A Vision of Pharmacy's Future Roles, Responsibilities, and Manpower Needs in the United States

This paper was prepared by the 1997-1999 ACCP Clinical Practice Affairs Subcommittee A: Michael S. Maddux, PharmD, FCCP, Chair; Betty J. Dong, PharmD; William A. Miller, PharmD, FCCP; Kent M. Nelson, PharmD, BCPS; Marsha A. Raebel, PharmD, FCCP, BCPS; Cynthia L. Raehl, PharmD; and William E. Smith, PharmD, PhD

Pharmacotherapy. 2000;20(8) 

In This Article

Executive Summary

Purpose

This White Paper examines the pharmacy profession's future. It discusses pharmacy's changing philosophy of practice, factors influencing the evolution of professional roles and responsibilities, preparation for future roles, future leadership and management needs, workforce manpower projections, and qualifications for practice. The paper projects a vision for this future and provides recommendations to the profession and to the American College of Clinical Pharmacy (ACCP).

Toward a Unified Philosophy of Practice

The time has come to unify the profession in pursuit of its patient care mission. Pharmacy is maturing as a clinical profession and presently is well positioned to transform itself from a product-oriented to a patient-oriented profession. At the root of this change is a movement to revisit the true focus of the profession -- namely, the patient. The profession as a whole now must unequivocally dedicate itself to a philosophy of practice that clearly identifies the patient as its primary beneficiary. We suggest that inculcation of this new philosophy will require a rational, practical, and inclusive approach that engages all segments of the profession.

Issues Influencing Change in Pharmacist Roles and Responsibilities

Pharmacists gradually are embracing changing professional roles. However, several factors may serve to impair the adoption of new roles, including lack of consensus regarding the profession's goals, resistance to broadening the pharmacist's responsibilities beyond dispensing functions, lack of professional competence and/or self-confidence, the false impression that managed care invariably will decrease pharmacist demand, dissension surrounding adoption of the doctor of pharmacy as the sole professional degree, work environments that provide little or no opportunity for patient-centered practice, lack of reimbursement for pharmacists' clinical services, and underdevelopment of practitioners' interpersonal skills. Factors that appear likely to promote changing professional roles include opportunities to positively impact patients' drug therapy outcomes through disease state management, expanded use of technology and technicians in the dispensing process, increased demand for drug information among health professionals and consumers, new opportunities for creating tailored drug therapy as the field of pharmacogenomics is better understood, and expanded practice roles in community, ambulatory, long-term care, and home care settings. Regardless of the issues confronting future practitioners, it is clear that we will be called upon to provide evidence that justifies these new professional roles.

Preparing for Future Pharmacist Roles

A number of steps should be considered as pharmacy prepares to shift toward a profession-wide, patient-centered practice model. More effective collaboration between pharmacy educators and the profession will be necessary to improve experiential education, develop new patient-centered practice models, and increase student professionalization. Pharmacy practice systems must be revised to support a level of patient care that genuinely impacts health outcomes. The time has come to accept the proven health care benefits of pharmacists' clinical activities and move forward to confidently promote these patient care roles to patients, payers, health care system administrators, and politicians. A broad-based, inclusive planning process involving all pharmacy organizations and associations will be necessary to address the profession's vast retraining needs. In this regard, pharmacy faculty and clinical practitioners must make the commitment to provide the expertise and cooperation necessary to develop efficacious education and training programs that can enhance the clinical practice abilities of community pharmacists. There is a need for community and institutional pharmacy leaders and managers to commit themselves to pharmacy's patient-centered philosophy of practice as they address the challenges associated with establishing new patient care roles. Increasing the recruitment and utilization of well-trained pharmacy technicians to carry out appropriate dispensing functions under pharmacist supervision will be critical to the successful development of new pharmacist practice roles. Clinical pharmacy would benefit from increased involvement in political advocacy at the state and national levels; this might be accomplished best by working synergistically with those national pharmacy organizations and associations that have well-established political links to important decision-makers. Pharmacy educators can strengthen their efforts to develop students' abilities to collaborate with other health care professionals, function in a team environment, and supervise technical personnel. Continued expansion of residency programs in all sectors of practice will be necessary to meet future needs for clinically trained pharmacists. Flexible and innovative approaches to residency training may provide practical and cost-effective mechanisms for some experienced baccalaureate-educated pharmacists who seek retraining. Schools and colleges of pharmacy have done a good job in effecting broad-based curricular revision but have not yet focused on optimizing the integration of general and professional education to better prepare patient-centered pharmacists.

