SPECIAL ARTICLES. Caring for the Underserved: Exemplars in Teaching. American Journal of Pharmaceutical Education 2009; 73 (1) Article 18.

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1 SPECIAL ARTICLES American Journal of Pharmaceutical Eucation 2009; 73 (1) Article 18. Caring for the Unerserve: Exemplars in Teaching Mitra Assemi, PharmD, a Laura Shane-McWhorter, PharmD, b Doneka R. Scott, PharmD, MA, c Juy T. Chen, PharmD, an Hazel H. Seaba, MS Pharm, BS e a School of Pharmacy, University of California at San Francisco b College of Pharmacy, University of Utah c College of Pharmacy, University of Minnesota School of Pharmacy an Pharmaceutical Sciences, Purue University e College of Pharmacy, University of Iowa Submitte April 1, 2008; accepte May 26, 2008; publishe February 19, The objective was to ientify exemplars in teaching pharmacy stuents awareness, knowlege, an the skills neee to provie care an services to the unerserve. A call for exemplars was sent out in spring A subcommittee of the AACP Task Force on Caring for the Unerserve reviewe all applications receive. The 3 best exemplars for teaching pharmacy stuents the awareness, attitues, knowlege, an skills neee to care for the unerserve were selecte an are escribe in this manuscript. Inclue are 1 iactic, 1 experiential, an 1 international experience. These exemplars in eucating stuents on working with the unerserve provie schools with moels which coul be aapte to fit iniviual programmatic curricular nees. Keywors: curriculum evelopment, unerserve INTRODUCTION Unerserve patients are those who face barriers to timely access to health care services which provie the best possible health outcomes. 1 In the Unite States, unerserve populations inclue ethnic minorities, women, chilren, the elerly, low-income groups, rural resients, an those with special health care nees. These groups are vulnerable to experiencing health isparities or ifferences in the quality of care resulting in poorer health outcomes. The Institute of Meicine (IOM) cite evelopment of interisciplinary health professions curricula to aress social, cultural, an other factors that impact patient care an health care outcomes as a strategy for elimination of health isparities in the Unite States. 2 In acknowlegement of the pharmacist s role in eliminating health isparities, the most recent accreitation stanars an guielines for pharmacy eucation reflect the imperative for introucing stuents to working with an effectively caring for unerserve patients by manating inclusion of content relate to cultural competence in the curriculum. 3 Such content shoul be woven longituinally throughout the curriculum in both iactic an experiential learning Corresponing Author: Mitra Assemi, PharmD, UCSF Fresno Pharmacy Eucation Program, 155 N. Fresno Street, Suite 224, Fresno, CA, Tel: Fax: assemim@pharmacy.ucsf.eu 1 environments in orer to allow stuents to evelop an apply the awareness, attitues, knowlege, an skills neee to meet the nees of all patients. 4 Despite these recent manates for pharmacy eucation, resources to assist schools in eveloping, implementing, an assessing content relate to working with the unerserve remain scarce. In orer to fill this nee, the American Association of Colleges of Pharmacy (AACP) convene a task force to evelop a resource to assist schools. The task force consiste of faculty members at ifferent colleges an schools of pharmacy in the Unite States who have experience in proviing care for unerserve patients. Together its members evelope a curriculum framework that escribes evience-base practice, clinical prevention an health promotion, health systems an policy, an community aspects of practice in caring for unerserve populations. 5 The task force also publishe a paper to ai schools an colleges of pharmacy in eveloping programs to train pharmacy stuents in the care of the unerserve. 6 This paper represents the task force s eneavor in ientifying an isseminating exemplars of pharmacy stuent teaching in both classroom an experiential settings in the care of the unerserve. RECRUITMENT AND SELECTION In 2007, a call went out to faculty at schools an colleges of pharmacy who might be intereste in submitting an example of their work with stuents in proviing

2 care to the unerserve. Thirteen faculty members from 10 colleges of pharmacy submitte 1 or more applications (Table 1). The submissions inclue stuent experiences in 3 settings: iactic, experiential, an international. A subcommittee of the AACP Task Force on Caring for the Unerserve evelope selection criteria, reviewe the applications, reache consensus on their inepenent rankings an selecte exemplars for inclusion in this manuscript. Faculty members of the selecte exemplars were invite to submit a escription of their course, incluing learning objectives, content, an stuent assessment, an to escribe an iscuss successes an challenges face to ate. The following section escribes each of the 3 selecte exemplars. TEACHING PHARMACY STUDENTS TO CARE FOR THE UNDERSERVED Diactic Learning: An Elective Course in the Professional Curriculum Course escription. Diminishing Health Disparities Through Cultural Competence was a thir-year elective course offere at the University of Minnesota College of Pharmacy on both the Twin Cities an Duluth campuses via interactive television. This 2-creit, seminar-base course examine various ynamics of health isparities an cultural competencies utilizing a sociological framework. The racial an ethnic isparities among unerserve an unerrepresente groups in the Unite States (Asian, African, Hispanic, American Inian) compare to Caucasians were explore. The effects of history, health beliefs, an practices on minority health were also aresse. Emphasis was place on conceptual frameworks an strategies that foster cultural competence an sensitivity (focusing on attitue, knowlege, an skill acquisition) as a basis to alleviate health isparities. Table 1. Exemplar Submissions (N512) Eucator Institution Juy Chen Purue University Sharon Conner a University of Pittsburgh John Conry St. John s University Patti Darbishire a Purue University Laura Hall Ohio State University Seema Patel University of Illinois, Chicago Brooke Patterson University of Missouri-Kansas City Kim Plake Purue University Ann Ryan-Haa a Creighton University Doneka Scott University of Minnesota Hazel Seaba University of Iowa Laura Shane-McWhorter University of Utah Jennifer Tillman a Creighton University a Submitte more than 1 exemplar application The class met once weekly for 1 hour, 50 minutes. A course irector on each campus was present for each class session. At least once per semester, the irectors travele to the other campus to facilitate lectures. Class size was cappe at 10 stuents per campus. Course objectives. The overarching goals of the course were (1) to provie an opportunity for intellectual ialogue an analytical engagement on major health isparities among cultural, ethnic, an socially isavantage groups in the Unite States; an (2) to evelop strategies to foster cultural competence when interacting with iverse groups. These goals were supporte with a set of learning objectives (Table 2) vis-à-vis the course content. Since communication was paramount to proviing optimal patient care an playe a pivotal role in intercultural interactions, the course provie stuents with opportunities to enhance their written an oral abilities. The course was also structure to further evelop skills outline in the College s general ability-base eucational outcomes, which inclue competencies in thinking, formulating values, ethical ecision making, social an contextual awareness, social interaction, an selflearning abilities. Course content. The course was ivie into 2 sections: Introuction to Health Disparities an Introuction to Cultural Competence. The case to eliminate health isparities unerscores the importance of becoming culturally competent. The course explore the following issues: conceptualizing race, culture, an ethnicity in Table 2. Seminar Course Objectives Define culture, race an ethnicity Describe the nature an extent of health isparities that exist in US between Caucasian Americans an Non-Caucasian Americans an immigrants Discuss an reflect on one s iniviual worlview (incluing personal stereotype thinking, common prejuices, an ethnocentrisms) an own cultural attitues/beliefs regaring cross-cultural interactions Describe the social-historic anteceents of istrust of health care in some groups Ientify the levels of care (iniviual, social, cultural, an environmental) that contribute to competent appropriate health care Summarize the National Stanars for Culturally an Linguistically Appropriate Services (CLAS) in Health Care an Title VI of the Civil Rights Act of 1964 Describe the nee for cultural competence in pharmacy practice Recognize how cultural health beliefs can be a resource for health an healing an their effects on conventional western treatments an pharmaceutical care 2

3 health; historical founations in race, ethnicity, an health; epiemiology of health isparities; etiology of health status; health care practitioners an health systems impact on health isparities; assessing one s own worlview; communication techniques an approaches to culturally appropriate behavioral changes; cultural an linguistic competence, incluing health literacy; international health an meicine; an isability, ethnogeriatric, an religious competence. (A table illustrating the links between course content with the AACP Curriculum Framework eucational outcomes is available upon request from the corresponing author.) Require course materials consiste of a textbook 7 an a course pack containing relevant articles from pharmacy, meicine, nursing, an public health literature. Active-learning strategies employe in the classroom inclue case-base iscussions, role play, in-class free writing exercises, scenarios, presentations, an smallgroup assignments. Multimeia such as film an online eucation were use to accommoate iverse learning styles. Guest facilitators, such as interpreters, other health care practitioners, an community leaers le iscussions. The course conclue with a cultural potluck inner in which stuents brought a ish representing their own culture or one stuie uring the semester. At the inner, stuents fille out a postcar ocumenting ways they planne to provie culturally competent care. These postcars were maile to stuents uring their fourth-year experiential training to remin them of their commitment. Assignments. Stuent assignments inclue reflections, a cultural activity, ebates, an a final presentation. Reflection was a critical component of professional an personal growth. Stuents wrote a review of the assigne reaings twice uring the semester (after each respective section) to facilitate synthesis of an reflection on the conceptual moels provie in the reaings. The review inclue (1) critical analysis of the most important themes, logic, an evience in the reaings from each respective section, (2) a iscussion of a theme that resonate with them as the reaer, (3) a iscussion aressing how they woul incorporate this newly acquire knowlege into