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

Preparing for Future Pharmacist Roles

[We must] work to solve the challenges of attaining adequate numbers of pharmacists to manage the increasing prescription volume, and adequate support help for dispensing functions, so pharmacists may devote an appropriate amount of time to direct patient care.
NACDS-APhA-NCPA White Paper, 1999 [14]

...the continued requirement for pharmacists to maintain ownership and oversight of drug distribution requires that we re-think the linkage of the systems of pharmaceutical care and dispensing."
Cohen, 1999 [53]

Pharmacy education has a responsibility of preparing not only for the present but also for the future, even innovating for the future and guiding the course of the profession.
Alan Brands, 1969 [54]

Whereas forecasting the future may be impossible, preparing for the future is possible if one gathers and analyzes information based on knowledge of past and present trends. Germane to the themes of this White Paper are some important observations that should be considered as pharmacy prepares to shift toward a profession-wide, patient-centered practice model.

Revising the goals, content, and processes of pharmacy education will not in and of itself change practice.[7] Although pharmacy educators have a responsibility to prepare their graduates for evolving professional roles, academia alone cannot create these roles in sufficient number to impact broadly on the practice of pharmacy. Academia can help to innovate, but any sustainable change in pharmacy practice ultimately must be driven and maintained by the practice community. Indeed, past efforts to educate and prepare graduates better for new professional activities have, ironically, distanced academia from the profession it serves.[17] In the absence of an empowering practice environment, new graduates eventually become disenchanted by the mismatch between what they are "taught" and what they actually "do"; and more mature members of the profession grow increasingly convinced that the academy has lost touch with the real world. "Overeducated and underutilized" has served at times as a mantra for the profession.

Implications. Pharmacy educators must work more closely with the profession, particularly in the areas of experiential education, development of new patient-centered practice models, and student professionalization. Likewise, involving pharmacist leaders from the community who are willing to serve as adjunct faculty can promote leadership development and enhance profes-sionalization among the student body. Colleges also must seek to collaborate with health systems and organizations to finance and develop demonstration projects that explore new, evolving models of pharmacy practice. Exposing students to these practices may foster further development and propagation of successful models in years to come. However, it is important that academia recognize that a substantial period of time may be required to develop empowering practice environments that globally impact the profession. In the interim, pharmacy school faculty and administrators should make every attempt to ease student frustrations with the mismatch between education and practice, while still maintaining their resolve to prepare graduates for future patient care roles.

A revolutionary practice mission will not revolutionize practice if it cannot be implemented. As noted previously, since the profession-wide endorsement of the pharmaceutical care mission, the vast majority of pharmacists' practices have undergone little change.[7,14,24]

Implications. Practitioners should recognize that new roles can be achieved only if a new practice model is established that is aligned with the new professional mission. This requires investment in the new mission by all segments of the profession. As a reality check, pharmacists and pharmacy students must be made aware of the fact that traditional pharmacist activities, including patient education and counseling, do not alone constitute pharmaceutical care. Professionals must work together patiently, honestly, and meaningfully to revise pharmacy's practice systems to support a level of patient care that genuinely affects patients' drug therapy outcomes.

Patient-centered, clinical services have a positive impact on patient outcomes and health care costs.[55,56,57,58,59,60,61] The efficacy of the clinical patient care activities provided by pharmacists has been demonstrated convincingly in institutional, ambulatory, and community pharmacy settings (Table 1). These data provide ample evidence that pharmacists' patient care activities can be fiscally and medically prudent, regardless of practice setting.

Implications. The time has come to accept that adequate data have been generated to validate the benefits of pharmacists' clinical activities. All sectors of the profession (academia, clinical, community, institutional) now must move forward in a unified fashion to confidently advocate and market pharmacy's patient care roles to patients, payers, health care system administrators, and politicians. Meanwhile, additional randomized, controlled studies are needed to rigorously analyze the true costs of pharmacists' clinical patient care activities and to document the relative outcomes produced by these activities compared to those of traditional medical care.[62] These data will be invaluable to the profession as it seeks to establish its place in our increasingly competitive health care environment.

Approximately 90% of practicing pharmacists hold the baccalaureate pharmacy diploma as their sole degree and have been involved primarily in dispensing prescriptions.[63] Inadequate mechanisms are currently available to accomplish the retraining necessary for these practitioners to fulfill new clinical practice roles.

Implications. This observation leads us to the undeniable conclusion that profession-wide retraining will be needed for pharmacists to assume true patient care roles. We believe that some segments of the profession may have underestimated the importance and enormity of this task. A broad-based, inclusive planning process involving all pharmacy organizations and associations must be initiated to address this issue.

Collectively, the clinical pharmacy practice community (including ACCP) and pharmacy education possess the expertise necessary to create new, practical, and valid means of retraining pharmacists for emerging patient care roles.[64] However, these sectors of the profession have not yet fully committed to partnering with community pharmacy to create effective, appropriately rigorous retraining mechanisms.

Implications. 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. The ACCP's involve-ment in community pharmacy training and certification is essential. We believe that the clinical pharmacy community, working collabo-ratively with academia, is both ready and able to begin this task.

Community pharmacy, and to some extent institutional pharmacy, face serious challenges in establishing patient care practice roles. Barriers to change include rapidly increasing prescription volume; limited opportunity to appropriately deploy pharmacy technicians in the drug distribution process due to legal prohibitions; inability to fully employ technology due to its expense; lack of access to patient-specific data; inefficient and restrictive pharmacy benefit programs; lack of reimbursement for non-distributive services; workforce dissatisfaction; a relative paucity of clinical education and practice models in community pharmacies; and shortages of both traditionally prepared practitioners and clinical pharmacists.[14,56]

Implications. We believe that it is essential that academia and clinical pharmacy recognize the significant challenges facing community and institutional pharmacy. It is equally important that community and institutional pharmacy leaders commit themselves to pharmacy's patient-centered philosophy of practice as they address these challenges. Finally, pharmacy educators and clinicians should begin immediately to work cooperatively with community and institutional pharmacy to assist in development of new education and practice models, share data on the cost-effectiveness of clinical pharmacy services, and develop new types of training programs.