Providing Necessary Leadership and Management for the Future

The future health care environment may hold many opportunities for pharmacists if the leadership and management of the profession can respond quickly to focus the profession's efforts on improving patients' drug therapy outcomes. The role of future pharmacy leaders will be to establish innovative working environments by projecting a unifying vision for the profession and providing mentoring to pharmacy managers and staff. All pharmacists must become agents of change. Pharmacy managers who have assembled successful pharmacy teams will be better able to produce data that justify current and future pharmacist roles. All future pharmacists will require greater leadership and management abilities.

Forecasting Manpower Needs

Future demand for pharmacists remains an unresolved issue for the profession. Both future surpluses and shortages of pharmacists have been predicted. Once technology, new centralized dispensing systems, and technicians are widely utilized to increase drug distribution efficiencies, it is likely that the need for pharmacists engaged solely in distribution will decrease. Thereafter, future manpower needs no doubt will be affected by the profession's success in redefining and transforming itself into a discipline that provides care and impacts patient outcomes. If a majority of pharmacists become involved in collaborative drug therapy (both patient-specific and population-based), disease management, and other evolving areas of practice, then manpower demands likely will increase. If pharmacists' professional roles remain unchanged, manpower requirements will be determined primarily by cost-driven changes in drug distribution management. These changes eventually could produce an environment that requires fewer pharmacists to support the future health care system successfully. To address academic pharmacy's manpower problem, there is a need for the academy to recruit new graduates into academic career tracks more effectively, promote expansion of residency and fellowship programs, place increased emphasis on the mentoring of new faculty, and incorporate formal pedagogical instruction into postgraduate training programs.

Qualifications for Pharmacy Practice

The requisite education and credentialing of pharmacists will be important issues as the profession pursues patient-centered practice roles. We believe that the credentialing issue -- in particular the controversy associated with certification -- has the potential to spark the same level of discussion that occurred during the "B.S. versus Pharm.D." controversy. Certainly one must hope that the credentialing/certification issue will not result in the marked polarization that was spawned by the entry-level degree controversy. However, there is still confusion within the profession concerning contemporary education and credentialing. A coordinated national strategy to clarify pharmacist credentialing clearly is needed. The current proliferation of credentialing processes and certification programs that do not undergo rigorous review and assessment has the potential to undermine pharmacists' credibility with providers, the public, and payers. We believe that credentialing within the pharmacy profession should meet rigorous national standards. Pharmacist certification would be administered best through a coordinated national certification board that assuresassures assessment of knowledge and skills while also validating the appropriate level of training or experience. We further suggest that the entire voluntary pharmacist credentialing process (including certification and perhaps postgraduate training) should be coordinated by a national, broad-based credentialing coalition or governing body. Finally, the profession is encouraged to study and assess the value of certification.

A Vision for the Future

The White Paper authors were asked to develop a vision of pharmacy as it might exist at the conclusion of the first decade of the 21st century. Like all visioning efforts, much of what we expect may not come to pass; new, unforeseen developments may profoundly influence the future of the pharmacy profession. However, we offer the following predictions of how events affecting pharmacy may unfold during the next decade:

  • Health care will place increasing emphasis on drug therapy to improve patient outcomes and quality of life. Prescription drug use will continue to rise, creating greater risk of drug-related morbidity.

  • Society will become increasingly technology literate and technology driven. Technology will be deployed fully to dispense most prescriptions, provide drug information to patients, and facilitate the exchange of patient-specific data among and within health care systems.

  • Pharmacy will transform itself from a primarily product-centered profession to a patient care-oriented profession.

