Lauren Jonkman

Diversity, Equity, and Inclusion in Pharmacy Education: Population Health Required Course

About the Program

The population health course is required for third year professional students. The course is 6 weeks long (i.e. the first half of the semester) and uses a flipped classroom model and team-based learning to allow for more application of the material.  Students have pre-class work (lectures, videos, readings) that pull from diverse perspectives and then, in class are held responsible for the pre-class work through individual readiness assessments (quizzes) and team readiness assessments.  The purpose of the team readiness assessment is to build team collaboration and some team teaching.  Students receive immediate feedback on their readiness assessments and I can provide mini-lessons for content that wasn’t clear.  The bulk of the class time now focuses on team application exercises. 

The teams (5 or 6 students) work together to discuss cases and scenarios that are based on actual situations, and intentionally address a variety of perspectives.  After the teams come to consensus, we discuss the scenarios as a large class allowing students to share their smaller discussions. 

Active Learning Strategies

Beyond the primary team-based learning structure, the course has 2 major active learning practical into the class. 

Poverty Simulation
The first activity is a poverty simulation that is structured similarly to the old board game “PayDay.”  Each student is assigned a scenario of a family living in poverty – all scenarios are based roughly on actual families that I have cared for as a clinical pharmacist at the Birmingham Free Clinic and other safety net settings in Pittsburgh.  The scenarios and the activity overall are designed to incorporate situations that push students to consider the effectiveness (or more honestly, the failure) of the safety net in protecting families with incomes under 250% of the Federal Poverty Limit from homelessness, food insecurity, and medical indebtedness.  Further, the activity is designed to give students insight into the difficulty of implementing health change in the midst of so many other stressors.  The families represent the diversity of Pittsburgh including folks who are immigrants.  After the simulation, students are asked to reflect on the activity.  During the past 2 years, students were also pushed to consider the impact on COVID19 on their particular family – i.e would employment be secure? If not, what would be the impact on the family?  How is childcare impacted if the schools close? What would happen if one of the family members got sick?  Student reflections showed that they were able to connect the dots.

Medicine Practicum
The second active learning activity that I expanded and rebranded is an inclusion medicine practicum. In past years, I called this activity a cultural competence practicum, but I wanted to highlight that the need for cultural competence is more than just caring for people from different backgrounds, but instead requires us to consider the ways in which people are engaged in their healthcare and what roles we have as health care providers in motivating or demotivating change.  Last year was the first year that I was able to implement this practicum as a “standardized patient” experience.  True standardized patients (SPs) are actors who receive information about a case and can role play the scenario in the same way many times.  Unfortunately, the SPs that are available through the School of Medicine are not particularly diverse.  Opportunity for students to work with transmen or transwomen, or for students to work with non-English speakers is limited if using trained SPs.  To address this, I worked with faculty, friends, alums, and graduate students to create a more inclusive panel of SPs.  Students worked in small groups with an SP and facilitator to practice health behavior motivation and assessment, inclusive patient engagement and interviewing, navigation of health beliefs and cultural practices, and the use of medical interpreters.  I was surprised of the number of students who wrote in their reflections that they had not seen any other cases that were similar to these, and that they were challenged to apply their clinical knowledge to these new situations. 

Program Reach

This course is offered as a required course every fall for third-year professional pharmacy students. The general cohort size in our Pharm.D. program is 115.

Program Implementation & Resources

The population health course has been a requirement for students at the University of Pittsburgh School of Pharmacy for a number of years. In 2019, as the course coordinator, I made a renewed effort to integrate social justice and health equity more clearly into the course.  In 2021, after spending the summer of 2020 reflecting on our roles in the academy as implicitly promoting racism (or at least not fully embracing anti-racism), I made even more explicit changes to the curriculum.  I was particularly motivated to more clearly and explicitly make the connection between my content and social justice and equity after being invited to a discussion in the summer with several passionate alumni who asked our Dean to make intentional changes in the curriculum in the wake of George Floyd murder, civil rights protests, and the inequities made even more apparent from the COVID19 pandemic. I felt called to do more and be clearer to ensure that all students had the knowledge and skills to identify, call out, and address inequities.  In this most recent iteration, I have made many changes to improve the course to focus more explicitly on equity, justice, and inclusion. 

 As noted previously, the course uses a flipped classroom and team-based learning approach. In addition to foundational content on population health, I added new content specifically focusing on 1) racism as a determinant of health and as a factor influencing our health care system on many levels, and 2) structural violence and structural competency that can be used as a framework for identifying and then dismantling structures that contribute to poor and unequal health outcomes.