Pharmacy technician training is not standardized and remains inconsistent across the profession.[14,25,65] Given this potentially uneven preparation of technicians, a valid certification process is necessary to ensure that technicians possess the knowledge and skills required to perform competently. Although more than 54,000 pharmacy technicians currently are certified by the Pharmacy Technician Certification Board (PTCB), this represents a significant minority of the total workforce of more than 150,000 pharmacy technicians employed in the community or institutional setting.[66,67,68] Even if it were universally permitted by law, many pharmacists would hesitate to delegate distributive functions to technicians due to a lack of confidence in the competence of some support personnel.

Implications. Pharmacists must advocate the recruitment and utilization of well-trained, nationally certified pharmacy technicians who can be deployed in appropriate dispensing roles, under pharmacist supervision. The term "pharmacy technician" should be applied only to those individuals who have completed minimum training requirements and who are certified by the PTCB.[69] Standardized training of pharmacy technicians should be a high priority for the profession to ensure public safety, and pharmacy employers must be encouraged to employ only nationally-certified technicians.[65] Pharmacy education should consider expanding its role in the standardization and validation of technician training. We agree with the Millis Commission's assertion:

"The definition of that [technician] training will be the joint responsibility of the pharmacy profession, pharmacy education, and the state boards of pharmacy. The general supervision of training, however, should be the responsibility of the colleges of pharmacy... the pharmacy colleges must play a significant and active role in the curriculum design, in the setting of standards, and in supervising the teaching of pharmacy technicians." [25]

Despite its position as a highly trusted profession, pharmacy has been unable to advocate its patient care role effectively with political decision-makers.[7] In particular, we believe that the clinical pharmacy community has maintained a relatively low degree of visibility on state and national political landscapes. This observation notwithstanding, national community pharmacy organizations and trade associations appear to possess greater strength in these arenas.[70]

Implications. We suggest that this is an opportunity for pharmacy organizations to work together synergistically on state and national political advocacy efforts that both strengthen and unify the profession's message regarding pharmacists' contributions to patient care.

Although attempting to prepare graduates for the collaborative roles necessary to share responsibility for drug therapy with other health care professionals, the vast majority of pharmacy schools are not yet delivering interdisciplinary didactic course work.[63] There is also a relative underemphasis on team-building and inter-disciplinary health management skills in the typical pharmacy curriculum. Similarly, acquisition of the abilities necessary to collaborate with and manage pharmacy technicians is not a component of most current program curricula.

Implications. If pharmacists are to be skilled in working collaboratively with other health care professionals, then a portion of their educational experience, including didactic learning, should be conducted in interdisciplinary settings. Whereas most experiential rotations today are interdisciplinary, this could change in the future if increasing numbers of pharmacy practice experiences are conducted in the community pharmacy and managed care settings. The Millis Commission made the following recommendation: "Because pharmacists must practice in association with other health workers, pharmacy education demands an environment in which other health professionals are being educated and other health professions are being practiced."[25] Similarly, if students will be expected to supervise and manage pharmacy technicians, then learning to work with them also should be an objective of the pharmacy curriculum.

Current residency training opportunities are inadequate to meet both contemporary quantitative and qualitative needs. Although the past 20 years have produced significant progress in the development of postgraduate clinical training programs, the vast majority of these programs are restricted to institutional and clinic practice settings. It has been estimated that approximately 5% of the pharmacy workforce has completed residency training.[71]

Implications. Clearly, there is currently an inadequate supply of clinically trained pharmacists to deliver widespread patient care. As pharmacy's professional roles change, there will be both an enhanced need within the profession, and an acute demand among graduates, for residency training. Academia and practitioners must continue to place high priority on the development and expansion of pharmacy residency training. We agree with Ray's recommendation that every effort should be made to preserve the current levels of pharmacy residency reimbursement that are secured through Medicare.[71] In addition, expansion of residency training in the community pharmacy setting should be pursued aggressively through partnerships among community pharmacy, clinical pharmacy, and academia. Flexible and innovative approaches to the development of residency programs in the community pharmacy setting (e.g., mini-residencies) may provide practical and cost-effective alternatives for those experienced baccalaureate-educated pharmacists who seek retraining.

Pharmacy education has engaged in widespread curricular change to better prepare graduates to assume increased responsibility for patient care.[7] Whereas considerable emphasis has been placed on expanding and integrating course work in the basic and applied sciences, information technology, literature evaluation, and population-based management, less attention has been devoted to the development and growth of pharmacists as professionals.[55]

Implications. Pharmacy education should seriously consider placing renewed emphasis on the integration of general education outcomes (e.g., critical thinking, decision-making, valuing and ethics, communication, social interaction and citizenship, self-learning) with professional outcomes to prepare truly patient-centered, caring pharmacy professionals.[72] By integrating and building on the perspectives and skills obtained from the liberal arts, the pharmacy curriculum will produce graduates able to function as professionals and informed citizens in a changing society and health care system.[73]

The foregoing observations are not intended to offer a comprehensive list of all factors that will impact the preparation of pharmacists for future professional roles. However, they do provide opportunities for increased thought and dialogue among the profession as it seeks to plan strategic action for the future.

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