  • Patient care rendered by pharmacists, including those not directly involved with drug product distribution, will be reimbursed by payers.

  • Corporate pharmacy and independent pharmacy owners will find pharmacists' patient care services to be profitable and will commit resources to this market, including enhanced use of technology and technicians.

  • State boards of pharmacy and governmental legislation will enable and facilitate pharmacists' patient care activities, both individually and in collaboration with other health care professionals.

  • Technician certification will be mandated to protect the public.

  • Pharmacy education will prepare graduates for increasingly complex patient and population drug therapy management and problem-solving, and supervision of prescription dispensing and processing by technicians and automated technology.

  • Pharmacy schools will experience an unprecedented increase in graduates due to a continued rise in demand for pharmacists, popularity of health care careers, and an increased visibility of pharmacists' patient care roles in the 21st century.

  • Appropriate credentials that document clinical practice abilities will be a prerequisite for all pharmacists that provide patient care services. Eventually, residency training will be an expectation of most entry-level pharmacists.

Recommendations

The White Paper recommendations have been divided into two categories: (1) recommended actions for the entire profession, and (2) recommendations for ACCP and its membership. The recommendations reflect the analyses, forecasts, assessments, and opinions offered in the body of the paper.

Recommendations for the Pharmacy Profession

  1. Adopt a unifying philosophy of practice that establishes the patient as the primary beneficiary of the profession, with the pharmacist accepting shared responsibility with other health care professionals for patient care.

  2. Capitalizing on the collective strengths of national pharmacy organizations, develop a coordinated strategy to secure financial compensation for pharmacists' patient care services that are not directly related to drug distribution.

  3. Create a profession-wide strategy for both the development and use of technology. This strategy should engage pharmacy education and all venues of pharmacy practice to enhance pharmacists' training in, and use of, technology in prescription pro-cessing and distribution, drug information, and drug therapy management.

  4. Work with professional regulators and state legislators to revise pharmacy practice acts to enable shared responsibility for direct patient care, use of appropriate technology and technical support personnel, and collaborative drug therapy management.

  5. Develop credible, coordinated certification and credentialing processes whereby all qualified pharmacists can demonstrate patient care competence.

  6. In academia, focus not only on manpower, but also (perhaps even more) on profes-sional empowerment. Pharmacy educators must maintain high expectations for per-formance of both general and professional educational outcomes; contribute to the development of new post-licensure education and training programs that help existing practitioners "retool"; promote continued expansion of residency programs, including nontraditional programs (mini-residencies); and assume leadership roles in technician training and certification.

  7. Foster collaborative efforts by professional organizations, academia, and health care systems to develop new models of pharmacy practice in the community practice setting.

  1. Collaborate closely with other national pharmacy organizations and assume a leadership role in the profession's adoption of a unifying philosophy of practice.

  2. Place increased emphasis on the development of leadership abilities among the rank-and-file membership.

  3. Embrace community pharmacy and seek to assist community practitioners in acquiring additional knowledge, skills, and attitudes that can expand pharmacists' impact on patient outcomes.

  4. Encourage colleges and schools of pharmacy to explore how current doctor of pharmacy programs can better prepare graduates for contemporary generalist practice.

  5. Encourage the National Association of Boards of Pharmacy (NABP) and individual state boards of pharmacy to continue their efforts toward creating licensure exams that are more reflective of pharmacists' patient care responsibilities.

  6. Support, and assist in the development of, certificate programs and certification processes that provide for appropriate assessment of knowledge and skills while also validating adequate levels of experience.

  7. Oppose pharmacist certification that lacks unique (differentiating) and definable knowledge domains, or adequate assessment of clinical training or experience.

  8. Work inclusively with other pharmacy organizations/associations and the Council on Credentialing in Pharmacy to establish a cohesive and coherent plan for pharmacist credentialing.

  9. Explore the feasibility of engaging in cooperative political advocacy efforts with community pharmacy organizations and trade associations for the purpose of pursuing agendas of mutual professional interest (e.g., reimbursement for pharmacists' clinical activities that improve patient outcomes).

