a student fails an exam that is a real stressor. A perceived stressor would be when the student thinks “I did horrible. I failed my exam.”  It hasn’t actually happened (yet). External or environmental stressors are things that are out of one’s control. For example, “there are tornado warnings so I will not be able to drive to the school to take my exam.” Internal stressors are based on the way you evaluate yourself or based on your beliefs.  A panic attack before an exam due to negative self-talk is an example of an internal stressor.² Seeking an advanced degree can stressful – and these stressors are both real and perceived, external and internal. Wanting to be successful in school and making sure that one has a job post-graduation adds more pressure. While some stress can positively drive performance, excessive stress can negatively impact a student’s learning.⁴ Therefore, stress management and coping strategies should routinely be taught in health professions educational programs.

The correlation between stress and learning is multifaceted. There are different factors that influence or cause a person to be more susceptible to feelings of stress. Coping style, personality type, genetic vulnerability, and social support are all factors.² When a student is confronted with a problem, the first step is to identify the source of the problem and then determine what resources are available to address the problem.² If a student is unable to find the resources necessary to cope with the problem, it often results in stress.³

A cohort study entitled Patterns of Stress, Coping and Health-Related Quality of Life in Doctor of Pharmacy Students: A Five Year Cohort Study focused on evaluating perceived stress, coping strategies, and health-related quality of life (HRQOL) in pharmacy students. One hundred forty-five pharmacy students at the University of California San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) participated in the study. The researchers measured stress and HRQOL using 3 tools: the Perceived Stress Scale (PSS), Brief COPE, and Short Form-36. Surveys were administered to the students three times a year over five years. The study found that there was a significant increase (worsening) PSS scores and an increase in students’ maladaptive coping behaviors over time. This corresponded, not surprisingly, with worsening scores on the mental health domain of the health-related quality of life instrument. Thus, the research found a significant increase in perceived stress, increased maladaptive coping, and worsening in mental health across the three pre-clinical curriculum years.⁴  To address this problem, the school implemented strategies for reducing stress and provided coping skills training sessions for the students as well as a peer-to-peer tutoring program.  Moreover, they initiated a curricular review.⁴

To better cope with stress, a student must learn how to take control of the triggers that may cause stress. At the University of Massachusetts Medical School, they have a Mindfulness-Based Stress Reduction (MBSR) curriculum that has been extensively studied and replicated around the world. MBSR guides the students on how to practice, integrate, and apply mindfulness every day.⁶ The primary purpose of the MBSR is to create a structured pathway to increase well-being and alleviate stressors. MBSR can be added and incorporated during early course work in the first year of the curriculum. MBSR is typically taught over 8-weeks with 10 sessions training students to engage in mindfulness meditation and mindful yoga. Even if MBSR course isn’t practical, all students should be introduced to mindfulness. It seems simple but developing mindful habits is actually very difficult. To be truly mindful, students must be able to reflect on all of their actions and be aware of how everything internally and externally can affect their minds and lead to stress.

In a MBSR program, students learn about stress, habitual, automatic behavioral, physical, emotional, and cognitive patterns. In addition the students learn to analyze how they approach and tackle the demands in their everyday life.⁶  Students learn how to recognize their perceptions of a potentially stressful event and then how to creatively respond. Students learn how they can control the way they react or respond. Once the students learn how to condition and focus on the way they respond to stress then they can use the strategies they’ve learned to address future stressful events and thoughts. The MBSR program provides many examples of how to complete each task.⁶ Studies have shown that participants who have completed a MBSR program experience a 35% reduction in the number of somatic symptoms and a 40% reduction in psychological symptoms.⁷ Furthermore, MBSR has been shown to significantly improve health-related quality of life⁷.

Mindfulness-Based Stress Reduction (MBSR) should be routinely taught to first-year health professions students. The earlier the students are exposed to mindfulness practices, the sooner they will able to use those tools to manage stress. Teaching students how to productively managing stressors might vary well lead to improved learning outcomes and reduce drop-out rates.

References

1. Schneiderman N, Ironson G, Siegel SD. Stress and health: psychological, behavioral, and biological determinants Ann Rev Clin Psych 2005; 1: 607-28.
2. Salleh MR. Life event, stress and illness. Malays J Med Sci 2008; 15: 9-18.
3. Votta J and Benau E. Predictors of stress in Doctor of Pharmacy students: Results from a nationwide survey. Curr Pharm Teach Learn 2013; 5: 365-72.
4. Hirsch JD, Nemlekar P, Phuong P, Hollenbach KA, Lee KC, Adler DS, and Morello CM. Patterns of Stress, Coping and Health-Related Quality of Life in Doctor of Pharmacy Students: A Five Year Cohort Study. Am J Pharm Educ [Internet]. (2019).
5. Silvester JA, Cosme S, Brigham TP. Adverse impact of pharmacy resident stress during training. Am J Health-Syst Pharm 2017; 74: 553–554.
6. Kabat-Zinn J, Saki F. Santorelli, Florence Meleo-Meyer, Lynn Koerbel, Mindfulness-Based Stress Reduction (MBSR) Authorized Curriculum Guide. [Internet]. (2007).
7. Kabat-Zinn J. Mindfulness-Based Stress Reduction Research Summary.[Internet]. Waterloo, Ontario, Canada; 1992 Dec.