Students lead charge to provide context for race in pharmacy education

Mock patient cases appeared on the screen, one by one. They were followed by questions like “Is the patient receiving enough of drug X?” and “Which of the patient’s medications are likely to cause harmful interactions or side effects, and why?”

But as UCSF pharmacy student Temi Sofeso made her way through the exam, in the spring of 2020, she noticed something that seemed off: each of the hypothetical patients described was Black.

“It wasn’t ever fully fleshed out, why we identify our imaginary patients as a certain race when we haven’t really talked about what this means and what the impact of this is, as students and as a Black person myself,” said Sofeso, Class of 2022, who at the time was nearing the end of her first year in the UCSF School of Pharmacy’s PharmD program.

Sofeso contacted Jennifer Cocohoba, PharmD, MAS, faculty member in the Department of Clinical Pharmacy, to open up a dialogue about the use of race in the PharmD curriculum.

Months later, after a summer punctuated by worldwide protests over racial injustice, Sofeso, Cocohoba, and other students and faculty members began to improve how the UCSF PharmD program addressed race. Students, hired as health equity interns, would meet monthly with faculty members to review the next month’s teaching materials and make suggestions for improvement.

In August 2021, Sofeso and fellow health equity interns Laura Rambaran, Sheila Mohebbi, and Anahit Tatarian (all Class of 2022) published an editorial providing guidance on this kind of approach to health equity—from the student’s perspective—in the American Journal for Pharmacy Education (AJPE). Their article provides concrete suggestions for reducing racial bias in PharmD programs based on a modern understanding of race, genetics, and health care.

Today, the Health Equity Internship that Sofeso, Rambaran, and their peers piloted continues, bridging the faculty and student bodies in pursuit of an antiracist curriculum.

“The article is a stark reminder that sometimes we do need to have these really uncomfortable conversations to get to a better place with addressing race in pharmacy education programs,” said Cocohoba, who co-mentored the student interns with fellow faculty member Stephanie Hsia, PharmD. “It also shows that it’s possible to break down hierarchical structures and have faculty and students work very closely together towards a shared, common goal.”

A critical mass for change

When Sofeso and Cocohoba began their dialogue about the use of race in PharmD education, Hsia was working on an approach of her own, with the same goal in mind. Hsia and Rupa Tuan, PhD, who together lead the program’s neuropsychiatry unit, had designed a series of discussions in which students could grapple with intersections between pharmacy practice and race.

“A lot of my inspiration came from the students,” said Hsia. “Right after all the protests that happened about George Floyd, I facilitated a critical reflection where I had an open and honest discussion with the students on the topic, which led me to think about incorporating these discussions into our curriculum.”

Stephanie Hsia, PharmD

Hsia and Tuan’s 10-week-long health equity curriculum, which they hoped could be applied throughout the PharmD curriculum more broadly, primed them, as well as many students, to think about addressing other gaps in the curriculum.

“We were looking for students who had a vested interest and a bit more experience with these topics [in health equity] to lead these discussions,” said Hsia. “And then luckily, we connected with Jen.”

Hsia had already recruited several students to facilitate these discussions led by students and for students. And Sofeso had recently served on the School’s Anti-racist Curriculum Task Force, which had drafted changes to the curriculum, and PharmD program more broadly, for School leadership to consider. Clearly, there was a desire to act.

A meaningful first step

As Cocohoba, Hsia, and the students brainstormed how to take action on these issues in pharmacy education, the revision of one aspect of the curriculum stood out as a “meaningful first step,” according to Sofeso—addressing the descriptions of patients that she had noticed her first year of pharmacy school.

“There are so many things in the curriculum that potentially, and eventually, need to be addressed in terms of health equity,” said Rambaran. “But the patient cases were something that we saw every week. We wanted to make sure that each example of a patient reflected the real world and was explained in a very equitable manner.”