  • Introduction and Purpose

  • Toward a Unified Philosophy of Practice

  • Issues Influencing Change in Pharmacist Roles and Responsibilities

    • Factors that Oppose Changing Pharmacist Roles

    • Factors that Promote Changing Pharmacist Roles

    • Justifications for Changing Pharmacist Roles

  • Preparing for Future Pharmacist Roles

  • Providing Necessary Leadership and Management for the Future

    • Leadership

    • Management

    • Meeting the Leadership and Management Challenges of the Future

  • Forecasting Manpower Needs

  • Qualifications for Pharmacy Practice

    • Curricular Preparation and Licensure

      • Curriculum Standards and Guidelines

      • Licensure

    • Post-Licensure Credentialing

      • Credentialing Options

      • General Elements of Post-Licensure Certification

        • Specialist Pharmacist Certification

        • Added Qualification within a Recognized Pharmacy Specialty

        • Generalist Pharmacist Certification

        • Interdisciplinary Certification

      • Disease-Specific Credentialing

      • Certificate Programs

    • Council on Credentialing in Pharmacy

    • Views on Credentialing

  • A Vision for the Future

  • Recommendations

    • Recommendations for the pharmacy profession

    • Recommendations for ACCP

  • References

... the great need is to look at pharmacy from the point of view of the patient -- that is, unless we come up with something which deals with people, not pharmacists, not research laboratories, not physicians, not nurses, not drug store proprietors, not the system, et cetera, we really have not added much..."
Millis, summarizing the first day of the Millis Commission's deliberations in September, 1973 [1]

It's deja vu all over again!
Yogi Berra, circa 1960 [2]

As these quotations suggest, the issues currently confronting the pharmacy profession are not new. Despite a vivid realization that it must redefine itself as a patient-centered profession, pharmacy's longstanding focus on product has continued throughout the last quarter of the 20th century. However, it is apparent that the changes in United States health care delivery, financing, education, and management systems that transpired during the 1990s have now finally set the stage for meaningful transformation of the profession. This paper presents a vision for the future in an attempt to facilitate that transformation.

In the fall of 1997, ACCP President Jerry Bauman charged a subcommittee of the ACCP Clinical Practice Affairs Committee with developing a White Paper on pharmacy manpower for the future that would "consider such things as likely future roles and responsibilities of pharmacists; the number of practitioners required to fulfill these roles and responsibilities; requisite education and training, and continuing education and training; types and numbers of supportive personnel required; and other issues identified by the committee." President Bauman's intent was to provide for ACCP and the profession an analytical and potentially provocative vision of pharmacy's future as it enters the new millennium. The purpose of this document is not only to provide leadership within the profession, but also to lend guidance to ACCP as it pursues in the future a variety of issues with other organizations. What follows is the subcommittee's best effort to address its task, relying on analyses of information available during its 2-year deliberations.

It is interesting to note that evolving controversies surrounding manpower availability have served as a primary stimulus for much of pharmacy's recent widespread dialogue concerning the future of the profession. Indeed, manpower issues were a major driving force behind ACCP's development of this White Paper, and we devote a section of the paper to this issue alone. This is certainly not a new phenomenon; past manpower problems have prompted segments of the profession to take pause and give due consideration to the future scope of pharmacy's role in health care.[3,4] And, therein lies the most important principle in addressing pharmacy manpower: although quantitative manpower availability is a critical issue that inexorably gains the entire profession's attention, it is only a symptom of more substantive problems that lie at the heart of the issue. In our estimation, quantitative manpower dilemmas can be addressed only through serious efforts that achieve commitment to the qualitative components of pharmacy's professional mission. Once this is accomplished, solutions to the manpower problem can be sought through appropriate strategic planning to operationalize the mission. Whereas in the past such determining and planning of mission may have been optional for many segments of pharmacy, the unfolding economic and political health care environment of the 21st century has positioned the entire profession at a crossroads. Previous published exhortations notwithstanding,[5,6,7] the time has come for concerted, unified action by all stakeholders. It is in this context that the White Paper's observations, analyses, and recommendations have been developed.

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