Changing the Structure of Pharmaceutical Education to Require Doctor of Pharmacy and Postgraduate Residency Education and Training

William A. Miller, Pharm.D., FCCP, FASHP Key Words: education, residency, training. (Pharmacotherapy 2006;26(5):587593) Residency education and training evolved from hospital pharmacy internships that were developed to prepare pharmacy graduates for hospital pharmacy practice. A plan for hospital pharmacy internships at the University of Michigan hospitals was described in 1935.1 The first accreditation survey was conducted in 1963 at Jefferson Medical College Hospital in Philadelphia.2 The first accreditation standard for residency in hospital pharmacy was adopted by the board of directors of the American Society of Hospital Pharmacists (now called the American Society of Health-System Pharmacists [ASHP]) in 1963.2 In 1965, ASHP released a list of 33 hospitals accredited for residency in hospital pharmacy.3 Over the last 10 years (1996 through the fall of 2005), the number of accredited residency programs (including programs pending accreditation) grew from 391 to 761a 95% increase and the number of residents in training increased from approximately 700 to 1400a 100% increase.4, 5 These increases have occurred in spite of manpower shortages and increasing salaries for pharmacy graduates. Residency programs are now offered in hospitals, ambulatory care settings, community pharmacies, managed care organizations, pharmaceutical companies, public health agencies, and other sites. Growing professionwide consensus on the
From the Division of Clinical and Administrative Pharmacy, College of Pharmacy, University of Iowa, Iowa City, Iowa. Address reprint requests to William A. Miller, Pharm.D., College of Pharmacy, Division of Clinical and Administrative Pharmacy, University of Iowa, Room S525 Pharmacy Building, Iowa City, Iowa 52242-1112.

value and need for residencies is evidenced by the publication of a summary of a stakeholders roundtable discussion on residency training held by ASHP, 6 a paper from the Commission on Implementing Change in Pharmaceutical Education,7 a recent report from a task force on residency training by the American Association of Colleges of Pharmacy (AACP),8 editorials and speeches recommending expansion of residency training, 911 the American College of Clinical Pharmacy (ACCP) position statement on residency training as a prerequisite for direct patient care practice (published in this issue of Pharmacotherapy), 12 national practice organizations supporting residency through official policy positions or statements (ASHP and ACCP),13, 14 and increased organizational sponsorship for residency standards (ASHP, ACCP, Academy for Managed Care Pharmacy [AMCP], and the American Pharmaceutical Association [APhA]). In addition to growing support for residency training by the profession, students are increasingly opting to complete 12 years of residency training to further improve their practice skills, confidence, and competence before entering pharmacy practice. Although this trend is impressive, if a diffusion of innovation curve were plotted to show the state of adoption of residency training as a prerequisite to practice, the curve would show that we are still at an early stage, with less than 1520% of pharmacy graduates completing a residency before entering pharmacy practice.15 As noted in the ACCP position statement,12 even though finances are a major barrier to full adoption of this educational model, given the

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With this vision and the evolutionary nature of change or innovations in mind, I offer the following commentary to help accelerate adoption of residencies as a prerequisite to entering pharmacy practice. Pharmacy Residencies versus Doctor of Pharmacy Programs Pharmacy residencies are a component in the continuum for pharmaceutical education (i.e., baccalaureate degree, professional doctorate degree, postgraduate residency training, and continuing professional development). This continuum needs to be designed as a system, with each part building on the next part, and the whole system being greater than the sum of its parts. Curriculum committees guide the development of doctor of pharmacy curricula. Medical residencies are described as being curriculum based, which reflects that they are viewed as educational programs and need to be systemically designed. Some hospital pharmacy leaders view residencies as pharmacy training programs, not as educational programs. Some academic leaders and faculty agree with this viewpoint and feel that residency training is about practical training and not basic education. From my viewpoint, education and training take place in both doctor of pharmacy curricula and residency programs. The training portion of contemporary doctor of pharmacy curricula primarily occurs through professional experience, pharmaceutical care laboratory experience, and case-based courses. Faculties also use active learning methods in the classroom to not only educate but train students. Residents, on the other hand, receive education as well as training to gain new knowledge, develop new skills, and improve practice proficiency throughout their program. The ASHP stakeholders roundtable discussion concluded that residencies are needed to develop the clinical maturity of pharmacy graduates.6 Pharmacy graduates in residency programs mature by gaining additional pharmacotherapy knowledge, sharpening problem-solving and critical-thinking skills, and developing practice proficiency (i.e., competence derived from training and practice). Competency statements in the AACPs Center for the Advancement of Pharmaceutical Education competency list,16 ACPEs competency requirements,17 and ASHPs required outcomes, goals, and objectives for a postgraduate 1-year

