A Pharmacy Political Advocacy Elective Course

INTRODUCTION

Students of accredited doctor of pharmacy (PharmD) programs are expected to have some awareness and involvement in public health issues after graduation.¹ The Accreditation Council for Pharmaceutical Education (ACPE) accreditation standards require that pharmacy students understand the health care delivery system in the United States, including the factors that may influence this care.² These standards require that pharmacy students learn pharmacy law and regulatory issues, but not necessarily how to change them. Pharmacy students also should understand how their involvement with pharmacy organizations potentially could affect regulatory and legislative issues. Most importantly, pharmacy students should be aware of the current and future roles of pharmacists as part of the health care team and the effect of health care reform on this role. The Joint Commission of Pharmacy Practitioners has clearly stated that by 2015, “Pharmacists will be the health care professionals responsible for providing patient care that ensures optimal medication therapy outcomes.”³ Although this is explicitly stated, pharmacists will need to advocate for this expanded role in order to make it happen. Based on this, the American Association of Colleges of Pharmacy (AACP) has proposed that students learn more skills in leadership and advocacy as part of the AACP Curricular Change Summit.⁴

Little information is available in the literature regarding the incorporation of pharmacy advocacy into the curriculum.^5,6 A policy analysis project in a required Pharmacy Law and Ethics course taught basic law to pharmacy students and allowed them to propose changes in state laws to the state board of pharmacy.⁵ However, this was a project within a required law course rather than an entire course devoted to pharmacy advocacy. As a result of a leadership and advocacy elective at the University of Maryland in collaboration with Virginia Commonwealth University intended “to develop doctor of pharmacy students’ leadership and political advocacy,”⁶ students and faculty members became more involved in advocating for the pharmacy profession. However, this course focused on developing leadership skills in an effort to create future leaders rather than promoting pharmacy advocacy in average pharmacy students who may not be interested in leadership positions.

A review of the South Carolina College of Pharmacy (SCCP) curriculum and discussion with course coordinators determined that minimal time was devoted to discussing current legislation that could affect the pharmacy profession or methods to affect this legislation. Periodic updates were given during the Health Care Systems and Management course, which is offered in the fall semester of the third year. Approximately 2 hours were devoted to advocacy but only as it related to Medicaid and Medicare. Student organizations minimally exposed students to the advocacy efforts of pharmacy organizations. Additionally, the newly integrated SCCP increased the requirement for electives to 8 hours. Because the previous curricula for the Medical University of South Carolina (MUSC) and the University of South Carolina College of Pharmacy required fewer elective hours, faculty members were requested to develop more elective courses. To meet this demand and to increase student exposure to legislation and advocacy, the Pharmacy Political Advocacy elective was created.

DESIGN

The Pharmacy Political Advocacy elective was offered initially to second- and third-year pharmacy students in the spring semester of 2008. Due to time constraints and room availability, however, the course was limited to second-year students. At this point in the curriculum, second-year pharmacy students had completed mostly basic science courses and an Introduction to Drug Information and Self-Care and Complementary Medicines course. During the same semester as the elective, students began their first pharmacotherapy course and an outcomes course. As the elective did not require a strong knowledge of clinical sciences, faculty members felt it was appropriate for all student levels. The 2 credit-hour elective met for 2 hours 1 day a week. The goal of the course was to increase pharmacy students’ awareness of and involvement in legislative issues affecting the pharmacy profession and/or healthcare by providing various ways for them to become advocates and influence legislative decisions. Students were required to actively participate in class discussions and work with their peers to present various assignments related to advocacy and legislation. In addition, students learned how to identify their legislators and any legislation that may pertain to the pharmacy profession, and then determine methods to support the legislation or recommend revisions that would make the legislation more amenable to the practice of pharmacy. The objectives for the course are listed in Table 1 and were designed using all levels of Bloom's Taxonomy in order to provide students with basic knowledge of political advocacy and then have them use that information to advocate for the pharmacy profession.⁷

The elective convened during spring semester 2008 to coincide with the session of the South Carolina Legislature. Because the SCCP-Columbia campus is located 2 blocks from the state house, students had easy access to state legislators, 3 of whom were pharmacists. Columbia also is a central location for many state-based health care organizations, increasing the availability of guest speakers who advocate for pharmacy and other health professionals. Because of the interactive nature of the course, the elective was offered only at the Columbia campus and not by distance technology to the college's other campus.

