by Samuel Houmes, Pharm.D. PGY 1 Community Pharmacy
Resident, University of Maryland School of Pharmacy
Close your eyes for
a moment and picture a community pharmacy. You are standing in aisles looking at the amusing cards when you observe a tan-skinned
man approach the pharmacy counter. Based on the man’s curious looks around the
store, it would be a reasonable assumption the man has never been to this
pharmacy before. The pharmacist stops to assist the man. As the pharmacist begins
to counsel the patient, it becomes apparent the patient speaks little English.
The pharmacist realizes this, and to complete the required counseling, raises her
voice and speaks slowly in an attempt to help the patient understand. After
a confused look, the patient pays, takes the prescription bag, and walks out
the door.
What is wrong with
this encounter? The lack of communication between the patient and the
pharmacist significantly increases the risk of a poor outcome. The pharmacist
made no effort to find an avenue to elicit additional information about the
patient’s past health history or cultural beliefs. What if, in this situation,
the patient had a belief that alternative health practices should be used to
supplement Western medicine? The patient may take something that diminishes the effectiveness of the treatments or cause a drug-drug interaction that leads to another physician visit ... or worse. In order for the pharmacist to provide
patient-centered care, she needs to assess the patient’s cultural beliefs.
Culture is difficult
to define—but includes aspects of language, thought processes, communication,
values, beliefs, customs, personal identification, and actions relevant to
social, ethnic, racial, religious, or geographic groups.1 Achieving cultural competency requires the
healthcare professional to take into account an individual’s beliefs and
practices when making healthcare decisions and recommendations.1
In a 2007 survey of
pharmacy schools, only 51% of respondents indicated that they made changes in
their curriculum to include cultural competency.2 Research indicates
that pharmacy students are ineffective when it comes to addressing cultural
issues in practice.3,4 This is problematic given the growing needs
of a diverse patient population. While the integration of cultural competency
into pharmacy curricula has increased, unfortunately, there is not a lot of
research data on effective educational frameworks.2 Ideally, the curriculum
should address cultural concepts, instruction on health disparities, patient
interactions with practitioners and health-systems, and the provision of
patient-centered culturally sensitive care.2
This sounds great,
but how should a school actually teach
cultural competency? Considering how broad the working definition of culture is
and the current lack of data on outcomes, no one knows what is the “best”
teaching method. Thankfully, instructional strategies used to teach
patient-centeredness may also be used to teach cultural sensitivity. Didactic
instruction, active learning, and reflective assignments all play a role in
assisting the student learn about cultural beliefs and how to practice in a
culturally competent manner.
Service-learning
provides an excellent learning opportunity for students to gain personal
experience with patients who are underserved. Through service learning,
students integrate patient care into the development of civic responsibility,
empathy, professionalism, and communication skills by caring for a patient (or
a group of patients) over a period of time.2 This allows the student
to learn to about cultural beliefs and practices and how they impact health
problems.
Objective Structured
Clinical Examinations (OSCEs) are another way for students to gain personal
experience, but in a simulated environment. Students communicate one-on-one
with their patient and work to reconcile the patients’ beliefs against the
provision of patient-centered care.2
OSCEs enable student to learn competency skills in a safe environment.
International
rotations provide another avenue to develop cultural awareness and competency. When students travel to another country, they are exposed to a
culture and belief system they may otherwise have never encountered. Necessarily,
if students want to provide effective healthcare to the new patient
population, they need to understand the populations’ beliefs on healthcare
and medicine.2
One activity that
can be used in the classroom to teach small groups of students how culture impacts
our daily lives is called ‘BaFa’BaFa.’ In this activity, the students are split
into two cultures (the ‘Alphas’ and ‘Betas’). Each culture spends 15-20 minutes
learning the intricacies of their assigned culture before interacting with one
another. The resulting stereotyping,
misperceptions, and misunderstandings are discussed during debriefing.5
Ideally, cultural
competence should be taught throughout the pharmacy curricula rather than in a
single didactic course. Indeed, a single
course about cultural differences may only further solidify stereotypes. Within
the first and second years, the goal should be to develop cultural awareness
through the use of reflective papers, didactic instruction, and active learning
activities (like an OSCE or BaFaBaFa). In the third year, students should begin
to learn how to integrate patient-centered decisions making with an awareness
of cultural issues. For example, this may be accomplished by utilizing diverse
patient cases in a pharmacotherapy course. Finally, the fourth year should
focus on exposing students to diverse populations while on advanced practice
rotations and include discussions regarding cultural issues with their
preceptors.2
More research is
needed to evaluate effective methods of instruction, in and outside the
classroom, that promotes the development of cultural competency. By keeping abreast of the literature, educators
can identify and implement effective learning strategies that motivate students
towards becoming culturally competent practitioners.
References:
- NIH.gov [Internet]. Clear Communication: Cultural Competency.
- O’Connell MB, Rodriguez de Bittner M, Poirier T, Karaoui LR, Echeverri M, Chen A, et al. Cultural Competency in Health Care and Its Implications for Pharmacy Part 3A: Emphasis on Pharmacy Education, Curriculums, and Future Directions. Pharmacotherapy 2013;33:347-367.
- Jungnickel PW, Kelly KW, Hammer DP, Haines ST. Addressing Competencies for the Future in the Professional Curriculum. AJPE 2009;73: Article 156.
- Sears KP. Improving cultural competence education: the utility of an intersectional framework. Med Edu. 2012;46:545-551.
- O’Connell MB, Jackson AN, Karaoui LR, Rodriguez de Bittner M, Poirier T, Echeverri M, et al. Cultural competency in health care and its implications for pharmacy Part 3B: emphasis on pharmacy education policy, procedures, and climate. Pharmacotherapy 2013;33:368-81.
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