their practice, an (4) a iscussion of material they woul like to further investigate. To gain insight into an experience with the traitions of a culture ifferent from their own, stuents attene an actively participate in a non-western cultural/ethnic public event at the University, Twin Cities, Duluth, or surrouning areas. Prior to attening, the stuent ha to research the history of the event to gain conversational knowlege of it. They also interviewe another participant (from the cultural group) to gain aitional insights regaring the event an its relevance to the culture as well 3 as the interviewee. Upon completion of the experience, the stuents wrote a letter aresse to their aunt (a retire English composition professor), who was not familiar with this event or culture. In the letter, an event summary was provie, incluing a brief history, a escription of their participation, an reactions/reflections before, uring, an after the event. Their experience was then share uring a class session. Stuents also engage in formal classroom ebates to avance their critical thinking, literature searching, oral an written communication skills, an their ability to civilly yet assertively iscuss ifferent perspectives on controversial issues. Topics inclue rug importation, pharmacists conscience clause, interpreter services, an patient-practitioner concorance. After completion of their ebates, stuents wrote a mock article for the University stuent newspaper highlighting the affirmative an negative arguments proffere uring the ebate. As a mock platform presentation given at a national association meeting, the stuents presente a efine community an a major health isparity issue in that community. Barriers an challenges to optimal health status an care were elineate. Available programs aressing the health isparity were also highlighte. Each presentation was peer-reviewe an feeback was provie to the stuent. Assessment. All assignments were uploae to the course site on WebVista. Both instructors ha access to uploae material, simplifying the istribution an graing process between campuses. Stuents knowlege acquisition was assesse in several ways. Stuents took a multiple-choice an short answer test prior to beginning the course an a multiple-choice an short answer test upon completion of the course. The test consiste of questions on cultural norms an isparities in health for nonmajority groups, health literacy, an historical aspects of health care. Class iscussion, writing assignments an oral presentations also serve to assess knowlege. Since the success of this course an the learning process epene on the presence an meaningful contributions from all class participants, incluing instructors, participation comprise 25% of the grae. Stuents complete anonymous weekly online evaluations using SurveyMonkey (SurveyMonkey.com, Portlan, OR), which ynamically shape the course throughout the semester. A final course evaluation was complete at the en of the course which inclue an overall assessment of the course, the instructors, an the guest facilitators. Successes. The class was offere twice, with 12 stuents completing the course. This class provie an opportunity for all participants to co-construct an

4 4 environment that allowe freeom in iscussions, regarless of ifferences in experiences, values, or perspectives, an minimize the effect that interactive television coul potentially have on group iscussions. This was accomplishe by setting groun rules at the onset that were evelope an agree upon by the entire class. A safe haven was create to support thoughtful an nonjugmental ialogue. Stuents consistently came to class prepare for thoughtful iscussion of the assigne weekly reaings. Their critical thinking skills an epth of reflections continuously improve throughout the semester. One stuent asserte that, [his] attenance at the [cultural event] gave [him] an appreciation of how other cultures feel when they are subjecte to the majority s behaviors or preferences...[he is] better equippe to go out into the community an learn even more about other cultures. He further state that before being introuce to [issues iscusse in class], [he] woul have approache situations without gathering the appropriate information neee to unerstan an iniviual s nees. Examples of stuent course evaluation comments inclue that the course woul have a strong impact on them as future pharmacists, shoul be a requirement for all pharmacy stuents, an was the best class that I have ever taken. Finally, the instructors were able to engage community partners in the course, which may positively impact institutional-community relations. Remaining challenges. Since many stuents ha not previously experience a iscussion-base seminar, one challenge was orienting stuents to this course format. Compare to other pharmacy courses, the seminar was reaing-an-writing intensive an there were no grae examinations. To be successful an maximize learning, it was imperative that stuents rea all of the weekly course material an focus not on factual memorization, but on synthesizing an reflecting on the material. Another challenge was helping stuents unerstan that reflection was a critical component of professional an personal growth an not just busy work. Two curricular challenges existe. First, the class was offere at a time that conflicte with one of 2 sections in a require pharmaceutical laboratory course for Duluth stuents, which preclue some intereste stuents from registering for the course. In those instances, enrolling in the alternate section was not a viable option. Also, there