Applying Intersectionality to Health Professions Education

by Caitlin Leach, Pharm.D., PGY1 Community Pharmacy Practice Resident, University of Maryland School of Pharmacy

Health professions are comprised of a distinct group of people with specific domains of inquiry possessing language, methods, and skills within a focused framework.  While health professions education encourage the acquisition of an impressive depth of knowledge, they limit the scope of practitioners’ expertise.  A common solution to this issue involves promoting interprofessional education. Theoretically, this exposes learners to other areas of specialization in order to provide a more holistic approach to the task at hand.

I argue that this is not an adequate solution.

Interprofessional approaches involve temporary overlap of profession-specific frameworks to provide insight and new knowledge regarding a particular task. Unfortunately, this categorizes information outside the practitioner’s framework as the responsibility of other professions. This approach is appropriate when complex tasks have access to an interprofessional perspective. However, often in pharmacy practice, particularly in settings where patients face barriers-to-care and lack-of-access, complex cases must be solved independently of additional practitioners’ perspectives. To address this gap, pharmacy students need more exposure — not to interprofessional education, but to intersectional education.

“Intersectionality” is a sociological theory coined by Kimberlé Crenshaw in 1989.¹ The theory postulates that multiple axes of identity contribute simultaneously to a person’s experience of oppression and discrimination.  The typical manifestations of oppression - sexism, racism, classism, biphobia, homophobia, transphobia, and belief/cultural-based prejudice – cannot be examined independently because they contribute to inequality in a way that is interconnected and interrelated. Instead, intersectionality offers a holistic framework to evaluate the impact of multiple identities contributing to a person’s experience of inequality.¹ Borrowing the concept of intersectionality, it can be applied in health professional education and used to help students see the multiple determinants contributing simultaneously to a patient’s experience of health.

This figure illustrates various axes of human identity converging to a point of intersection

Image from: http://www.clydefitchreport.com/2015/01/intersectionality-going-forward/

Similar to identity, the origin of poor health is multifactorial and cannot be examined through a singular lens. Pathophysiologic and psycho-social determinants of health are interconnected and interrelated. While interprofessional approaches provide a different perspectives, from ability (physical therapy), family and income status (social work), to mental health (psychology, psychiatry), and others, it is imperative for pharmacists to be able to incorporate these health determinants when making therapeutic decisions in the absence of consulting other professions. In healthcare education, intersectionality can be applied to patient cases with the realization that health is not determined by any one thing. Through addressing psycho-social health determinants and discussing their impact on pharmacotherapeutic decision-making, intersectionality can provide students with a more complex understanding of health in order to address the needs of diverse patient populations.²

Intersectional case studies could explore a variety of questions including:

• What does lifestyle modification look like in a patient with diabetes on a fixed-income, with limited access to reliable electricity and heat, and sporadic medication adherence due to transportation issues to the pharmacy?
• In a patient with metabolic syndrome, depression, and anxiety that loses insurance coverage and can only afford half of her medications, which 5 of 10 medications are the most important in maintaining her health?
• What preventative care and screening recommendations do you make for male, female or transgender patients lacking primary care providers?

Adding layers of complexity regarding the human experience to patient cases can aid students in making the transition from the classroom to practice. Using intersectionality to address health disparities and improve health outcomes will also lead to more encompassing, holistic healthcare.³ Intersectionality provides a framework for pharmacy education that takes into account the complexity of health and human experience rather than reinforcing barriers-to-care as the responsibility of other health professionals and, in effect, perpetuates health disparities.

References:

1. Sumi C, Crenshaw K, McCall L. Toward a Field of Intersectionality Studies: Theory,Applications, and Praxis. Signs: Journal of Women in Culture & Society. Summer 2013;38(4):785-810.
2. McGibbon E, Rochester C. Applying Intersectionality & Complexity Theory to Address the Social Determinants of Women’s Health. Women's Health & Urban Life. May 2011;10(1):59-86.
3. Hankivsky O. Women’s health, men’s health, and gender and health: Implications of intersectionality. Social Science & Medicine. June 2012;74:1712-1720.

Maximizing e-Learning by Maximizing Interaction

by Ryan D’Angelo, B.S., Pharm.D., PGY1 Pharmacotherapy Resident, University of Maryland

I have always believed in welcoming technology into the classroom. Why not bring the wealth of information that exists today and increase what you can present to your students? It seems with increasing acceptance of technology and changing pedagogy techniques, the tide is turning. More and more institutions and teachers are relying on electronic learning (e-learning) to reach their learners in an effort to improve access and learning outcomes.

Most e-learning platforms use web-based systems to make information available to users anywhere in the world, on their own time, and at their own pace.^1,2 This can help decrease the amount of time lecturing to students and use in-class time to engage in active discussions. One thing to keep in mind when deciding to employ e-learning — there are a variety of implementation strategies and some are better than others. When e-learning techniques fail to engage learners, the results can be potentially worse when compared to learning outcomes observed in a traditional classroom environment.

