Integrating Social Determinants of Health into Experiential Education

While health inequity is considered by many to be the #1 issue in healthcare today, we’re still just learning to talk about it as part of pharmacy education. As preceptors, health equity and social determinants of health may not have been a language we learned as part of our education, and yet we rely on preceptors to help develop our learners in this area. What is our role in incorporating conversations and education around health equity and social determinants of health to better educate our learners in improving the lives of patients?
 
Host
Kathy Schott, PhD
Vice President, Education & Operations
CEimpact

Guest
Sally Arif, PharmD, BCCP
Professor of Pharmacy Practice/Clinical Cardiology Pharmacist
Midwestern University College of Pharmacy
Rush Medical Center
Chicago, IL

Get CE: CLICK HERE TO CPE CREDIT FOR THE COURSE!

CPE Information
 
Learning Objectives
At the end of this course, preceptors will be able to:
1. Discuss a preceptor's role in educating student pharmacists and pharmacy residents about social determinants of health
2. Describe strategies preceptors can use to incorporate social determinants of health into their teaching

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-210-H99-P
Initial release date: 7/17/2024
Expiration date: 7/17/2027
Additional CPE details can be found here.

The speakers have no relevant financial relationships with ineligible companies to disclose.

This program has been:
Approved by the Minnesota Board of Pharmacy as education for Minnesota pharmacy preceptors.

Reviewed by the Texas Consortium on Experiential Programs and has been designated as preceptor education and training for Texas preceptors.

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Transcript

Speaker 1: 0:12

Hello. If you are a regular listener, welcome back. If you're new to Preceptor Practice, then welcome. We're glad you're here. Ce Impact brings you this podcast on the third Wednesday of each month. Each episode engages insightful guests who share resources and ideas to help you improve your precepting practice, become a more effective teacher and mentor, and balance your work with these additional but important responsibilities.

Speaker 1: 0:38

While health inequity is considered by many to be the number one issue in healthcare today, we're still just learning to talk about it as part of pharmacy education. As preceptors, health equity and social determinants of health may not have been a language we learned as part of our education, and yet we rely on preceptors to help develop our learners in this area. So what is our role in incorporating conversations and education around health equity? To better educate our learners and to improve the lives of our patients? That's the focus of today's discussion.

Speaker 1: 1:13

Sally Aref is a pharmacist and professor of pharmacy practice at Midwestern University, downers Grove, and founder of the Equity Minded Collective. She joined me recently for a conversation on the topic of health equity education within pharmacy. During this enlightening discussion, she shares the importance of teaching about health inequity and social determinants of health and provides effective strategies for integrating these concepts into practice. Let's listen in. Welcome everyone. I'm very excited to welcome Sally Aref, a pharmacist and professor of pharmacy practice at Midwestern University, downers Grove, and also the founder of the Equity-Minded Collective. She's here to help us with a conversation around health, equity and pharmacy education and our role as preceptors. Sally welcome, it's so good to have you here. Thank you so much.

Speaker 1: 2:05

Yeah, could we start by just having you share a little bit about your background and what really has led you to focus on this aspect of education in your career?

Speaker 2: 2:17

Yeah, thanks so much, kathy.

Speaker 2: 2:18

I'm excited to be here.

Speaker 2: 2:21

I think I would say that a lot of just my personal and professional experiences throughout my life have really fueled my passion for patient advocacy and equitable health.

Speaker 2: 2:32

I grew up as a first generation immigrant and, growing up in a working class family, I got to see my own family struggle through their own navigating the health care system, and that profoundly shaped just how I see inequities play out, and that was further reinforced just through my own professional experiences.

Speaker 2: 2:51

I've had the privilege of working across multiple pharmacy settings, from community practice as a student to big academic centers and community hospitals in my postgraduate training and my career, and so seeing where a lot of patients have been marginalized and kind of pushed to the fringes of our society when it comes to delivery of quality health care has really again fueled my desire to, within pharmacy education, assure that our learners are not going to be part of the problem in the future, but rather part of the solution. When it comes to patient advocacy, I think there's a moral necessity that we should all have when we take our oath as pharmacists, to achieve fairness and to make sure that everyone has equal care, and so I think that's really been a lot of what's fueled again my passion for this work.

