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.

Atypical Awareness - Responding to the Educational Needs of Patients with Autism Spectrum Disorder

by Elizabeth Yett, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Mississippi School of Pharmacy

In 2018, 1 in 59 children had a diagnosis of autism spectrum disorder (ASD) by the age of 8 in the United States, based on the DSM-5 criteria.¹ However, we are unable to determine a reliable estimate of the prevalence of ASD among adults. Given that there is a spectrum of characteristics that a patient with autism might display, healthcare practitioners have an obligation to identify patients who may have ASD and adapt patient education strategies to meet their needs. As a resident, I have had the pleasure of interacting with 2 pediatric patients (to my knowledge) with autism. They are quite different in their ability to receive information and respond to questions. One patient is completely non-verbal, while the other prefers to play games on his phone rather than engage in a conversation — just like a typical teenager. Reflecting on my own experiences, it is no wonder that people with disabilities, including patients with autism, face significant health challenges and health care inequities. Patients with disabilities report lower satisfaction with health care, lower health self-efficacy when navigating the healthcare system, and lower use of recommended preventative care services.²

Effective patient-provider communication is essential in improving health outcomes. Yet if we do not know (or understand) the patient’s specific educational needs, how can we be certain we are meeting them? Luckily, the Academic-Autistic Spectrum Partnership in Research and Education (AASPIRE) has created the Autism Healthcare Accommodations Tool (AHAT) to assist us in understanding the needs and preferences of people with ASD.³ Reflecting on the ADDIE model of instructional design assists with the analysis of each patient’s individual needs and how best to communicate and interact with the patient. Patients and/or their caregivers can create a personalized accommodations report that includes information to assist with the patient’s preferred communication style, tips to help patients answer questions, and how to approach physical exams. The AASPIRE website also includes great information for healthcare providers regarding the diagnosis of ASD as well as legal and ethical considerations in caring for patients on the autism spectrum.

Finding the most effective communication mode for a patient with ASD can be challenging, especially if it involves changing your usual communication style. Although patients with autism have unique educational needs – indeed, all patients do for that matter – it can be beneficial to understand a few ASD-related characteristics that often impact communication and learning. This recognition, along with a few recommended strategies to accommodate the patient with ASD, can facilitate a more effective patient interaction (Table 1). Along the same lines, this can help you implement ADDIE with an effective design and development of instructional materials that are most appropriate for the patient.

Table 1

ASD-Related Characteristic	Instructional strategies/tips
Tendency to take language literally and a need for precise language Tendency to be visual thinkers	Avoid figures of speech, broad questions, and vague statements Be concrete and specific with questions Show patients lists of symptoms or visual scales to assist with the assessment Create a visual schedule for the patient for when to take his or her medications
Difficulty understanding and carrying out nonverbal communication	Recognize that patients may struggle to understand your body language or tone of voice Respect a patient’s methods of nonverbal communication
Repetitive behaviors (self-stimulatory behaviors or “stimming”) - including hand-flapping, rocking, jumping, squealing, pacing, echoing, and obsessing	Recognize these behaviors as outlets for anxiety and energy Aim to thoughtfully provide an environment to minimize potential stressors Play soothing music during encounters, teach mindful breathing, reinforce appropriate behavior
Need for consistency Limited awareness of time Difficulties organizing	Help patients set up an alarm for when to take medication Link the act of taking medications to specific parts of their daily routine Help patient or caregiver set up pillbox or organize medications Provide worksheets or handouts that can be used to keep track of symptoms or concerns between visits
Adapted from: AASPIRE Healthcare Toolkit. Available at: http://autismandhealth.org/.

 

It is important to evaluate current practices in place in order to make positive improvements. In England, the perspectives of 40 families of children with ASD were gathered through a survey to gain a better understanding of their healthcare experiences.⁴ Families noted the need for healthcare providers to be more knowledgeable and trained about the heterogeneity of ASD, and to view families as allies in facilitating during patient encounters. Earlier this year, Children’s Hospital and Medical Center of Omaha launched a new program called PATCH (Patient Assistance Team at Children’s Hospital & Medical Center) that intends to do just that. PATCH creates a pathway that facilitates communication between parents of ASD-impacted patients and hospital staff. This helps ensure patient needs are clearly and efficiently identified and necessary modifications can be made to the care plan. Wouldn’t it be amazing if a similar program could be implemented at all medical centers!

