Advocating for Patient Care Literacy

• patient care literacy
• humanities
• arts
• educated

During the past few years, I have had the opportunity to develop and teach a health humanities course in the undergraduate honors program. As part of my learning, I have been able to attend health humanities consortium conferences involving faculty members from disciplines outside of pharmacy. As I have developed my scholarship in this area, I have investigated the value of the humanities as it relates to an educated health care professional.¹ Pharmacy academics acknowledge the need for literacy in terms of scientific literacy, health literacy or information technology literacy. These literacy trends have served as frameworks for redesigning professional curriculums. Kim and colleagues advocated that the term health literacy should also be focused on patient-provider communication and cultural competence (ie, a more interactive literacy).² There also needs to be an understanding of how to navigate health care systems, and how to interpret health information via media, including the internet. To provide the best possible patient care, there needs to be the acquisition of key skills and what I termed as “patient care literacy.”

Patient care literacy is the ability to provide care using interpersonal skills of self-awareness to relate to others empathy, patient-centered care attitudes, and culturally competent communication. Patient care literacy is also the ability to assist patients with navigating the health care system, making informed health care decisions, and using health information available via media, including the internet. Patient care literacy goes beyond counseling and requires a high level of communication skills.

To advocate for patient care literacy, a conceptual framework for curriculum reform that focuses on using the arts and humanities is proposed. Kahn and Zeidler mentioned the use of not only “Heads but also HARTSS” (humanities, arts, and social sciences in science education).³ The arts are generally considered the creative ones like drawing, music, painting, photography, dancing, acting, and performing. The humanities include literature, philosophy, religion, history, language, and communication and cultural studies. The social sciences include psychology, sociology, anthropology, political sciences and economics. The metaphor of a heart is a very appropriate model. The focus on the affective domains while also integrating varied scientific disciplines pumps life into training for a competent pharmacy professional. Kahn provides numerous examples of using this conceptual framework for developing perspective and socio-scientific reasoning that is practical for pharmacy curriculums. To be a patient care literate pharmacist, one needs to apply the scientific knowledge along with interpersonal skills to care for patients. To be a more humane pharmacist, one must be “educated.” This implies that it is not only about learning the sciences nor the technical and clinical aspects. It is experiencing and learning about the values of the arts and humanities. If it was just about scientific knowledge then pharmacy education would be merely training.

Macnaughton discussed the instrumental and non-instrumental value of arts and humanities in a professional health education.⁴ The instrumental role of the humanities is in developing communication skills, skills of argument and analysis, and interpersonal skills of empathy, self-awareness, ability to relate to others, and ethical thinking. Literature is a source of case histories and experiences. Literature stimulates our imaginations and enhances our relatedness to the characters. Drama teaches about communication between people including verbal and non-verbal. Paintings express non-verbal ways for feelings or attitudes. History teaches the importance of evidence and how it can be manipulated by others and how knowledge changes over time. Philosophy helps to organize thoughts, construct an argument and reach a logical conclusion. Learning about the sociocultural issues of health care could be achieved through HARTSS. This is described as a means to an end.

Arts and humanities can serve other instrumental purposes in a professional health curriculum. There is evidence that supports use of arts-based teaching tools and visual thinking strategies to enhance clinical observation skills.⁵ Observation skills help to develop attention, self-awareness and empathy. Examples of elements in a curriculum that can develop these skills include use of photography exercises where students take photos documenting details in their routines; observing arts used to describe what was seen; visiting museums; and training in mindfulness; use of poetry to learn to be more observant and to describe findings with greater precision; and use of reflective writing to describe observations. Students need to learn to see with an open mind. They must practice describing what they see to improve communication skills. Jones discussed the need to teach students by developing reading skills.⁶ She discussed how reading helps students tolerate ambiguity. Reading also helps to develop personal reflections about moral values. Literature helps students to develop openness, curiosity, and empathy.⁶ It helps the interpersonal skills for patient care. It can help teach cultural competence. Teagarden described how the humanities can help pharmacy students develop more meaning with a patient’s illness experiences.⁷

However, the arts and humanities have non-instrumental value as well. They have intrinsic value and are essential for being “educated.” There is overlap between the instrumental and non-instrumental role. For example, learning about the human condition may develop empathy but is also helpful in learning about life in general. To be educated implies developing a broad open perspective, which is different from the narrow focus of professional training. To be educated is a process. Peters states “to be educated is not to have arrived; it is to travel with a different view.”⁴ Philip Hansten, in his book, Premature Factulation. The Ignorance of Certainty and the Ghost of Montaigne, advocated for reading good literature for enjoyment and philosophy, which offers more wisdom than all of the self-help books.⁸ The educational process should be valuable as an end in itself. Using arts and humanities can allow professionals to reflect on different ways of viewing the world. Arts and humanities also helps in developing and defining the kind of person one becomes. It develops self-awareness of one’s own biases and prejudices.