continued growth in the number of residency programs and residents in training, students increased interest in residencies, and professionwide leadership and support for residencies, the profession appears to be poised to accelerate the rate of adoption of residency training as a prerequisite to practice. With this in mind, it seems reasonable to envision that over time the structure of pharmaceutical education will be changed to include both a doctor of pharmacy degree and postgraduate residency education and training. Vision for Pharmacy Residencies I fully support the recommendations made in the ACCP position statement 12 and expect the following to occur over time: All residency programs will be accredited. An appropriate organizational structure representing the entire profession (pharmacy practice, academic pharmacy, boards of pharmacy, and the Accrediting Council for Pharmacy Education [ACPE]) will be created to plan, develop, and accredit residency programs. All colleges of pharmacy will offer residency programs through practice sites of the university or through partnerships with affiliated practice sites. All residency programs will be systemically designed, planned, and implemented and will build on the outcomes of doctor of pharmacy degree programs. Outcome assessment data will be used by residency program administrators to improve program design and implementation. Outcome data will also be used by the residency accrediting body to improve standards and make accreditation decisions about specific programs. All pharmacy generalists and pharmacy specialists will be required to complete postgraduate residency education and training programs. All employers will require candidates for pharmacy generalists and specialists positions to have completed appropriate residency education and training (i.e., 1 or more years, depending on the specialized practice area). All employers who are committed to pharmacy practice excellence will require pharmacy generalists and specialists to be board eligible or board certified to practice.

CHANGING THE STRUCTURE OF PHARMACEUTICAL EDUCATION Miller (PGY1) residency 18 are very similar. These similarities beg the question, what is the difference between the competence of a new doctoral graduate and a residency program graduate? Competence of Pharmacy Graduates Pharmacy graduates entering the profession do not have sufficient competence to practice at the level envisioned by the Joint Commission of Pharmacy Practitioners (JCPP). The JCPP vision statement proposes that pharmacists will have the authority and autonomy to manage medication therapy and will be accountable for patients therapeutic outcomes.17 Whether we refer to pharmacy graduates as pharmacists, pharmacy generalists, clinical pharmacy generalists, or clinical pharmacists, the vision of the profession is clearly aimed at producing graduates competent to identify patients drug therapy problems, implement or participate in implementing and managing treatment plans, dispense and administer drugs as needed, provide patient counseling, monitor drug therapy, and consult with other health care providers to improve patient care outcomes. So, the emphasis of pharmaceutical education today and in the future is on developing the clinical skills and abilities of pharmacy graduates. As a health profession, pharmacists are obligated by society to produce competent graduates. This viewpoint is shared by ACPE17 but is at odds with some faculty who believe that our responsibility is to provide pharmacy graduates with fundamental problem-solving skills necessary for practice, with the assumption that graduates will become competent through practice. I, however, prefer not to be a patient of a pharmacist who is still learning basic knowledge, skills, and abilities or who is not yet proficient. Is the inability of some, if not most, doctor of pharmacy degree programs to produce graduates who are competent to function independently at the level envisioned by JCPP due to inadequate design of their curricula? Common problems with curriculum design and implementation include the following: Some required skills may be developed in pharmacy practice laboratories but not in actual practice settings to allow students to demonstrate competence (e.g., training a student to give immunizations in a pharmacy practice laboratory but then never placing