Elisabeth Fall

Jennifer Cocohoba, PharmD, MAS

Hsia and Cocohoba had both helped revamp the School’s pharmacy curriculum into its current form over the preceding eight years, so the prospect of iterating further wasn’t so daunting.

“The new curriculum has facilitated our ability to be nimble, because nothing is set in stone,” said Cocohoba. “But also, developing the health equity portion of the curriculum requires us to listen to each other, find our way together, because language changes, things that are appropriate change and don’t change. It’s a moving target.”

With funding from the School, the two faculty members designed a Health Equity Internship to update these patient cases. The paid internship launched in September 2020, and Rambaran and Sofeso were two of the first seven interns in the program.

As the months progressed, a rhythm was established: two interns would lead a discussion on the cases presented for a specific theme, like the cardiovascular system, with Hsia, Cocohoba, and the other interns. The discussion would lead to recommended changes. And then the next month’s lecturers would consider those changes and incorporate them.

“We wanted to see what recommendations could be provided, if any, to faculty to make these descriptions a bit more intentional, more thought out, rather than just saying that this disease, this incidence of this disease is higher in this community,” said Sofeso. “Instead, we wanted to inspire students—and faculty—to think, ‘why does this seem to be the case?’”

A playbook for addressing equity in pharmacy education

In the spring of 2021, as the health equity internship hit its stride, Cocohoba encountered a paper that grappled with the role of medical education in propagating bias among physicians. She forwarded it to the health equity interns, knowing it lined up with their efforts.

The health equity interns realized that their own work could be a useful model for pharmacy students anywhere who saw the blind spots in their own curricula. Four of the interns, including Sofeso and Rambaran, decided to write their own manuscript, detailing their approach to working with faculty to update patient cases in the curriculum.

“The faculty here at UCSF is very much involved in this process, tackling equity head-on, but that’s not necessarily the case across the United States and other schools of pharmacy,” said Rambaran. “We wanted to share our perspective with other students to say, we’re seeing these things in our curriculum, so if you see these things in your curriculum, this is what you can do. This is how you can start a dialogue with your faculty.”

With only light editing and guidance from Cocohoba and Hsia, the students’ paper was published in the American Journal of Pharmacy Education in August 2021. It proposed a framework for students to work with faculty members in pursuit of equity in pharmacy education.

“The intent of the paper was really to raise awareness of the student’s perspective around these issues,” said Cocohoba. “As faculty members like Stephanie and myself shape our teaching elements, it’s important to always keep the student experience in mind.”

The two recommendations made in the paper, with regards to PharmD education—that examples of race and disease in patients need to be contextualized, and that race-based guidelines and clinical decision-making should be grounded in evidence—are in line with the very values that draw students to UCSF, said Rambaran, values that are worth spreading.

“I feel very proud that our students were the ones to put this paper out there,” said Hsia. “It’s one thing to enact change at your institution. But the bigger picture is to try to get all of the schools on board.”

An ongoing effort

As Rambaran and Sofeso approach their graduation from the PharmD program, they hope that their work in the Health Equity Internship will be carried forward not only by future interns, but by health care providers of all stripes, working together to serve a diverse patient population.

“It’d be great if this could be more of a collaborative effort, because we’re all part of a patient’s care in different ways,” said Sofeso. “If there’s a disconnect in how we’re learning how to give patient care, there’s going to be a disconnect in the real world as well. So maybe there’s a way to piece all of that together, across all of health care education.”

Hsia has obtained funding for the School’s next round of health equity interns, who will begin their work this summer. In addition to reviewing patient cases used by the curriculum, the next cohort of interns will also contribute to education research and curricular development, said Hsia, who herself continues to gather evidence for best practices in teaching health equity.

“One thing I really appreciate about UCSF is that all of our faculty, myself included, are given ownership and independence in how we teach. And I think our [recently retired] Dean Guglielmo has been great at encouraging us to try new things and be innovative,” said Hsia. “There’s plenty more for us to do, but with that kind of support, we really have the opportunity to make the change we want to see.”