Speaker 1: 3:43

Yeah, yeah, I mean certainly health equity is rising to the top of issues for our profession in general. You also, as I mentioned, founded the Equity-Minded Collective. Can you tell me a little bit about what that is and how it fits into pharmacy education, just to give everyone a little bit of background?

Speaker 2: 4:01

Yeah, so the Equity Minded Collective is a consultancy that I started a couple of years back because I really found a need that a lot of professionals whether that was in medicine, nursing, pharmacy and educators within healthcare really desired more professional development and preceptor development in this space, and so I've had the privilege, through the Equity Minded Collective, to work with other thought leaders in this space across the country and deliver workshops and lectures and seminars about these topics and really create safe spaces for people to have some of these difficult conversations. So I think that has been another avenue for me outside of the classroom and outside of my formal role within the university, to do this work.

Speaker 1: 4:52

Yeah, great, yeah, you're doing so many, so many things. It was fun to chat with you in preparation for this episode because you are you're doing a lot of interesting things in this area, so I'm anxious to dive in here. So, everywhere we Turn, I think we're reading and seeing and experiencing health equity as a huge driver of poor health outcomes for patients, and I think we probably agree that the didactic portion of the PharmD curriculum is still playing some catch up around this issue of the PharmD curriculum is still playing some catch-up around this issue In pharmacy education. What is the discussion around health equity and social determinants of health from your perspective and what strategies?

Speaker 2: 5:40

are you seeing being implemented on the coursework side? Yeah, so you're right. I think what we're starting to see is healthcare is transitioning to address these issues, which now we consider as an essential part of delivery of quality care. We are playing some catch up, because for many years we always had kind of this biomedical lens to how we would teach about various illnesses and disease states, and now we're starting to see that social factors of health are just as important to address. So this means that we think about education and employment. We think about life conditions that our patients are living through, from environmental safety to housing security, to food security and even the community support they may or may not have.

Speaker 2: 6:24

And so what I think a lot of PharmD programs are doing a good job of is starting to integrate this into more of the first preliminary years of didactic lecturing and workshops, where we are starting to show students and learners the models of cultural competency and how to really look through the patient's eyes when it comes to concepts of what is a health disparity, what fuels those health disparities, what is the definition of a social determinant of health, what are different health beliefs that patients may hold, health literacy concepts and assessment tools, but where we're still really at the infancy is how do we implement this?

Speaker 2: 7:03

How do we show our learners what this looks like on the ground, in practice? And that's really where experiential education is important and our preceptors play a really vital role of not just again highlighting their health disparities with this disease state, but saying what's behind that health disparity, what's fueling this health disparity in some cases to be the same disparity we've seen for decades across some illnesses, and making sure that we expose our students to social determinants of health that impact the health outcomes across various patient disease states, discuss the conditions in which patients live and how to interrogate some of the race-based tools that we use in clinical care to make sure that we're not delivering suboptimal care because of an unintentional discrimination within our practice. So how do we empower our trainees to think about these concepts? We're teaching within the didactic program to again create these interventions to be part of the discussions with other healthcare team members when we're creating our treatment plans for our patients. I think that's really where we're at right now within pharmacy education.

Speaker 1: 8:16

So you started to dive in toward the experiential learning component and you know, like so many things, we really do rely on our preceptors to bring the real world application and experience you know to the education you know that's been delivered in the classroom. Can you go a little bit deeper with that and kind of that critical role that preceptors play here?

Speaker 2: 8:45

Yeah, really important question. I think we all know that preceptors play a critical role when it comes to mentorship and modeling best practices, and I think we could take that even a step further, facilitating what activism looks like when it comes to striving for social justice within healthcare, and I think that's where some people get a little uncomfortable. But I think that there's many avenues in which preceptors can really help our learners see that they can address complex needs of diverse patients in our various communities, and so integration of some of these concepts into practice and giving our students hands-on time with some of these tools to promote and advocate for health equity, as the pharmacist's oath says we should be doing, is really a key role that I think our preceptors can help with. Competent care look like, and not that we can ever be fully competent culturally, but how can we strive to be in that practice of cultural humility? So that comes with just communication skills, right? So how do you respectfully address and interact with a patient that might feel unfamiliar to you? They might have health beliefs and lifestyles that you don't understand fully, but you still have to provide them with optimal care.

