Taking Action Towards Equity, Diversity, and Inclusion in the Pharmacy Curriculum and Continuing Professional Development

Current State of DEIA in Academic Pharmacy

As a primary consequence of overt racial inequities in health care and access to necessary health services prior and during the COVID-19 pandemic, many colleges of pharmacy recognized a need to further integrate cultural competence, implicit bias, and related topics into their curriculum.^4,5 This has also been recognized by the Accreditation Council for Pharmacy Education (ACPE) in standard 3.5, designating cultural sensitivity as an educational outcome: “The graduate is able to recognize social determinants of health to diminish disparities and inequities in access to quality care.”⁶ The role that implicit or unconscious bias plays in existing and arising health disparities and inequities must be considered because it has been observed in health care professionals and it can impact health outcomes.⁷ For example, graduates of pharmacy schools stated or were found to be deficient in their knowledge of unconscious bias.^8,9 Where unconscious bias went unrecognized, it was primarily aligned with race, with white students denying the presence of such bias or its effect on their professional behavior.⁸ Knowledge about lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual (LGBTQIA+) specific care and health or socioeconomic disparities, among other topics, were also lacking in student pharmacists and recent graduates.^10-12 While student pharmacists generally feel comfortable counseling and interacting with LGBTQIA+ patients, their knowledge and confidence in providing specific care for transgender patients was self-rated as low and also perceived as low by transgender patients.⁵ These deficiencies in knowledge and skill of student pharmacists can influence and likely impair their ability to equitably deliver care as future pharmacists, and thus contribute to disparities in patient care. Academic pharmacy has engaged in self-reflection with regards to DEIA, initiating incremental steps toward improvement in some areas fueled by societal changes (eg, health disparities) while other areas have yet to be examined (eg, personalized care for transgender patients).

In January 2021, the American Association of Colleges of Pharmacy (AACP) hosted its first Equity, Diversity, and Inclusion (EDI) Institute with a sequenced agenda encouraging pharmacy institutions to reflect, plan, and elevate/engage with their respective faculty and staff.¹³ Based on feedback from this three-day institute and AACP’s commitment to DEIA a second EDI institute was held in January 2022, indicating a continuing need in academic pharmacy. Particular DEIA spheres pertinent to pharmacy practice include race, gender, sexual orientation, gender identity, ability status, religion, socioeconomic status, and political beliefs. These themes are not separately addressed in the current ACPE 2016 standards, but clearly span the subject areas of cultural sensitivity as well as professional communication incorporated in the standards long ago.

In their approved 2021-2024 strategic plan, AACP has affirmed its commitment to DEIA as a priority and is currently considering revisions to the Pharmacist Oath to specifically address equity and inclusion.¹⁴ Accordingly, DEIA continues to fuel discussion in and around academic pharmacy. Since its mission is duly aimed at the evolving pharmacy curriculum, the climate is ripe for the Center for Advancement in Pharmacy Education (CAPE) to incorporate DEIA into the forthcoming CAPE 2022 Educational Outcomes, and the ACPE Standards 2025. Similarly, it is time to incorporate DEIA as an educational outcome and requirement for PharmD programs moving forward. The following discussion explores the critical importance of DEIA in pharmacy education.

Institutional Culture as the Basis for DEIA Implementation

Schools and colleges of pharmacy that have already made strides to incorporate and improve DEIA in their pharmacy curricula are to be praised for their vision, efforts, and dedication to equitable institutional culture. In a recent issue of the American Journal of Pharmaceutical Education, several pharmacy institutions illustrated their approaches to integrating cultural competency into institutional and curricular DEIA efforts.^15-17 Yet, DEIA are complex, evolving, and multi-faceted topics that require steady and continuous attention to foster their evolution at the curricular, institutional, and individual levels. Every administrator, student, faculty, and staff at an academic pharmacy institution must be an active and engaged participant of the DEIA journey, and their many voices must be heard in order to make lasting progress toward full integration and an inclusive and equitable environment for individuals representing all types of diverse identities. By embracing diversity and promoting equity in patient care, pharmacists are implementing the core tenant of the Oath of the Pharmacist which defines the pharmacy profession. Therefore, DEIA ownership, responsibility, and visibility throughout our pharmacy institutions should mirror the Oath’s essential principles. Ultimately, our pharmacy graduates will fully embody its core meaning, acquire more robust skill sets, and drive the change from a culture of confidence to competence in providing inclusive care to diverse patient populations.¹⁸ As such, the authors call upon institutional leaders to elevate DEIA to an integral element of each college and school, to lead by example with action, and to recognize that individuality and authenticity are valued and encouraged.¹⁹ Beyond institutional efforts, pharmacy professional organizations should offer support and emphasize the need for integrating DEIA into the pharmacy curriculum to enable graduates to meet societal needs. Moreover, pharmacy professional organizations should sponsor continuing professional development opportunities to educate pharmacists and other pharmacy professionals about how implicit bias and systemic racism contribute to health inequities. They should emphasize the important role of the pharmacist in holistic patient care to facilitate closing the disproportionate gaps in access to health care experienced by historically marginalized populations. Like academic institutions, professional organizations should also implement the Meyer Diversity, Equity, and Inclusion (DEI) Spectrum Tool (Appendix 1) to ensure diversity, equity, and inclusion are an integral part of the organizational structure.