The initial class session included an orientation to the course and an overview of the legislative process, highlighting the points in the process at which the greatest impact on a specific bill could be made by a citizen, advocate, or lobbyist. Additional class sessions consisted of either a topic discussion or a facilitated discussion by an invited guest. Guest speakers were selected based on their current role in creating or influencing pharmacy legislation or regulatory issues. Table 2 shows the variety of speakers who have participated in the course over the past few years. Optimally, guest speakers with varying opinions on current issues were recruited to expose students to diverse views and encourage them to form more objective positions on topics. The diversity of content allowed students to learn about the process of passing legislation and developing policy statements for pharmacy organizations, as well as to debate current legislation. Students toured the South Carolina State House to learn more about the legislative process. When possible, students were invited to attend subcommittee meetings in which pharmacy legislation was discussed. Feedback from students in the first course offering led to a requirement in subsequent course offerings for students to either attend the House of Delegates meeting for the South Carolina Pharmacy Association or watch the archived video of the most recent South Carolina Board of Pharmacy meeting. The remaining class sessions focused on discussions of current issues and student assignments facilitated by the course coordinator.

The first offering of this class occurred in spring 2008, during the presidential primaries, which provided a great opportunity to talk about each candidate's platform for health care reform. Students enrolled in subsequent semesters were able to review the development of the Patient Protection and Affordable Care Act and the implications of this legislation for pharmacists. Additionally, in some offerings of the course, students were required to present summaries of how specific pharmacy organizations advocated for the pharmacy profession, not only for health care reform, but also for other important issues. Because USC is a state-funded institution and requires faculty members to prevent their personal political beliefs from influencing students and other employees, great effort was taken to present multiple sides of each issue, remain objective, and limit political bias. A disclaimer for this objectivity was not specifically described in the syllabus but was mentioned verbally throughout the semester.

Multiple activities were assessed throughout the semester to calculate the final grade. Although the weight assigned to each activity changed as the course evolved, the components of the final grade remained the same (Table 3). To promote active engagement with guest speakers and faculty members, students were required to interact and be involved in discussions and were assigned a grade for class participation. Students also researched controversial topics in the pharmacy profession and engaged in debates with classmates (eg, creation of a separate class of behind-the-counter medications, the pharmacist's right to refuse, and allowing direct-to-consumer advertising of prescription drugs.

Halfway through the semester, students completed a midpoint examination. As the examination assessed the applicability of knowledge learned in the class, students were given 2 to 3 weeks to return the examination. The students were required to provide detailed responses to the questions and to reference the source used for each answer. Questions varied in complexity from students determining the specific legislators for the district in which they lived based on their zip code, to preparing a response to a legislator in support of or opposition to a current controversial topic. Students also were required to research other issues that might not have been discussed in class and to provide a summary of the issue and reflect on the possible outcomes associated with it. The examination assessed skills the students would need in the future to research various issues and then advocate for or against them.

The final assignment for the course was preparation of a legislative presentation. For the most part, students worked in teams of 2 to complete the assignment. Based on trial and error, the presentation assignment changed over the years. In the first offering of the course, students reviewed the health care reform platforms of 1 of the top 2 Republican and Democratic presidential candidates. The next year, student teams were required to contact the office of a US senator or representative to prepare presentations to determine the legislator's support of or opposition to the health care reform proposal submitted by the president of the United States as well as potential changes the legislator would recommend for the proposal. The presentation assignment also was required in the third offering of the course in 2010, but changed considerably. Students paired up to summarize the legislative process along with several state and national legislative and regulatory issues that would affect the pharmacy profession, including the Patient Protection and Affordable Care Act. The students then combined their work into a single presentation to present to other students in the pharmacy program at a monthly meeting of the Academy of Student Pharmacists and the Student Society of Health-System Pharmacists. This allowed the students enrolled in the elective course to share their newly gained knowledge in the hope of increasing awareness among and future involvement of other students in advocating for the pharmacy profession.