remaine a nee to shift from an elective to a require course or incorporate the course content throughout the curriculum. In many colleges an schools of pharmacy, the core curriculum is alreay rigorous an at capacity. This issue was scheule to be aresse in a future curriculum revision. Future innovative changes planne for the course inclue offering the course to other health profession stuents; aing a service learning component in which the stuents coul apply their newly acquire skills to improve health in the local community; an utilizing simulate patients to assess clinical skill performance. Experiential Learning: An Avance Pharmacy Practice Experience Course escription. The Avance Pharmacy Practice Experience (APPE) at Tippecanoe Community Health Clinic (TCHC) was an 8-week require ambulatory care experience offere to pharmacy stuents in their fourth professional year. At the time of writing, TCHC was the only Feerally Qualifie Health Center (FQHC) locate in the rural Greater Lafayette, Iniana area. Annually, this nonprofit clinic serve as a safety net for more than 9,000 meically unerserve patients, special populations, an the uninsure. Patient ethnic emographics inclue Caucasians (over 50%), Hispanics (25%), African Americans (9%), an Asians (6%). Approximately 70% of the patients serve ha incomes below 100% of the feeral poverty level, more than 50% receive Meicai or other government assistance, an 40% were uninsure. Coorinate primary healthcare services were provie to all age groups through 4 subclinics: ault meicine, women s health, peiatrics, an ental. Specialize services inclue pharmacotherapy referral, nutrition counseling, smoking cessation, telephone triage, meication assistance, health referral, an homeless outreach. Stuent assignment to the APPE epene on professional interests an geographic location. The experience emphasize proviing quality patient-centere care to the unerserve population in a primary care setting. The stuent-to-preceptor ratio was generally 2:1. Activities evelope at TCHC were esigne to enhance stuents unerstaning of pharmacotherapy for a variety of isease states relating to caring an management of unerserve patients. Course objectives. The goals of this clinical APPE inclue: (1) strengthening verbal an written communication skills; (2) eveloping skills in the provision of pharmaceutical care; (3) applying iactic knowlege to patient care; (4) managing an monitoring rug therapy; (5) refining problem-solving skills; (6) eveloping critical thinking skills; an (7) eveloping competency in pharmacy practice with the unerserve. Specific clinical experience objectives are liste in Table 3. Course content. The Pharmacotherapy Referral Program at TCHC was establishe by a faculty preceptor to assist patients with meication-relate issues an provie chronic isease management. Primary care physicians, nurses, an allie health care proviers requeste consults

5 Table 3. APPE Objectives at Tippecanoe Community Health Clinic 1. Describe the philosophy of clinical pharmacy practice, emphasizing its application to caring for the unerserve patients in a multiisciplinary ambulatory care environment. 2. Obtain, organize, an assess patients meication profiles for potential meication-relate problems: Untreate inication, rug use without inication Inappropriately prescribe rugs, osages, frequency of aministration Drug-rug, rug-isease, rug-foo, an rug-lab interactions Contrainications for rug therapy Averse rug reactions Compliance, accessibility an afforability Nee for alternative or aitional therapies to optimize care 3. Integrate information to esign, recommen, implement, monitor an evaluate patient specific pharmacotherapeutic regimens to prevent or resolve meication-relate problems in unerserve populations. 4. Assess patient meication aherence an evelop strategies for improving aherence in unerserve patients. 5. Develop a level of comfort in interacting with other healthcare proviers an an appreciation of the roles of the various members of the healthcare team. 6. Avise physicians an other healthcare professionals on appropriate rug therapy base on clinical efficacy, safety, availability, ease of aministration an cost-effective prescribing. 7. Demonstrate effective communication skills with unerserve patients in interviews an eucational sessions. 8. Demonstrate effective communication skills with healthcare professionals in written an verbal format. 9. Respon to information requests from patients an healthcare professionals through appropriate rug literature retrieval, evaluation, interpretation, an clinical application. 10. Demonstrate meication history taking skills, meication reconciliation skills, an physical assessment skills. 11. List 3 challenges an rewars of caring for the unerserve population. 