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the student in an actual site that requires the student to give immunizations to patients). Some required skills may be bundled together and assessed as a broad skill category (e.g., providing pharmaceutical care) without giving students sufficient experience to demonstrate competence in specific skills (e.g., a student may gain sufficient experience to demonstrate competence in monitoring drug therapy or providing patient counseling but not gain experience in developing, implementing, and managing treatment plans under a collaborative practice agreement with a physician or other provider). Due to considerable variability among advanced practice experience sites used by colleges, some students may not be able to develop advanced practice skills and abilities. Students who are placed in sites without preceptors that are providing advanced clinical services are less likely to develop the necessary skills to provide advanced services. It should be noted that preceptor variability is also a problem for residency programs. An insufficient amount of professional experience (i.e., insufficient number of repetitions with faculty feedback and coaching to help students become competent) in a curriculum may prevent average students from becoming competent in performing required skills. In the last decade, significant progress has been made by colleges of pharmacy in the area of outcomes assessment. The ACPE currently requires colleges to collect information about their attainment of desired curricular outcomes. Ideally, each college should provide objective assessment data that demonstrate that graduates have obtained the desired knowledge, skills, and abilities and are competent to enter pharmacy practice.17 Although colleges have made progress in collecting outcomes data, many are able to assess only common practice skills or abilities (e.g., patient counseling, rudimentary physical assessment skills such as taking blood pressure, or compounding skills) rather than more complex skills (e.g., developing a problem list and recommending and/or implementing a treatment plan, or assessing the likelihood of a drug causing an adverse event in a patient taking multiple drugs). The new ACPE standards are encouraging and hold the potential to raise the expectations and improve the outcomes of doctor of pharmacy degree programs. The ACPE is

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in advanced practice training, desired curricular outcomes could be achieved by doctor of pharmacy degree programs alone. Residency programs should build on doctor of pharmacy degree programs and should not be used to make up for their deficiencies. The commission should recommend achievable outcomes for doctor of pharmacy degree programs and the rationale for requiring or not requiring residencies as a prerequisite to practice. The commission should also define a curriculum for producing pharmacy specialists and emerging specialties or subspecialties. Labeling residencies (e.g., PGY1, PGY2) is a method to designate the year of residency training in a manner similar to the labeling of doctor of pharmacy students as P1s, P2s, P3s, and P4s. Preparing pharmacists for some specialized practices may require more than 2 years of postgraduate residency training. Integrated 2-year residency programs aimed at preparing pharmacy specialists may be more effective than having residents complete the first year (PGY1) independently from the second year (PGY2). In the same manner that curriculum committees plan knowledge, skill, and ability development over a 4-year period for doctor of pharmacy degree programs, specialized residencies may be better designed and planned over a 2-year period. The work of the commission will most likely take several years and may require collection of additional data from colleges of pharmacy and residency programs to increase the objectivity of the commissions findings and recommendations. Link Between Academic Pharmacy and Organizations Offering Residency Programs In the future, all residency programs should have an established link to academic pharmacy in order to capitalize on the expertise of faculty in systemically designing and implementing education and training programs. This does not mean that all residency programs need to be under the purview of academic pharmacy. Rather, an approach may be used like the one many programs for pharmacy technicians use, whereby the steering committee that provides oversight for the residency program includes faculty from affiliated colleges of pharmacy. Many preceptors who practice outside academic pharmacy settings now hold adjunct faculty appointments and precept advance practice experiences for doctor of pharmacy students.