EVALUATION AND ASSESSMENT

Forty-eight students completed the Pharmacy Political Advocacy elective from 2008 to 2010. Enrollment increased from 9 students in the first course offering to 20 in the third course offering. For the first 2 offerings, the elective was designated as a pass/fail course; however, based on student comments, it was changed to a graded course in 2010.

Grading rubrics were used to assess class participation, debates, and legislative presentations (Appendix 1 and Appendix 2), and students performed well on all assignments. Point values were assigned to each question of the take-home examination, with a maximum possible score of 50 points. The average cumulative score for the examination was 96.9% with a range of 80% to 100%, demonstrating the applicability of knowledge gained from the course.

DISCUSSION

Although some changes were made to the course over the 3 years since its creation, the overall goal of the course remained the same and appears to have been accomplished based on student responses. Once the course has been planned for the semester, little additional work is required of the coordinator except to remain aware of current issues and ensure guest speakers will be available. During the first offering, the coordinator prepared numerous lectures for the course, including a review of the advocacy agendas for several pharmacy organizations. However, the students lost attention easily and did not retain the material taught in the lectures. As a result, responsibility for course learning has been transferred to the students so that the coordinator only has to prepare 2 didactic lectures. Assuming more responsibility for their learning encourages active participation by students throughout the semester and minimizes faculty workload. Although fewer lectures have to be prepared, the coordinator still facilitates class discussions and debates and therefore must remain current on many regulatory and legislative topics.

Although students were given the opportunity to advocate for a specific issue in writing on the midterm examination, they were not required to do so as part of the class. Future offerings of the course may give students the opportunity to practice advocacy rather than just write about it. Caution will need to be used to ensure that the advocacy activity is not perceived as a reflection of the college's position. Additionally, other forms of advocacy will be addressed, including advocating for patient safety and improvement in quality of care. More attention also will be focused on regulatory issues and reasons why pharmacists are not actively involved in political advocacy.

The location of colleges and schools of pharmacy in reference to their state's capitol should not deter them from offering a political advocacy course. Although the location of the SCCP-Columbia campus in the state capitol and near the State House is fortuitous and enhanced this elective, few students actually have been able to attend a committee or subcommittee meeting involving the pharmacy profession because these meetings tend to occur during scheduled class time for required courses. Also, while many pharmacy and health care organizations are located in state capitols, their leaders often are practicing pharmacists/health care professionals who live and work outside of the capitol. For this elective course, several state and organizational leaders drove more than 2 hours to campus to speak to the students. All guest speakers expressed gratitude for the invitation to speak to the students due to a desire to increase student and new practitioner involvement in pharmacy organizations. Although student attendance at a meeting in which legislative issues were discussed was required, students unable to physically attend a meeting have been able to accomplish this virtually as the South Carolina Board of Pharmacy video records their meetings and streams them on the Internet. Students also had the opportunity to travel to other state pharmacy meetings not located in the capitol city.

Although law and regulatory issues already are addressed in required courses, the process of advocating for these laws and issues is not as prominent in the curriculum. Only a small number of students have completed the Pharmacy Political Advocacy elective compared to the number of students who have matriculated through the SCCP–Columbia campus. It would be ideal to begin incorporating more components of advocacy into the required law course. Lack of health policy education is not limited to the pharmacy profession. Delivery of health policy education also varies greatly among US medical schools and many have identified this as an area in which they must improve.⁸

While students’ grades and responses suggest that the elective did increase student awareness of pharmacy-related legislation and promote advocacy for the profession, additional research is needed to measure the lasting impact of this elective. The impact that this elective and various other advocacy activities have on increasing new practitioner involvement in the South Carolina Pharmacy Association is focus of another study.

CONCLUSION

Involvement in a Pharmacy Political Advocacy elective increased students’ awareness and knowledge of legislation that might affect the pharmacy profession. Students also demonstrated an increased knowledge of how to advocate for the pharmacy profession. As these students will be the future leaders of our profession, their interest in becoming more involved in pharmacy organizations in the future is encouraging. Colleges and schools of pharmacy could incorporate courses similar to this elective to promote advocacy for the profession.