12. Ientify the role of pharmacists in aressing health isparities. an referre patients to the program. Uner the supervision of a faculty preceptor, all stuents unertook the responsibilities of a primary care pharmacist, proviing comprehensive clinical services, an were accountable for their patients meication therapies an outcomes. Services provie inclue but were not limite to patient eucation, physical assessment, initiation, moification, monitoring, an evaluation of rug therapies, an contributions to meication-relate policies an programs. Multiple irect patient interactions provie abunant opportunities for stuents to evelop patient care skills, cultivate patient trust, refine counseling techniques, promote continuity of care, an foster positive relationships with the clinic staff members. In aition, stuents worke sie-by sie an collaborate with a primary care provier an nursing staff to recommen appropriate patient-specific rug therapy 2 half ays per week. This allowe stuents to establish themselves as the primary pharmacy resource for the team. All stuents contribute to eucational (eg, in-service presentation an pharmacy newsletter) an clinical services. (A table linking APPE activities to the AACP Curriculum Framework eucational outcomes is available upon request from the corresponing author.) Another unique feature of this course was the Patient Empathy Moeling exercises. Stuents were aske to 5 live the life of an unerserve patient with multiple chronic iseases while coping with an economic (homeless), cultural (Hispanic), or communication (illiterate or hearing-impaire) barrier for 10 ays. 8 This Patient Empathy Moeling peagogy was esigne to sensitize pharmacy stuents to the issues face by the unerserve an enhance stuents humanistic attitues in caring for unerserve patients. Assessment. Utilizing a scoring rubric for the mian summative rotation assessments, stuent performances were evaluate on 3 main components: (1) professional work habits an abilities; (2) clinical knowlege, jugment, an management; an (3) rug information an oral-written communication skills. Specific forms were use to evaluate assigne projects an presentations. As stuents complete require chart reviews before patient visits an provie proactive recommenations, frequent clinical iscussions on patient cases serve as a mechanism to assess stuents ability to retrieve an present relevant information, critically evaluate rug therapies, ientify rug-relate issues, an formulate eviencebase therapeutic plans. Successful elivery of patient-centere care require stuents to learn how to interact with iverse patients effectively. As each stuent worke alongsie the faculty preceptor uring patient encounters, their abilities

6 to integrate clinical knowlege an skills were ultimately assesse through patients feeback, comprehension, an response to etermine evience of clinical an cultural competence in elivering patient-centere care. Formative assessments were provie to stuents throughout the APPE. At the en of the rotation, stuents complete a final written assignment in which they reflecte on their overall learning an perceptions of caring for the unerserve patients. Successes. Although stuents gaine therapeutic knowlege, clinical skills, an confience uring the APPE, one of the most valuable aspects of stuent learning was their ability to tailor healthcare elivery to meet iniviual patient nees an formulate patient-specific rug therapy recommenations when optimizing care for iverse an unique iniviual patients. As stuents evelope a sincere unerstaning of patient s circumstances, they left the APPE with new perspectives an their preconceive notions regaring the unerserve ispelle. One stuent conveye in the final reflection paper, I ha some struggles at the beginning of the rotation when I walke into a consultation room an the patient ha boy oor, irty clothes, an poor hygiene. However, by the en of the rotation it seeme like I i not notice these things anymore. Instea of looking at the outwar appearance, I starte seeing the patient as someboy who neee my compassion an professional avice. This type of change in attitue was important since genuine concern an sensitivity towar the unerserve will be neee in future pharmacists if health isparities are to be alleviate. Successful stuent learning require consistent supervision an strong mentoring from preceptors uring the clinical APPE. These components were critical in this unique practice environment because many stuents are not comfortable with caring for the unerserve, a population that is often negatively portraye by the general public. Sufficient patient encounter time was crucial for stuents to personally interact an buil a trusting relationship with their patients that encompasse listening, unerstaning, an appreciating patients iniviual backgrouns. Fostering the pharmacist-patient relationship helpe stuents recognize an acknowlege the uniqueness an humanity of each patient. Through this mutually beneficial relationship, meically unerserve patients gaine access to quality healthcare an pharmacy stuents gaine valuable insights into patient care while they experience the enless rewars that caring for the unerserve offers. Remaining challenges. Although limite manpower an resources, lack of access, an psychosocial barriers will remain challenges for all healthcare professionals in 6 caring for the unerserve, one major barrier arises from the societal stereotype of this unerprivilege an unerserve population. Base on the faculty members unpublishe finings prior to starting the APPE, many stuents ha limite unerstaning of the unerserve an thus ha evelope negative misconceptions. These misperceptions may have negatively affecte stuents esire to work with unerserve populations an may have compromise the quality of healthcare elivery. Overcoming these prejuices an cultivating the esire an ability to provie quality care requires a team effort from pharmacy colleges an schools an eucators. To maximize the impact of APPEs such as this, colleges an schools woul benefit from longituinally implementing an integrating relate content early in the curriculum (eg, iactic an laboratory courses, introuctory pharmacy practice experiences) in orer to spark stuents interests an enhance unerstaning of the unerserve. Early, mentore, irect patient exposure will not only promote stuent