Arts and humanities help develop interpersonal relationships with others from different disciplines which is one of the core competencies for interprofessional education (IPE) and is often viewed as working with people from different health professions only. As pharmacists, we need to be able to work with different types of people and not just with those in our limited sphere of influence. Enhancing collaborations across disciplines, including arts and humanities, can be part of IPE endeavors for learning to work in teams. There is clear data that integration enhances student learning and mastery of content.³ Teaching in the professional curriculum should not silo subjects nor disciplines.

The other major benefit of arts and humanities is personal development and empowering people to desire health and well-being. There is plenty of literature describing the positive effects on health and well-being of creative arts.^9,10 These well-being outcomes vary from self-efficacy, creativity, subjective, psychological and physical well-being and may strengthen character, values, civic engagement and morality. Music engagement has been shown to decrease anxiety.⁹ Visual arts have been shown to provide benefits of creative expression for healing and wellness and improvements in depression.⁹ Dance has been shown to improve cognitive and psychological well-being.⁹ Expressive writing, including poetry, improves physical health and depression.⁹

Enhancing use of arts and humanities in pharmacy education is advocated. There are many ways that this could be addressed for graduating pharmacists (Table 1). Some of these methods are easier to implement than others. There are advantages and disadvantages to each. One method is by examining the pre-professional requirements for entering pharmacy school. The range of options vary from requiring a bachelor degree or a minimum of three years of pre-pharmacy to changing the pre-pharmacy requirements by creating a health humanities track. Vanderbilt University offers a minor in medicine, health and society, which can be an optional pre-medicine track.¹¹

In the pharmacy professional program, there are numerous ways to enhance patient care literacy with use of HARTSS. A method that may be easier to implement is through use of co-curricular activities, such as a book or movie club where students could voluntarily meet to discuss pertinent human sides of patient care. If one wants to expand the development to all students then implementing mandatory sessions where students are required to read short readings and then meet in groups to discuss can be an option. Another option is to require students to choose at least one humanities course prior to their graduation that could address a variety of issues.

A more feasible method is to enhance curricular integrations of HARTSS in the professional curriculum. Using either existing courses or through the creation of personal and professional development longitudinal courses in the first three years of the curriculum, many examples of integration of HARTSS could be implemented (Table 2). For example, requiring a book club for each of the first three years on key topics that relate to some aspect of the professional curriculum could be implemented. When introducing patient care concepts, having students look at the perspectives of side effects of drug from the medical side versus a prose from the patient’s experience could be discussed. Patients with specific illnesses could be brought into various classes to stimulate discussion on aspects of illness versus diseases. When discussing the socio-economic cultural perspectives of health, the board game, Last Straw Game could be played in groups.¹² Examples of how art, photography, writing and dancing are used for patients dealing with severe illnesses could be provided. The readings of poetry from the Health Humanities Reader and other sources could be used to emphasize patient-centered attitudes.^13,14 Various films could be used in courses to visually illustrate patient experiences and to develop empathy.

While we are moving toward a greater focus on humanistic concerns, there is a need for more empiric analytical methods to demonstrate the value of the arts and humanities. There is even less data supporting the empiric evidence of impact of the new health humanities programs on developing specific measurable competencies including skills, knowledge and attitudes.^15,16 There is a need for robust research that demonstrates the value of arts and humanities on developing a patient care literate professional. The assessment tools used to assess the impact should have psychometric properties of reliability and validity.¹⁷ Tay and colleagues proposed a conceptual model for developing empirical evidence on the role of the arts and humanities in human well-being.¹⁰ Both quantitative and qualitative methods should be used. We do not yet know whether students who have increased exposure to arts and humanities will make better health care providers.^15,17 However, surrogate markers for impact of arts and humanities can be studied and measured. For example effects on empathy, self-awareness, ability to relate to others, patient-centered attitudes and communication can be empirically studied.

In conclusion, I am advocating for a new curricular framework for pharmacy that develops patient care literacy. I am reminded about the early 90s when Hepler and Strand coined the concept of pharmaceutical care. The concept resulted in academic pharmacy re-examining its curriculum and the vision for pharmacy education including the Center for the Advancement of Pharmaceutical Education (CAPE) outcomes. However, even then the focus of the profession was too narrow as eloquently stated by Margaret Chrymko in the reactor panel in the invitational conference conducted by the American Society of Hospital Pharmacists on implementing pharmaceutical care in l993.¹⁸ Chrymko advocated that the focus should be patient care and not strictly emphasize pharmaceutical.

• Received November 20, 2017.
• Accepted December 5, 2017.

• © 2018 American Association of Colleges of Pharmacy