When working with an unfamiliar patient population, we have an obligation to educate ourselves to best serve their needs. This can include finding appropriate resources (listed below), seeking opportunities to work with or volunteer with patients with ASD, and demonstrating an interest in developing the diversity of our patient care skills. In this way, we can take steps to minimize disparities experienced by patients with autism by improving their satisfaction with healthcare and increasing their self-efficacy.

The main character in the television program The Good Doctor is a physician with autism. One of the other characters on the show, fighting to save the main character’s job, wisely states, “Aren’t we judged by how we treat people? I don’t mean as doctors, I mean as people. Especially those who don’t have the same advantages that we have.” I think we can all agree that it is impossible for us to always understand how to best interact with patients, especially those with ASD. There are always opportunities for improving communication with the patient, family, and other providers to create environments that address their needs. While we shouldn’t treat patients differently based on their disease states or disabilities, we should adjust to their needs. It might not always be easy to interact with patients with autism, but as educators, we need to do our part to achieve the most positive experiences for our patients.

Select readings and resources about Autism Spectrum Disorder:

• Straus J, Coburn S, Maskell S, Pappagianopoulos J, Cantrell K. Medical Encounters for Youth With Autism Spectrum Disorder: A Comprehensive Review of Environmental Considerations and Interventions. Clin Med Insights Pediatr. 2019;13.
• “Autism related guidelines for healthcare providers.” Autism Speaks. Accessed 24 March 2020. https://www.autismspeaks.org/science-news/autism-related-guidelines-healthcare-providers
• “What is autism and how to get involved.” Autism Society. Accessed 22 March 2020. https://www.autism-society.org/
• “Autism news and resources: from autistic people, professionals, and parents.” Thinking person’s guide to autism. Accessed 24 March 2020. http://www.thinkingautismguide.com/
• “Caring for Children with Special Health Care Needs.” National Resource Center of Health and Safety in Child Care and Early Education. Accessed 24 March 2020. https://nrckids.org/CFOC/Special_Needs

References:

1. Autism spectrum disorder (ASD) Surveillance Summaries. Centers for Disease Control and Prevention. 2018; 67(6):1–23.
2. Nicolaidis C, Kripke CC, Raymaker D. Primary care for adults on the autism spectrum. Med Clin North Am 2014; 98(5): 1169–1191.
3. AASPIRE Healthcare Toolkit. AASPIRE. Accessed 23 March 2020. https://autismandhealth.org/
4. Kouo J. Seeking Patient-and Family-Centered Care: The Experiences of Families of Children with an Autism Spectrum Disorder. Autism Open Access 2020; 10: Article 247.

Developing Residents into Preceptors Using the Layered Learning Practice Model

by Brianna F. Waller, PharmD, PGY-1 Pharmacy Practice Resident, Baptist Memorial Hospital – North Mississippi

During their year-long commitment toward becoming a competent practitioner, many pharmacy residents (and other post-graduate trainees) will suddenly find themselves partially or fully responsible for someone else’s learning as a “preceptor." Although assuming this role may make some residents uneasy, the positive benefits of “near-peer” teachers and layered learning have been repeatedly discussed in secondary and higher education literature. Indeed, medical school students report they value and respond well to learning from near-peers due to their recent experience and relatability.  Near-peer teachers are not too far removed from the students’ “struggles” and experiences.¹ Let’s take a closer look at how this can be applied within pharmacy education.

Layered-Learning Practice Model
Senior educators work with advanced learners to teach junior leaners

A survey sent to all residency program directors (RPDs) of ASHP-accredited programs determined precepting opportunities for residents, identified barriers to developing precepting skills, and discovered opportunities to optimize programming. Among the 538 responses, the researcher found that 71% of residency programs did not offer a formal precepting rotation despite the fact that 59% of RPDs admitted their graduates frequently accepted positions that involved teaching / precepting.² Just as importantly, there is a serious shortage of pharmacy preceptors!  In another survey (n= 4,396) of pharmacists, 73% accepted an invitation to precept two or more students in the past year but almost half turned students away.³ This gap is a glaring opportunity for the layered learning practice model.  One of the benefits of this model is the fact that it increases the amount of time that attending pharmacists (aka senior preceptors) can spend focusing on their practice while allowing the resident to spend the most time supervising students and thereby gaining valuable precepting experience. Engaging residents in this role increases the number of people available to precept the growing number of student pharmacists without causing the workflow to suffer. Providing structured experiences for residents to precept students not only helps fill the gap, but they get feedback about their precepting skills before accepting post-residency positions that require them to teaching/precepting.