awareness, attitues, an knowlege about unerserve populations, but also provie critical care an services to these patients. Learning Across Borers: An International Experience Course escription. A University of Iowa Service Learning Institute spawne a collaboration among faculty members in engineering, writing, an pharmacy that le to the creation of International Perspectives: Xicotepec, the University s first international service-learning course. The 2 semester-hour course was esigne to introuce multiisciplinary stuents to the benefits, challenges, an logistics of partnering with nonprofit organizations an community members to provie service in a community in a less evelope country. In collaboration with International District 6000 an Xicotepec Rotary members, stuents evelope iscipline-specific projects aime at aressing community ientifie health, social service, an environmental nees in Xicotepec, Mexico. These nees have been previously ientifie by the Xicotepec Rotary group. The course was coorinate by 3 instructors, each representing one of the 3 isciplines, an was given over over 9 consecutive weeks. It inclue 7 weeks of iactic coursework an project esign, 1 week onsite in Xicotepec executing the projects, an 1 week preparing an elivering a final report an public presentation. For spring 2007, the cost of the trip per iniviual was $1000. Stuents were informe of the costs associate with the course upon enrollment. Iowa Rotarians arrange all the travel, housing, an meals for instructors an stuents. Iniviual instructor travel-relate expenses were

7 Table 4. International Service-Learning Course Objectives Describe the process by which Rotary International establishe the Xicotepec Project: commitment, funing, nees assessment, sustainability. Collaborate to construct a fact book (portfolio) for Xicotepec an the various projects. Unerstan the concept an goals of reflection an systematically apply reflection to this learning an service experience. Interpret the tenets of professional behavior in the Xicotepec environment an apply them appropriately. Exhibit best practices for teamwork an team writing. Collaborate with Rotary International an Xicotepecians to construct a plan to achieve profession-specific goals for a team project. Work with Rotarians an local people to execute the plan in Xicotepec. Analyze the elivery, value, an sustainability of the plan. Recommen future irections for the project. Deliver a escriptive, evaluative, an reflective presentation following the experience in Mexico. covere to various extents through the University of Iowa International Programs, iniviual iscretionary faculty funs, an personal funs. While stuents were not guarantee funing support, course coorinators set a goal of ientifying funing for all but $200 of a stuent s expenses. In 2007, the goal was achieve by tapping into the University of Iowa international programs an stuent government funs, Rotary International funs, an each instructor s faculty iscretionary funs. Through the course an experiences in Xicotepec, stuents evelope an appreciation for the role of international service, enhance their knowlege an unerstaning of their primary isciplines, an prepare culturally an professionally for effective teamwork in an international environment. Reflection assignments/ exercises enhance the knowlege an skills stuents gaine an applie uring the service project in Xicotepec. Course objectives. The overall goal was to prepare stuents to successfully function in a profession-specific manner in a less-evelope country. Common course objectives for all stuents are liste in Table 4. Course content. During the first 7 weeks, the class met for 2 hours each week. The first hour was spent iscussing a variety of scheule topics that efine expectations, prepare stuents for the trip, an promote maintenance of the University of Iowa-Xicotepec Rotary relationship. (A table linking course content an activities to the AACP Curriculum Framework eucational outcomes is available upon request from the corresponing author.) In the secon hour of class, stuents separate into their iscipline-specific teams: engineers, pharmacists, writers. Instructors in each iscipline presente an le iscussions on topics relevant to their stuent group s project. A meication management project ientifie by the Xicotepec Rotarians as highly valuable to their community was school-base eworming for preschool an elementary school chilren. The prevalence of intestinal worms in Xicotepec chilren was estimate by local 7 health care professionals to range between 27% to 90%. Deworming in schools was an important public health activity an consiere safe an effective by the Worl Health Organization (WHO). 9 This project presente specific meication therapy management challenges, incluing ientification of the rug of choice, selecting the most appropriate source, ensuring rug quality, etermining the logistics of rug procurement an aministration, an ocumentation of both aministration an the intervention experience. Using information available from the WHO, the Worl Bank, an the literature, the stuents selecte albenazole, 400 mg, single ose, over mebenazole Both rugs are highly effective against ascariasis (rounworm). Albenazole is more effective for hookworm (Necator an Ancylostoma) infections, while trichuriasis (whipworm) may require multiple oses of either meication. Albenazole is also better absorbe than mebenazole. Multiple sources of a generic preparation were ientifie for use outsie the Unite States. The stuents ecie to purchase albenazole, 400 mg, chewable tablets from Cipla Lt, a prequalifie manufacturer with WHO inspection reports, base on cost an the provision of a certificate of analysis. 