A Call to Action for Cultural Humility in Pharmacy Education Student Assessments

INTRODUCTION

In pharmacy education, conversations in recent years have focused on diversity and inclusion within methods of pedagogy and assessment. Considering the social and racial injustices in the United States, pharmacy organizations have joined the conversation about diversity, inclusion, and equity in the profession and pharmacy curricula. On June 5, 2020, 14 national pharmacy organizations, including the American Association of Colleges of Pharmacy (AACP), issued a joint statement on the need to address racism and discrimination and to take action to promote social justice and address diversity, equity, and inclusion within pharmacy and pharmacy education.¹ As an organization, AACP values inclusiveness and developed the Equity, Diversity, and Inclusion Institute to promote the advancement of these elements at AACP member institutions. The Accreditation Council for Pharmacy Education (ACPE) appointed an Equity, Diversity and Inclusion Subcommittee to its Board of Directors with the goal of updating the Guidance for Standards 2016 with regard to equity, diversity, and inclusion.² As the profession focuses attention on these important areas, pharmacy educators are encouraged to reflect on what is called the “silent curriculum” and how unconscious bias may influence students’ thoughts, feelings, and actions.³ Unconscious bias describes associations or attitudes that reflexively alter our perceptions, thereby affecting behavior, interactions, and decision-making.⁴

At times, well-intentioned educators may introduce bias into their teachings and assessments by focusing on diseases that have a higher prevalence in minorities without engaging in conversations about why these health disparities may exist or examining them in the context of social determinants of health.³ Disregarding these critical components of the conversation may lead students to an unconscious impression that certain diseases may always impact certain groups and subgroups more than others. This type of unconscious bias may also influence quality of care (among other factors).

The ACPE Standards include the need for pharmacy students to demonstrate cultural awareness and sensitivity.² While curricula are reviewed to ensure they are inclusive of cultural competency, to date, assessment tools, including multiple choice examinations, clinical presentations, and objective structured clinical examinations (OSCEs) have not been subjected to the same scrutiny. Research in the area of unconscious bias in medical education assessment tools is limited and almost none exists within pharmacy education.⁵ While pharmacy and other health care educators are aware of how teaching can lead to unconscious bias, the question remains as to whether student assessments lead to unconscious bias. Previous research has illustrated that unconscious bias exists in medical school assessment tools, but whether it exists in pharmacy assessments remains unknown. Therefore, it is worthy of further exploration with the goal of ensuring culturally sensitive pharmacy assessment tools.

Cultural humility in health care has been defined as a “process of being aware of how people’s culture can impact their health behaviors and in turn using this awareness to cultivate sensitive approaches in treating patients.”⁶ Frameworks to integrate cultural humility into curricula have been described but have yet to be implemented and evaluated. Rockich-Winston and Wyatt described the essential elements of teaching using a blended model of cultural humility and cultural competency called culturally responsive teaching; however, literature on cultural humility in pharmacy assessment is lacking.⁷

An important concern in health care is the disparities associated with certain diseases. These distributions may be attributable to socioeconomic factors, and teaching should be focused on these factors that could be contributing to the disparities. Although the contributions of socioeconomic variables to disease etiology and progression have been acknowledged, the possibility of implicit bias in clinical practice must also be considered. For health care educators, this raises questions about how best to teach about diseases with genetic predispositions and/or greater incidences in certain racial or ethnic groups and how to construct assessment tools that are unbiased in their inclusion of race and ethnicity. This question is especially important when considering assessment tools with multiple-choice questions.

The research examined thus far on unconscious bias focuses on curricula, and very little has examined assessment. A study by Ripp and Braun analyzed a bank of questions used by medical students in preparation for the United States Medical Licensing Examination (USMLE).⁵ The study reviewed 2,211 questions purchased from a review test bank for the USMLE, identified questions that referred to race/ethnicity (n=455, 20.6%), quantified the number of mentions of race/ethnicity (n=474), and categorized those mentions as either descriptive (86.9%) or central (20.6%) to the case. An analysis of the 455 questions that mentioned race/ethnicity revealed that for almost all vignettes (90.5%), race/ethnicity was simply a demographic descriptor with no central relevance to case content. In addition, when comparing questions by ethnicity, questions mentioning Whites/Caucasians were distributed across the bank at a significantly higher rate than other ethnicities/races (p>.001) at a rate disproportionate to the US population: 85.8% of the questions referred to patients who were White/Caucasian, 9.7% to Black/African American, 3.16% to Asian, 0.633% to Hispanic, and 0.633% to Native American. Whether the use of race was descriptive or central to the case varied considerably. For the questions describing Black/African American patients, only one of the three most common diseases included in the cases (sickle cell) was correlated to genetics, while the other two conditions (coronary heart disease and hypertension) were not related to genetics but rather to environmental and lifestyle factors.⁵ Consistently linking one race to a specific disease may lead students to exclude that diagnosis when assessing their other patients. For example, although sickle cell disease may be common in African Americans, it may need to be considered in other races and ethnicities as well. Based on these findings, the authors of the study theorized that the routine use of race/ethnicity for no specific reason when preparing materials, such as question banks, risks contributing to racial bias. To avoid this, Ripp and Braun suggest that patient characteristics, particularly race and ethnicity, that are included in test item vignettes should reflect the national racial distribution or be excluded if they are not central to the question.⁵

Additionally, a study by Nawaz and Brett attempted to determine whether US medical students were being taught to mention race at the beginning of case presentations.⁹ The authors surveyed 122 medical schools and 104 responded (85% response rate). While 11% of the schools explicitly taught students to mention race at the beginning of case presentations and 63% selectively taught students to include race in the first sentence, only 9% of schools discouraged this practice. In addition, students claimed that physicians regularly mentioned race at the start of their presentations during clinical rounds.⁹ Clinical presentations are also a part of pharmacy education, both in the didactic and experiential settings. If students are encouraged to routinely include race when presenting a patient’s case even when race is not central to the case, this practice may lead to unconscious bias.⁹

To date, research on unconscious bias in assessments has been limited to medical education, and there has been no focus on investigating unconscious bias in pharmacy assessment tools. As assessment tools evolve in consideration of cultural humility, pharmacy educators should begin to evaluate their test items and explore their own practices for writing test items and whether those practices may be leading to unconscious bias.

While medical educators are reviewing their assessments for cultural humility, pharmacy educators should also be examining their assessment tools to ensure they are yielding their intended purposes. For example, if every question item on the topic of sexually transmitted infections (STI) begins with the opening sentence, “An African American male with a history of STI…,” it could lead students to believe STIs are infections that predominately occur in African American males, thus adding to unconscious systemic racism. Educators should consider following the item writing guidelines issued by the National Board of Medical Examiners.¹⁰

The recommendation is that race and/or ethnicity be defined by the patient and not the provider, included when relevant, and not necessarily placed in the opening sentence.¹⁰ In item creation, patient characteristics should be included in the vignettes if they add to the understanding of the case and should never contain negative stereotypes.¹⁰ We are not suggesting that race be removed from all vignettes, but rather the vignette should describe the patient self-reporting their race to the provider or that the patient’s race only be included in the vignette when clinically relevant.¹⁰