Speaker 2: 10:08

How do you integrate social determinants of health into your practice and discussion.

Speaker 2: 10:13

So when we're talking about a patient, are we discussing what are some of the again those barriers to care that they're experiencing in the community setting, whether those are social, economical, environmental factors, and then even simple things like when you're going in to talk with a patient.

Speaker 2: 10:30

I work on the inpatient side of clinical care, so when my students are going in, for example, and I'm precepting them around a medication history that they're taking, are we teaching our students? We teach them about open-ended questions, but are we teaching them to integrate questions like what barriers are you experiencing when it comes to transportation or food or community support? Have you had a lack of ability to have transportation to get to doctor's appointments or to your pharmacy to pick up your medications? How often do you need someone to help you understanding some of the pamphlets that we're giving you or instructions around self-care at home? And that, again, is ways that we can unlock data around a patient's health literacy level and then adjust the way we communicate with them. So I think that that's one thing that we can consider is just the language around this content as preceptors and modeling how this may look when they're interacting with their patients.

Speaker 1: 11:29

Yeah, so much is just, yeah, modeling and mentoring, isn't it? You know, one of the challenges we talked about last time we were chatting is the unique challenge preceptors might have in this space, given they really didn't receive any formal education around health, equity or social determinants of health, necessarily, and you know, this is one of those topics where we're all learning as we go and it's things are evolving and we're becoming, you know, wiser, you know in in some of these things. So we talked, I know we talked about the concept of having to do some self-work around this topic. What does that look like for a preceptor? You know, how can we, you know, make sure we're maintaining a language and a framework around these issues so that we can be that coach and mentor for students?

Speaker 2: 12:29

Yeah, I love this question, Kathy, because I think it really normalizes what we often talk about, which is lifelong learning, and that we're never really done.

Speaker 2: 12:37

And also the fact that in my interactions with many preceptors around the country, including myself, I didn't get formal education around what does health equity look like and advancing it and social justice work within my PharmD curriculum. Many of us didn't, and here we are in the driver's seat with mentoring and modeling this to our learners, who are very eager to want to understand how to apply this in the real world so that they are again part of solutions, not part of the problem. So what I have done in a lot of my preceptor development is create a framework that I call shift, and it's just a mnemonic to help us with what are some of the practical components to that self work that needs to happen in order for us to kind of be in that place of lifelong learning around this topic. So S stands for self reflection. I think it all starts with I. So this means examine your own biases, your own assumptions, your own social identities and where do you hold privilege, where do you hold power to amplify these topics, to help advocate for certain populations when healthcare is delivered? H stands for honoring the practice of cultural humility and structural humility, which is a component that's been integrated now into some of our educational outcomes within pharmacy. So, by practicing cultural and structural humility, what we're saying is we recognize the value of diversity of patients in our care and also, at the same time, the hard point that the systems that uphold inequities need to be dismantled, need to be looked at more carefully in order for us to build more equitable structures. So what are the policies that need to be looked at? What are the practices that we've kind of done for many years that don't necessarily serve all of our disadvantaged patients?

Speaker 2: 14:37

I stands for inviting vulnerability and discomfort to the table. I often hear that folks are, you know, kind of default to this. Well, I don't know very much about this, so it's not my area of focus, it's not for me to talk about, I don't have all the information and I think it's just saying instead that we need to step outside of our comfort zone and embrace that. Discomfort is important, and I think modeling and practicing vulnerability in front of our learners is also an important thing for us to show them that we don't have all the answers and we're part of the conversation of what do we do next and how do we foster the solutions and challenge the inequities and the structures of inequity and create an environment that's authentic to these discussions. I think that when our students and learners see that we're being vulnerable in these moments and I see there's problems out there but I don't have all the solutions it really shows them the human side of being a preceptor and a healthcare provider.

Speaker 2: 15:45

F is for fostering connection over content, and this is really about the role of the educator and saying that sometimes we've been conditioned as educators and preceptors to get a learner on our rotation and say let's maximize how much content I can deliver to you and how much knowledge you can gain on my rotation, instead of saying let's center that we need to connect and build a relationship with each other first.