working to develop better and more standardized ways to evaluate achievement of the standards, including the identification of process and outcomes measures to be monitored across all accredited programs. With time, these efforts should allow ACPE to assess more objectively whether required outcomes from doctor of pharmacy degree programs are actually achieved by all colleges of pharmacy. Residencies as a Prerequisite to Pharmacy Practice At this time, based on available evidence and my own experience, I believe that residencies should be required as a prerequisite to enter practice. I remain skeptical that sufficient change in doctor of pharmacy degree programs will occur, which would eliminate the need for all graduates to complete a residency. Another reason I believe that residency training should be required is that the knowledge, skills, and abilities of pharmacists needed for the future will continue to become more complex, requiring even more education and training than is currently needed. Since this is an extremely important and contentious issue and one that will never be fully resolved by objective data, a professionwide commission should be appointed to put forth a convincing and conclusive direction regarding the role of residencies in the education and training of pharmacists. The ASHP, through the Commission on Credentialing, should facilitate the formation of a commission, in collaboration with interested practice organizations as well as with AACP and ACPE, to jointly determine required and feasible outcomes for the doctor of pharmacy degree and PGY1 residency programs. This commission should assess available educational outcome data to formulate clearly defined, measurable, and achievable outcomes for both programs. Although outcomes for both the doctor of pharmacy degree and PGY1 residency may be similar, the question is if students can fully achieve all outcomes in a doctor of pharmacy degree program or if some outcomes take more education, training, and practice repetitions to achieve. The latter would require students to complete both a doctor of pharmacy degree and residency program. However, by increasing the experiential component of doctor of pharmacy degree programs to at least 2 years and reducing the variability in the experiences students obtain

CHANGING THE STRUCTURE OF PHARMACEUTICAL EDUCATION Miller These existing collaborative relationships could serve as a basis for practice organizations to use college faculty to improve residency programs based on their educational perspectives. Colleges of pharmacy with missions that include offering and advancing residency training should develop a network of residency programs that are linked to the college through partnerships with practice sites. Eventually some colleges of pharmacy will have enough residency positions associated with the college to allow all graduates of the college to obtain residency positions. Strategies to Increase Available Residency Positions All interested organizations must continue to work with ASHP through the Commission on Credentialing to obtain funding from the Centers for Medicare and Medicaid Services (CMS) for PGY2 residency programs. As a part of this effort, practice organizations must prove that pharmacy specialists who have completed both a PGY1 and PGY2 residency are preferred candidates for clinical pharmacy specialist positions needed by the nations health care system. Government funding at the state or federal level should also be explored to support residencies that take place in community settings that are unattached to hospitals or health care systems (e.g., community pharmacies, physician office practices). Colleges of pharmacy associated with university hospitals should further develop pharmaceutical care delivery models that rely on faculty and residents to participate in the delivery of patient care. Pharmacy residents should participate on patient care teams with attending pharmacy faculty year-round to provide consistent and high quality services. Just as it takes a critical mass of faculty and an administration to run a college of pharmacy, a critical mass of preceptors and administrative support are necessary to run a quality residency program. It is not efficient to run a residency program for one resident. From a service perspective, it is not effective to have residents on service 1 month and not the next; the services provided by residents cannot be integrated into the pharmaceutical care delivery model if they are not consistently provided on the delivery team. The best way to increase residency positions in health care systems and hospitals is to increase the number of residents/accredited residency

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program. For example, if the average PGY1 residency had at least 10 qualified preceptors who practice with a specific patient population and an interdisciplinary team, the institution should have at least 10 PGY1 residents to provide consistent service coverage by preceptors and residents. Currently, the average number of residents/program for all accredited residency programs is approximately 1.9. If the number of residents were raised to 10 for each PGY1 program in hospitals, three for each PGY1 program in community pharmacy and managed care settings, and three for each PGY2 or specialized program, we could produce approximately 4355 PGY1 and 840 PGY2 residents, or a total of 5195 residents/year. With this growth alone, we would be more than halfway toward our goal of having all graduates complete a residency program. Programs with large numbers of preceptors would have many more residents (e.g., university hospitals with 30 preceptors would have 30 residents) whereas other programs in hospitals or community pharmacy settings would have fewer residents based on fewer preceptors. A large portion of this increase in residents could be funded using CMS funds and through reallocation of positions to support the services provided by residents while they are learning. Although these projections are overly simplified, to make substantial gains in the number of residency positions available, we need to increase the number of residents/program. For a program to be effective and efficient, it must be large enough to support several residents. The Commission on Credentialing and pharmacy organizations involved with residency training should promote the value and efficiency gains from large residency programs. Greater emphasis should be placed on growth in the number of residents in existing residency programs rather than on growth of new residency programs with one or two residents. Development of a Formal Professionwide Organizational Structure for Planning, Development, and Accreditation of Residency Programs In 1987, ASHP lead an effort to obtain professionwide agreement on the definitions of residency and fellowship. 19 This effort helped the Commission on Credentialing establish standards that require residency programs to be systemically designed and