The layered learning practice model (LLPM) is a teaching strategy designed to train residents to precept students and, in some cases, more junior residents with oversight from a more experienced pharmacist. The four recommended steps to help all parties get the most out of the LLPM are orientation, pre-experience planning, implementation, and post-experience evaluation.⁴ I will use my own experiences with the Teaching & Learning Program during my PGY-1 program through the University of Mississippi School of Pharmacy (UMSOP) to illustrate concepts of the LLPM.

Let’s start by breaking down each component of the LLPM. Orientation to the LLPM is vital not only for the resident but also for the attending pharmacist. This helps outline goals, expectations, and responsibilities for each party, thus reducing the potential for overlap and confusion.⁴ In my own experience, this was extremely beneficial given the chaotic effect that COVID-19 seemed to have on nearly everything at the School of Pharmacy and the Medical Center. I had several meetings with faculty and staff regarding my role, a list of things I needed to accomplish, and, most importantly, how to use the tools to host virtual seminar meetings and IPPE rotation experiences. Typically, during the orientation the resident gets some feedback regarding his/her performance which can help build their confidence and independence.

Table 1: Typical Roles and Responsibilities in the LLPM

Primary Preceptor	Orient resident & student to layered learning practice model, practice site, and staff Create or obtain resident and student syllabus Outline trainee responsibilities Define the expectations of all learners Assist resident performance for clinical and teaching activities Evaluate resident performance for clinical and teaching activities Oversee all patient care activities and pharmacy education
Resident Preceptor	Discuss learning experience with preceptor prior to the first day Assist in the development of student calendar and rotation activities Orient student to practice site and establish goals Integrate student into patient care activities Supervise student during patient care activities Obtain any resources students need to perform required activities Provide regular feedback to students Lead topic discussions and other educational activities Evaluate the performance of the student and provide regular feedback
Student Learner	Report directly to the resident preceptor Actively participate in patient care and rotation activities Provide feedback on the layered learning practice model and resident performance as an experiential educator

Once everyone's roles (see Table 1) are established, pre-experience planning begins. The resident is involved by developing activities and materials for students to uses. Examples include developing calendars, rubrics, and activity descriptions.⁴ For me, I develop presentations and getting a once-in-a-lifetime opportunity to create a 4-hour IPPE experience on chart review & labs.  Because students were no longer allowed at our practice site due to the risk of COVID-19 exposure, I had to deliver this instruction using a videoconference tool. The LLPM process allowed enough structure for me to develop these activities independently, while also having the support of my preceptor when needed.

The implementation stage is relatively self-explanatory. The material prepared by the resident is delivered. The resident is considered the primary preceptor for the student(s), and depending on the activity, they are responsible for assigning them specific patient care duties, evaluating student performance, or providing feedback. The senior preceptor continues to be available and provides guidance to the resident. In longitudinal settings, such as precepting over the course of the month, the preceptor directly observes the resident periodically in order to assess progression.⁴ In situations such as delivering a presentation, it is important that the senior preceptor observe the session in order to provide constructive feedback to the resident, as was done in my case.

Finally, post-experience evaluation occurs whereby the primary preceptor solicits and provides feedback to resident(s) and student(s).⁴ An additional benefit is the identification of potential improvements that can be made within the LLPM at the institution, as well as the opportunity to solicit feedback from both layers of learners regarding their experiences and suggestions for improvement. One of the most helpful ways this was achieved in my own experience was by surveying the students in an effort to measure the effectiveness of my presentation, as well as obtain recommendations for improvement.  Afterward, I discussed this feedback in great detail with my preceptor.

More residency programs should adopt the layered learning practice model, as it appears to not only address the need for more preceptors but also affords the resident meaningful teaching experiences, and provides a more relatable role model for students. 

References

1. Lockspeiser T, O’Sullivan P, Teherani A, and Muller J. Understanding the experience of being taught by peers: the value of social and cognitive congruence. Adv Health Sci Educ 2006;13(3):361-372.
2. Dipaula BA, Mohammad RA, Ayers P, et al. Residents as preceptors and educators: What we can learn from a national survey to improve our residency programs. Curr Pharm Teach Learn 2018;10(1):21–7.
3. Skrabal MZ, Jones RM, Nemire RE, et al. National Survey of Volunteer Pharmacy Preceptors. Am J Pharm Educ 2008;72(5): Article 112.
4. Loy BM, Yang S, Moss JM et al. Application of the Layered Learning Practice Model in an Academic Medical Center. Hospital Pharm 2017; 52 (4): 266-272.