Speaker 2: 16:10

That's really the place where we can develop a psychologically safe space to have these difficult conversations about inequities in our healthcare system, instead of jumping into the content, sitting with that idea of collaboration and community building with our learners that we they may have they may have more answers sometimes than we do.

Speaker 2: 16:31

And then T is really thinking about active allyship and accountability, and why I include that in the self-work is because we all have a role in allyship and I think that we often think of that word as a noun, like we're an ally and we hold this badge of ally, but actually I see allyship as action-based and it's a verb.

Speaker 2: 16:53

So every day we wake up and we say where do we leverage our going back to that self-reflection our power and privilege in society, in the healthcare system, in our titles that we hold, in the places of power and spheres of influence that we hold to make change happen? And how do we hold ourselves accountable to making change happen as we advocate for communities and for populations and individuals that have often again been marginalized or pushed to the fringes within our healthcare system? And so to me it's looking at that SHIFT acronym and saying where can I start Maybe it is just at self-reflection and saying what do I know and what do I not know? At this point? Where do I need to deepen my learning? And this day and age we've got podcasts like this one, we've got books we can read and there's so many other resources we can go to to really again deepen our understanding of some of the health inequities that many of our patients and communities face.

Speaker 1: 17:58

Yeah, I love the acronym and all the components of that. I'm stuck on self-reflection because I participated in a webinar that I think you helped facilitate as one of the presenters and we used a great tool on that webinar to sort of examine our own self-identity right, and where we held power and where we didn't. And it was a simple tool but it was very eye-opening and I'm sure there are others and maybe we could talk about pulling a couple of those together to share with listeners in the show notes. But I think the only thing I could really circle as a place where I didn't hold power was being female. Otherwise, you know, I was, you know and all these other things that it just it gave me a lot of things to think about.

Speaker 1: 18:47

The other thing you talked about too, is the importance of vulnerability, and you know we've talked about that a million times on this podcast in different contexts, but you know, again, showing that vulnerability is a way that preceptors can demonstrate their own personal and professional development and commitment to lifelong learning. Right, and also it's the only way we can build a language around something new is by experimenting with it. You know, reading about it, having conversations about it, building community around it, about it, building community around it, and you know that's what these things take to make change, right? Is that we all start to build a language around it and have the ability to talk and, you know, to take action. Yeah, yeah.

Speaker 2: 19:32

And I think, just having grace for ourselves that we are learning and that we don't have to have it all 100% right off the bat. I think that some of us again, I jokingly say I don't like stereotypes, but I often stereotype pharmacists as perfectionists. I know that was a large part of what I had to grow through is that I have to be perfect and know everything about a topic before I can really speak to it. And I've really learned in this space. We're all still learning and we all come at it from different angles and, like you said, with our social identities and if you've ever mapped your social identities, we may hold privilege in certain areas where we can speak to and be an ally to certain topics and other areas where it's not safe to, it's too vulnerable and too uncomfortable in a negative way that it might cause more harm because I've been subjected to my own discrimination in certain ways and I need allies to be there for me. So I think it's just examining, kind of where is our place in all of this and that we're all on a journey with it and normalizing the fact that it is a journey and that's really again that idea of cultural humility is that we never end, and I think that's why I really like that idea of cultural humility is that it's never, we never end.

Speaker 2: 20:40

And I think that's why I really like that framework of cultural humility over cultural competency, because cultural competency makes it sound like we'll get there, like it's a test and I'm now competent and now I know everything about all these different populations and components of inequities in our society and I can now do the work. But it's actually the opposite. It's saying that we're in a state of being like it's constantly that we're learning more. I wake up every day and have to examine what do I know and what do I not know. Where is my place for action? Where are places where I'm still learning and I need the language? And so I think, you know, giving ourselves some grace with this process is important as well.

Speaker 1: 21:21

Yeah, yeah, no, that's a great point and, yeah, important differentiation between those two words. For sure, you know we have had some the opportunity, I think, to experience some of this health equity activity in a more personal way. In the last couple of years. We've worked with a group to develop community health worker training, and it's targeted primarily at pharmacy technicians. You know who are in their communities and building relationships with patients, and so you know, training them on the concept of social determinants of health and how they can play an active role in connecting patients to resources, identifying what those needs are, and so the stories that have come from technicians who have gone through the training and the difference they're making in their community has been really, really moving.