11 The portion of the course spent onsite also raise spontaneous challenges an learning opportunities for the stuent teams. The community requeste an aitional intervention from the pharmacy group, fluorie application for the chilren s teeth, in conjunction with the eworming. Aitionally, the pharmacy stuents serve as the meical information resource for over 40 travelers in the group. Assessment. Each course instructor evelope their own stuent assessment an iscipline-specific graing rubrics. The pharmacy stuents were assesse in 4 omains: (1) participation (20%), (2) reflection (20%), (3) written final report (40%) an (4) platform presentation (20%). Participation was objectively etermine by irect instructor observation of iniviual stuent contri-

8 bution to the group project an interaction in group work. Activities inclue weekly iniviual performance reflections an 3 iniviual critical incient reflections of the Xicotepec experiences. Following the week in Mexico, the stuent teams compose a group reflection. The final written report escribe the project, ocumente its outcome, an provie recommenations for future trips. Each group s platform presentation consiste of a slie presentation ocumenting the projects, outcomes, an impact on the stuents professional an personal lives an was elivere through a program hel for District 6000 Rotarians, friens an family of the travelers, university aministrative officials from each college, an representatives from the International Programs an Provost s Offices. The stuents evaluate the course an its instructors using stanar university course evaluation survey instruments. Written reflections an iscussions with faculty members an Rotary District 6000 members after the trip provie aitional information regaring the impact an efficacy of course logistics an experiences. Aitional feeback from the Xicotepec Rotary Club was solicite by District 6000 an relaye irectly to course instructors an stuents. Successes. International Perspectives: Xicotepec was foune on the philosophy that the course shoul provie collaborative service, reflect provision of self-ientifie community nees an be sustainable. In the year following its first offering, the course became a highly visible an unique example of interisciplinary internationalization of the curriculum at the University. Overall, it has been a resouning success for all partners stuents, faculty members, the University, Rotary International, an the Xicotepecians. Five pharmacy, 6 engineering, an 5 writing stuents participate in the first course offering. One of the 5 pharmacy stuents grauate in spring As further evience of the personal an professional growth obtaine through the course, the remaining 4 stuents chose to participate in international APPEs. One stuent, a PharmD-MPH joint egree caniate, will o an MPH practicum in Xicotepec. Iniviual stuents were approache an aske to present their Xicotepec experience in several acaemic an non-acaemic venues. The impact of the course on stuents is reflecte in these comments from the 2007 pharmacy team: The experience of the Xicotepec Project has allowe us to be comfortable ealing with patients who come from ifferent cultural an socioeconomic backgrouns as well as communicate using a ifferent language. In response to this language ifference, we were able to improve our Spanish skills which will certainly benefit 8 us in communicating with our future patients. Perhaps the greatest professional avantage of this experience was the opportunity to interact with real patients in a non-scripte, uncontrolle environment. We were force to aapt our plans, problem solve an make ecisions without the luxury of lengthy eliberation. As future pharmacists, these skills will prove invaluable to our clinical jugment an management capabilities. Through the course experience, the pharmacy stuents successfully functione in a profession-specific manner in a less-evelope county. During the 2007 trip, approximately 2000 preschool an elementary school chilren were eworme. As proof of the perceive beneficial value of the project, the Xicotepec public health officials requeste that stuents provie the eworming service annually. Rotary International District 6000 members believe their partnership with the University of Iowa an the Xicotepec Rotary Club was a scalable moel for other Rotary clubs. The Xicotepec collaboration has been highlighte at state, national, an international Rotary meetings. The overall success of the course itself was also emonstrate by the interest it attracte from other isciplines on campus. The spring 2008 trip inclue a nursing faculty member an an eucation faculty member who participate to ientify roles for their stuents for the 2009 course. Spanish language stuents will also participate in the 2009 course. The experiences of the original instructors allowe them to provie structure an support to new faculty members as they became involve in the course. Finally, the projects offere expane opportunities for collaboration with faculty members in other isciplines. The course experiences an projects also offere the potential for future international community-base research an scholarship for faculty members an stuents. Remaining challenges. As the first course offering unfole, instructors ientifie several content an peagogy-relate issues to be aresse in subsequent courses. Due to perceive time constraints for covering common course content, future offerings were a full semester (16 weeks) an increase to 3 creit hours. The extene length allowe stuents aitional time for group reflections an processing recommenations for future course offerings an trips. Serious logistical challenges encountere uring actual travel (ie, supplies confiscate by Mexican customs), offere opportunities for stuents to problem solve, cooperate, an evelop leaership skills. The 2008 goal for the pharmacy project was to reach 3000 chilren. Over 3100 were eworme. Unfortunately the University s 2008 spring break coincie with Holy Week in Mexico. Rotary scheule the trip for the week