One key in making interactive e-learning effective is providing learners with easy, fast, and instinctual access to content.^1,3,4 This can be achieved by utilizing diverse multimedia methods (audio, video, text) to deliver the content. Allowing for random access to information gives learners the ability to select content of their interest and is more likely to capture the mental attention of users.4 Allowing random access to content (rather than prescribing what content should be accessed and the sequence) requires interactivity by forcing the user to select what content they want to review, instead of forcing them to start at a particular point.^1,4,5

Interactive e-Learning Strategies

 

• Interactive Text: Terminology within text can be made interactive by providing definitions of text when the cursor is placed over the word, hyperlinks to images or video, and creating space where users can annotate within the margins of the page.
• Audio and Video: Providing video content in segments that are indexed allows for random access to different portions of the video. Many on-line continuing education courses utilize this technique by allowing viewers to pick the sections they would like to watch in the order they prefer.
• Simulation: Simulation can allow learners to put their knowledge to the test in “real-life situations”. Simulation can be created for nearly any subject including hard sciences (chemistry and physics), healthcare (patient cases), and personal interactions (psychology). While its technically more difficult to create high quality simulations, it can escalate interactivity to the next level!
• Learning by Asking (LBA): Allowing learners to assess their understanding by creating online questions and answers is an effective means of increasing interaction with the material. After the answer is selected, the correct response can be displayed to provide learners with real-time reinforcement and a detailed explanation. In addition, allowing students to propose questions related to the content can encourage learners to reflect on what they had just read, seen, or heard.
• Asynchronous Discussion Boards: Similar to learning by asking, asynchronous discussion boards can encourage critical thinking and examination of content.  Writing about the material forces learners to provide their interpretation of content. This can stimulate a discussion among students regarding the content and can inspire further inquiry.

Many studies have evaluated the impact interactivity on learning effectiveness and have found improvements in learner satisfaction, increased attention and better test performance compared to traditional classroom methods like lecturing.^1,4,5,6 This may be in part to enhanced self-directed and self-paced learning allowing students to be in a more focused and motivated mind-set when they engage with the material. One of the common limitations of these studies is that they generally evaluate only one form of interactivity. However, McLaughlin and colleagues evaluated a application of diverse set interactive tools using a multi-media website. The website was designed to provide instruction in a neurologic pharmacotherapy module — part of a required course in a doctor of pharmacy curriculum.3 The multi-media site blended video, assessment questions with immediate feedback, an interactive pop-up glossary within text, and allowed students to pose questions within each section of the text. The questions were answered by the instructor within 24 hours. This format was compared to a conventional 38-page downloadable text version of the material. When student performance on the final exam was compared, those with access to the interactive media site achieved significantly higher scores (80% vs. 74.5% p-value = 0.04). In addition, students with access to the media-site reported higher satisfaction with the module but this difference was not statistically significant. In class quiz scores were similar between the two groups (83.5% vs 84.1% p-value 0.89).

One of the major difficulties with implementing e-learning is the time it takes to develop interactive multimedia. Most faculty lack the knowledge to program the software to include these interactive approaches. Development of e-learning content requires a large investment of time, at least initially. But one thing to keep in mind is that the materials are enduring and can be updated and built on. Resources (people, equipment, and software) available through information and technology (IT) departments may also be able to assist with the initial development of e-learning materials. This can ease the time burden.

E-learning can be a useful tool to enhance learning and allow the more effective use of classroom time by using it for discussions and other “flipped classroom” activities. Building interactive multi-media requires dedicated time but when developed appropriately it enhances learning outcomes. E-learning has tremendous potential because the diversity of methods can meet the needs of students with different learning styles. Teachers should not be dissuaded from using interactive e-learning strategies because it requires us to learn new ways of delivering instruction. Rather, it is an opportunity to increase our skills to reach our learners.


References

1. Sun PC, Tsai RJ, Finger G, Chen YY, Dowming Y. What drives a successful e-learning? An empirical investigation of the critical factors influencing learner satisfaction. Computers and Education. 2008;50:1183-1202.
2. Zhang D, Nunamaker F. Powering e-learning in the new millennium: an overview of e-learning and enabling technology. Inf Sys Front. 2003;5(2): 207-18.
3. McLaughlin JE, Rhoney DH. Comparison of an interactive e-learning prepatory tool and conventional downloadable handout used within a flipped neurologic pharmacotherapy lecture. Currents in Pharmacy Teaching and Learning. 2015;7:12-19.
4. Zhang D. Interactive multimedia based e-learning: a study of effectiveness. American Journal of Distance Education. 2010;19(3):149-62.
5. Zhang D, Zhou L, Briggs RO, Nunamaker JF. Instructional video in e-learning: assessing the impact of interactive video on learning effectiveness. Information and Management. 2006;43:15-27.
6. Chumley-Jones HS, Dobbie A, Alford CL. Web-based learning: sound educational method or hype? A review of the evaluation literature. Acad Med. 2002;77:S86-93.