Speaker 1: 22:14

You know, and it's not just about finding ways to pay for your medication, it's about finding transportation, it's about housing, it's about food, it's about, you know, all kinds of things. So it's been a really wonderful experience for us as an organization to be a part of that. I would love to hear from you I'm sure you have many examples, but whether you know, you're a residency preceptor or preceptor working with students Could you share some practical strategies that anyone could start working? You know they can start working these concepts into teaching.

Speaker 2: 22:49

Yeah, that's a wonderful question, kathy. Actually, I'll layer on to what you just mentioned about your community health training program, because one of the things that you can do, even with your students as a preceptor, is have them engage in the community-based learning model, and that means that maybe you take a day of your rotation or two and you actually find opportunities for your learners to work with local organizations in the community that you serve. So, for example, I work on the West Side of Chicago at my medical center and we've got an initiative called West Side United, and so I've had students volunteer with something called Veggie RX, where they go and just repackage produce and restock shelves at local grocery stores that a lot of our patients will frequent so they get an idea of what type of food access is available, distribute different food, deliver food to people that don't have transportation. On the west side of Chicago We've even worked on a project one day where we worked out beautifying the neighborhood, and so there was a mural, an initiative where the students got to just paint and beautify the neighborhood, and so there was a mural initiative where the students got to just paint and beautify the neighborhood for the community members that live in it, and so these are really great ways to just get familiar with what's happening within that community.

Speaker 2: 24:13

Another thing that preceptors can do as part of orientation is have a conversation with learners about different social vulnerability indexes or maps that you can use to show how vulnerable is the community in which you know your hospital is located or clinic is located or your pharmacy is located. Talk about the impact health literacy maps that are available. So what does the health literacy look like in that community? Or health access points? Where are the schools? Where are the first urgent care facilities available? Are there emergency rooms that can take all different types of triaging? What are the different various free health care services that are available? Where is the local health department? What services do they provide? Where is the local health department, what services do they provide? So having those conversations, I think, with learners is really important so they get an idea of the landscape of the community as well.

Speaker 2: 25:11

Another thing that you can do is when we're walking through different patient discussions is make sure and that could be even for case presentations students are doing or learners are doing on your rotation is have them share out what are the health disparities related to that disease state or the various disease states the patient has and what fuels those health disparities. It's not just saying here's a statistic about diabetes or a statistic about cardiovascular disease, but what are the root causes upstream from a public health lens, that fuel those disparities? Is it power, imbalances in social access to healthcare? Is it where there might be public health initiatives that are not being delivered to that certain communities and having the students really engage with that as part of their patient discussions? I even have it on my patient monitoring form for my students to not just collect social history and family history but what are some of the social determinants of health, orienting them to that in the medical chart as well.

Speaker 2: 26:18

If that's something that your health system is collecting, where would I find out about transportation or to what communities or location my patient is living or financial barriers my patient is experiencing? That might come from certain progress notes, for example. That again should be part of my orientation for my students when they are learning about their patients. I think also when we're doing journal clubs or evidence-based medicine assignments, having encouraging our students to and learners to like, again think about that lens of health equity with the topic that we're talking about and not just again, like you said, limiting to cost of medication. I think that's often where we go. But think broader, think about all of those social factors that play into access to care.

Speaker 2: 27:08

And then I also really think it's important to have intentional moments of reflection around this topic and not kind of sideline it or if we have time, we'll get to it. So I often have, like many preceptors, friday feedback sessions with my learners and I'll ask them what was a patient that really impacted you this week and what parts of their social identities or social determinants of health was surprising to you and why? And really have them think about that as a moment of intentional, again reflection. Where did they see that they got curious about the patient? Where did they see their own limitations to understanding? Where do they see their need for further learning? And so I think that's also important to integrate into our daily practice or weekly practice with our learners.