9 prior to spring break, when first- through thir-year pharmacy stuents were in class. Therefore, only fourth-year stuents who coul take the course as an APPE participate in the trip for Two fourth-year stuents enrolle in the 2008 course offering as an APPE. In the future, the trip will be arrange to avoi scheuling conflicts. The pharmacy stuents also ientifie aitional challenges encountere uring project rollout to be consiere in the future. Linking the pharmacy team with teeth fluoriation was eeme an inefficient use of time. The unexpecte extent of cavity presence in the chilren s teeth raise questions about the public health value of fluorie application. Stuents observe that a significant number of chilren ha trouble chewing the albenazole tablets. The tablets ahere to ental caries an crevices, making it ifficult to apply the fluorie. For future course offerings, pharmacy projects will concentrate on eworming an other specific meication-relate issues. A future pharmacy team will be charge with the clinical problem of creating an albenazole prouct suitable for chilren who cannot chew the tablets. Finally, the multiisciplinary nature of the course was clearly one of the course s greatest strengths, as eucators are increasingly focusing on interprofessional learning environments an opportunities. As the number of isciplines an instructors in the course increases over time, it may be challenging to maintain the cohesiveness an the ientity that evelope within the initial small group. It may be necessary to either exten course offerings an/or limit the number of isciplines/stuents involve in each offering over time to maintain a consistent quality of experience from the course itself. DISCUSSION The exemplars escribe illustrate innovative curricular approaches to proviing stuents with the opportunity to learn an gain experience working with unerserve populations. They provie a variety of examples of how this material may be imparte an aresse in ifferent learning environments. At a time of continuing faculty shortages an, for many public institutions, contracting financial resources, issemination of novel curricular approaches allows schools to benefit from the knowlege an experience of other institutions. The exemplars also provie examples of how schools may collaborate with acaemic an community partners to evelop an eliver curricular opportunities for stuents to gain knowlege, skills, an experiences in serving the unerserve. Limitations inclue enforcement of stanars/guielines by accreiting boies that continue to emphasize the nee for soun curricular evelopment, implementation, an assessment in this subject area. Continuing scrutiny 9 an evaluation in these areas woul ensure grauates are able to assess an meet the nees of unerserve populations. This may positively impact patient care an outcomes an iminish health isparities. Further research in this area is necessary to emonstrate the effect that making curricular changes to aress the nees of unerserve populations may have on patient care. CONCLUSION The 3 exemplars presente provie concrete, etaile examples of how some colleges an schools of pharmacy are proviing innovative eucational experiences relate to unerserve populations. In isseminating these moels, we hope other schools may utilize an share knowlege to implement an/or refine their own curriculum. Ultimately, it is hope that pharmacy schools will share their eucational innovations an experiences in caring effectively for the unerserve. ACKNOWLEDGEMENTS The authors woul like to acknowlege all of the eucators who submitte 1 or more applications for an exemplar to the Task Force for their innovation an eication to fostering stuent pharmacists awareness, attitues, knowlege, an skills in caring for unerserve populations worlwie. The authors woul also like to acknowlege their colleagues on the Task Force for their contributions towars the exemplar selection process an support of the manuscript. REFERENCES 1. AHRQ National Healthcare Disparities Report. Rockville, MD: USDHHS, AHRQ; December AHRQ Pub No Accesse February 4, Institute of Meicine (IOM).Unequal Treatment: Confronting Racial an Ethnic Disparities in Health Care. Washington, DC: National Acaemy Press; American Council on Pharmaceutical Eucation (ACPE). Accreitation Stanars an Guielines for the Professional Program in Pharmacy Leaing to the Doctor of Pharmacy Degree. Chicago, IL: ACPE; ACPE_Revise_PharmD_Stanars_Aopte_Jan pf. Accesse January 12, American Association of Meical Colleges (AAMC). Cultural competence eucation for meical stuents. Washington DC, Accesse January 12, American Association of Colleges of Pharmacy. Caring for the Unerserve. A elineation of eucational outcomes organize within the Clinical Prevention an Population Health Curriculum Framework for Health Professions. April Available at: _CaringfortheUnerserveCurriculumFramework(2).pf. Accesse February 4, 2009.

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