The Meyer DEI Spectrum Tool does provide for a systematic approach to evaluating current and future standing for both academic institutions and pharmacy practice settings on 12 different dimensions.²⁰ Each dimension covers an aspect of organizational components that contribute to fully integrating and embracing DEI on all levels. Although the spectrum ranges from “not yet started” to “exemplary/leading” for each dimension, depending on which dimension is attainable over a short, intermediate, or long-term period, it may not be feasible for every academic institution or pharmacy setting to meet the highest level in all 12 dimensions. This acknowledges the unique culture and setting of each organization and institution. However, it is critical for institutions to understand where they currently stand with DEIA. As such, institutions can utilize this tool to develop priorities and set specific DEIA goals and strategies to move forward. This tool can also be employed to monitor progress and continue to identify gaps and priorities for the future.

DEIA in Action and Call for Best Practices

Recruitment and retention of underrepresented populations to schools and colleges of pharmacy as both students and faculty are a critical step to achieving DEIA implementation. The Sullivan report noted that health care professionals from underrepresented and underserved communities are more likely to practice in those communities.²¹ Identifying underrepresented student pharmacists who could serve their communities as graduates with an aim to close the health disparity gap has been a major challenge during the COVID-19 pandemic and has aggravated the long-established inequity in access to health care.²² One clinical application suggested a collaborative approach between pharmacists and community health workers familiar with local customs and culture to improve medication adherence.^23,24 If we do not begin to integrate DEIA into the fabric of pharmacy education now, the mistrust prevalent among patients due to historical and contemporary systemic racism, an unequal health care system, and both conscious and unconscious biases by health care providers could take generations to overcome.⁵

In order to make substantial change and observe progress, deliberate modifications to the PharmD curriculum and continuing professional development are necessary. Sample strategies include frequent and/or routine evaluation of DEIA in academic institutions along with a stepwise integration into the pharmacy curriculum. This process should incorporate and assess required curricular outcomes that aim at developing students' knowledge, attitudes, and abilities related to overcoming unconscious bias, awareness and dismantling of systemic racism, and reducing and eliminating health inequities based on marginalized identities, to name a few.²⁵

At the institutional level, implementing an operational DEIA vision as part of a strategic plan to engage all stakeholders lays the foundation for commitment and building a solid infrastructure (for academic institutions, stakeholders include internal faculty, staff, and students, as well as external preceptors, patients, other colleges, and the surrounding community; for pharmacy professional organizations, stakeholders include staff, the organization’s membership, and those who benefit from the work of these organizations, such as pharmacy educators, other health care professionals, and patients). Training for all present and future stakeholders, especially on general topics related to implicit bias and microaggression, appears to be of value to create a more diverse and inclusive work and learning environment.⁴

Achieving diversity among stakeholders in the academic and professional setting, including student pharmacists and pharmacy educators, will take time because it requires dismantling those processes, practices, and beliefs that have enabled DEIA to be an inconsequential topic in our profession until the last 10 years. This issue has been raised by an AACP special task force with examples of next-generation scholarship programs from the University of Maryland, University of New Mexico, University of North Carolina, University of Illinois at Chicago, University of the Incarnate Word, and Xavier University of Louisiana College of Pharmacy.²⁶ As mentioned above, cultural sensitivity training addresses a cross-section of DEIA topics that can form an excellent starting point for institutions. Assessment of cultural competency as a necessary part of the pharmacy curriculum and continuing professional development program for faculty and staff can form a launching point in terms of commitment and accountability for an institution or professional organization.²⁷ The data generated from these assessments can then be used by curriculum and assessment committees to further implement DEIA activities to ensure all stakeholders remain engaged, challenged, and can competently serve in their role to “assure optimal outcomes for [their] patients.”²⁸

We call on academic pharmacy to critically review current institutional DEIA practices and incorporate these practices into their strategic planning efforts with measurable and actionable goals; proactively implement unconscious bias training; intentionally hire diverse senior leaders and faculty reflective of national/state averages; embrace solutions to health disparities from those who belong to historically marginalized populations; incorporate and assess core DEIA principles throughout required pharmacy curricula, including experiential education; and advocate for diverse patient populations in a culturally responsible manner. Academic pharmacy institutions and pharmacy professional organizations must provide more continuing professional development opportunities to practicing pharmacists on DEIA topics as well as interprofessional opportunities to improve public health. These topics are essential to addressing health disparities and inequity in medication access for underserved populations. ACPE has recently published guidance urging continuing education providers to incorporate DEI into activities so pharmacists and pharmacy technicians are better prepared to serve historically marginalized and underrepresented minority populations.²⁹ Additionally, pharmacy licensing boards in the states of Michigan and Illinois have taken measures to require implicit bias training.^30,31 We urge boards of pharmacy in other states to make implicit bias and other DEIA topics a required component of continuing education for licensing and, more importantly, continuous development purposes.