Program Assessment

The poverty simulation has been evaluated using the Attitudes Towards Poverty scale.  Students had statistically significant improvements in all domains of the tool before and after participating in the activity.  Reflection notes are included above.

 Overall feedback for the course identifies the value of the activities in the student's ability to recognize and act on social determinants of health and structural factors related to poor health outcomes.  

Program Feedback

Student feedback on this course has shown a deep understanding and appreciation for the content. A few reflections from student participants are below.

Specific to Poverty Simulation, student reflections include:

“This experience has undoubtedly allowed me to gain a whole new understanding of what it means to be empathetic.  Having had some experience working with patients who struggle to afford their medications at [a faculty member's ambulatory care clinic], I always felt bad for the patients when they told me about how expensive their medications were. I would do my best to help them through supplying them with free samples to make it to their next payday or signing them up for patient assistance programs.  Most of them would thank me profusely for helping them, some to the point of nearly breaking down in tears. At the time, I was not fully able to understand why a few free insulin pens or an application to patient assistance program could be, but now I do. These patients know that their medications are what keep them from potentially declining in health and being admitted to the hospital, which is an expense that these patients cannot afford.  Knowing how important these seemingly simple acts are to these patients ensures that I will continue to look for any and all alternatives that will allow my future patients to gain access to the medications that they are struggling to afford.

“I will use the lessons I learned in the simulation when performing patient counseling and interviews. I hope to add to my normal questions certain screening of financial situation so that, if needed, I can provide information on available resources which my patients would be able to take advantage of. By providing this additional care, I can work to limit disparities in their care and promote better health outcomes regardless of finances.”

“At the end of the day, me going the extra mile for a patient and treating them with the respect that they deserve may be the best thing that happens to them all month.”

Specific to the Medicine Practicum, student reflections include:

“We have to remember that we as healthcare providers are the patient’s bridge to understanding their medications and we must take the time to fully understand the patient’s trials and tribulations in order to help them. In doing so, we allow the patient to tell us what is important to them which allows to tailor our modifications/recommendations to suit their needs.”

“This activity was a good reminder that trans folks are nuanced individuals who seek care for a variety of reasons unrelated to dysphoria or HRT.”

“The most important take-away point I learned from this activity stemmed from my realization that what we say to patients is often meaningless if we don’t pay attention to how we say it. All too often, important messages are misconstrued or misinterpreted because of actions of the healthcare provider.”

“To bring this long-winded story full circle, my main takeaway from this experience was its reality. So many of the exercises we do in pharmacy school feel like practicing on a tape keyboard. Fine, but not effective in preparing us for the challenges ahead when confronting the sickest, most vulnerable members of society.”

Closing Advice

Our communities, patients, and students all need for us as pharmacy educators to level-up in our acknowledgement of the structural causes of health inequities.  By incorporating structural perspectives and focusing on strategies for engaging with people in a contextually-mindful manner, pharmacy-educators can prepare students for a world in which pragmatic solutions can enhance patient care and patient outcomes.  

About the Author

Lauren Jonkman, PharmD, MPH is an Assistant Professor at the University of Pittsburgh School of Pharmacy.  She serves as the Coordinator of International Pharmacy Student Experiences, co-director of the Area of Concentration in Global Health, and co-director of the Global Health track within the PGY2 Ambulatory Care Residency Program.

 Dr. Jonkman mentors trainees on research and practice in limited resource settings globally.  She is passionate about addressing the structures that influence access to and quality of health care for marginalized populations both locally and globally. Specifically, her goal is to advance the role of pharmacists to provide care for non-communicable diseases in limited resource settings globally.

In Pittsburgh, Dr. Jonkman serves as a core clinician at the Birmingham Free Clinic providing direct care and teaching for pharmacy and medical trainees. Outside of the United States, she provides clinical support and teaching at the University of Namibia where she served as a Fulbright Scholar in 2018.  She continues to work with UNAM to build clinical pharmacy services in Namibia, holding a Visiting Professor appointment.  She also supports formulary/inventory management, clinical practice development, and research with Shoulder to Shoulder Pittsburgh-San Jose (Honduras), a non-governmental organization working in rural Honduras.

She is a 2016 recipient of the University of Pittsburgh Chancellor’s Distinguished Public Service Award, the 2020 recipient of the Renee T. Holder Award for Global Health Practice from ACCP, the 2021 recipient of the AACP Global Education Program Award, and a 2021 recipient of the University of Pittsburgh Provost’s Award for Diversity in the Classroom.