Speaker 1: 28:05

Yeah, those are all great, great examples and really super practical and doable. You mentioned the social vulnerability index and I'll link that in the show notes for anybody who's not familiar with it. But we use that in our CHW training and, have you know, have the technicians, you know, do some research around their zip code and look at neighboring zip codes and you know, see, you know what the differences are. You know, based on their geography. The other thing, you, you know. I also really appreciate the concept of engaging in the community and that's something we have these technicians do. They have to complete so many hours of community work, basically, but it's really about gathering resources, learning what resources are in the community. What can you connect your patients to that might help them with their overall health? And it could be anything you know, as we mentioned from you know, from transportation to food, to child care, to you know who knows, whatever is getting in the way of their, you know, general well-being, yeah.

Speaker 2: 29:12

I work really broadly yeah, no, that made me think of also. It's not just that sometimes it's a lack of resources, but it's a lack of understanding how to use those resources. So we do a lot of work with my student organization with immigrant and refugee health in Chicago and often my students will come back and say it's not that there isn't access to different resources within their communities where they resettle, but it's that they have linguistic or cultural barriers that make it hard for them to understand how to navigate those resources. They might not realize that when it's a free food pantry, that it truly is free, there is no strings attached, or that they might show up and not understand, or there's no one to interpret what the process is for signing up for certain social services and so they, you know, kind of withdraw back to I'm not going to be able to get this resource.

Speaker 2: 30:07

So I think it's also having cultural ambassadors and I like to empower my learners to realize that they come with their own social identities and sometimes they can be that social ambassador or cultural ambassador to some of these communities that they might have been part of at one point or are still part of in their current day and kind of integrate that intersectionality piece of those existing identities that you come in with as a pharmacy learner into your professional identity. As you develop that as a pharmacist, that that's an asset to you, and I think it's important that we realize that diversity within our workforce is an asset, not a deficit, and so that's a way to kind of again shift that mindset that our students again sometimes can be the teachers in these moments where they will teach me more about communities than I ever knew, because they have some sort of personal connection to some of this, these life experiences.

Speaker 1: 31:04

Yeah, yeah. No, that's a great, that's a great call out Good point. Well, this has been a really, really helpful conversation. You're so articulate in this space and it's just lovely. It's lovely to be able to talk with you about it. In wrapping things up, sally, what is the one thing a preceptor could begin doing today? You know, regardless of how much you know time and space they've given to this area in the past. What's the one thing they could start doing today with their learners, whether it's a student or a resident, you know to start having an impact in the health equity space.

Speaker 2: 31:43

I would say if there's one place to start that doesn't take a lot of homework and a lot too much discomfort is just for preceptors to incorporate discussions every time they talk about a patient, with one of their learners to ask the question what social or economical or environmental factors do you think is affecting this patient's health? And that immediately starts to raise awareness and encourages our learners for some critical thinking around health equity, the idea of the impact of social determinants of health on health outcomes. So even if it's as simple as just incorporating that one open-ended question into inquiring more from the student as they gather information about the patient or they are coming back for advice around what to tell the patient is just to ask that question and see you know, how does that bleed in to our decision making for their care.

Speaker 1: 32:40

Yeah, I think that's a great recommendation, a great place to start. It's where we live, the air we breathe, where we go to school, the food we eat, right, just all those basics of life. So, yeah, perfect, perfect, well, thank you very much. I so appreciate the time and I hope that we can pick this up again at some point.

Speaker 2: 33:05

Absolutely. Thank you so much, Kathy. I had a great time with this discussion and I appreciate you all centering this topic.

Speaker 1: 33:11

If you'd like more education on this or related topics, check out the show notes for some links to past episodes and courses from the Preceptor by Design catalog. I've also included links to a couple of resources we discussed during the podcast the CDC's Social Vulnerability Index, where you can determine your community's vulnerability relative to their social determinants of health, and the University of Michigan's Social Identity Wheel, a great activity that you could facilitate with your learners to build a foundation for health equity concepts. As always, be sure to check out the full library of Preceptor by Design courses available for preceptors on the CE Impact website and be sure to ask your experiential program director or residency program director if you are a member so that you can access it all for free. If you do have access, thank your program director and be sure to log on to CE Impact and claim your credit for this episode. Thanks again for listening and I'll see you next time on Preceptive Practice.