Why Teaching Cultural Competency is Essential

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:

1. NIH.gov [Internet]. Clear Communication: Cultural Competency.
2. 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.
3. Jungnickel PW, Kelly KW, Hammer DP, Haines ST. Addressing Competencies for the Future in the Professional Curriculum. AJPE 2009;73: Article 156.
4. Sears KP. Improving cultural competence education: the utility of an intersectional framework. Med Edu. 2012;46:545-551.
5. 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.