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clinical practice as envisioned. I am optimistic about the future of pharmacy and believe that the forces favoring continued change in the role of pharmacists will focus on providing direct patient care through the provision of clinical pharmacy services, and this will become normative for the profession. For this reason, the structure of pharmaceutical education needs to be changed sooner, rather than later, to include both doctor of pharmacy and postgraduate residency education and training. References
1. Whitney HAK, Watts ED. A plan for pharmacy internships at University of Michigan hospitals. J Am Pharm Assoc 1935;24:852. 2. McLeod DC. Pharmacy residency and fellowship programs. In: McCleod DC, Miller WA, eds. The practice of pharmacy. Cincinnati, OH: Harvey Whitney Books; 1981:47797. 3. American Society of Hospital Pharmacists. Directory of approved residencies available. Am J Hosp Pharm 1965;22:416. 4. American Society of Health-System Pharmacists. 1996 ASHP national residency preceptors conference: structuring residencies to meet the challenges of changes in contemporary pharmacy practice. Am J Health-Syst Pharm 1997;54:211014. 5. American Society of Health-System Pharmacists. Residency training for pharmacists who provide direct patient care. Policy position 2005. Available from http://www.ashp.org/ bestpractices/education/Educ_Positions.pdf. Accessed February 22, 2006. 6. American Society of Health-System Pharmacists. Pharmacy residency training in the future: a stakeholders roundtable discussion. Am J Health-Syst Pharm 2005;62:181720. 7. American Association of Colleges of Pharmacy Commission to Implement Change in Pharmaceutical Education. The responsibility of scholarship, graduate education, fellowships, and postgraduate education and training. Am J Pharm Educ 1993;57:3869. 8. Lee M, Bennett M, Chase P, et al. Final report and recommendations of the 2002 AACP task force on the role of colleges and schools of pharmacy in residency training. Am J Pharm Edu 2004;68:article S2. 9. Miller WA. Planning for pharmacy education in the 21st century: AACPs leadership role. Am J Pharm Educ 1989;53:3369. 10. Miller WA. Postgraduate residency education and traininga call for action. Am J Pharm Educ 1989;53:31011. 11. Nappi J. The role of residencies in the education continuum. Am J Pharm Educ 2005;69:article 58. 12. Murphy JE, Nappi JM, Bosso JA, et al. American College of Clinical Pharmacys vision of the future: postgraduate pharmacy residency training as a prerequisite for direct patient care practice. Pharmacotherapy 2006;26:72233. 13. American Society of Health-System Pharmacists. Residency town hall. Available from http://ashp.org./rtp/ TownhallMCM 2005.ppt. Accessed February 22, 2006. 14. American College of Clinical Phar macy. A vision of pharmacys future roles, responsibilities, and manpower needs in the United States. Pharmacotherapy 2000;20:9911022. 15. Rogers EM. Diffusion of innovation. New York: The Free Press; 1995. 16. American Association of Colleges of Pharmacy, Center for the Advancement of Pharmaceutical Education. Educational outcomes 2004. Available from http://aacp.org/site/page.asp? TRACKID=&VID=1&CID=1031&DID=6074. Accessed February 22, 2006. 17. American Council on Phar maceutical Education. Accreditation standards and guidelines. Available from http://www.acpe-accredit.org/standards/default.asp. Accessed

implemented as sound educational programs. It helped change the perception of residencies as simply internships or on-the-job training for hospital pharmacists. Before managed care and community pharmacy residency programs began to be accredited by the Commission on Credentialing, residencies were perceived mainly as preparation for hospital pharmacists, which was a reflection of the lack of curricular content on hospital pharmacy in most pharmacy curricula. In addition, there was the belief that clinical pharmacy was only something practiced in institutional and other organized health care settings. The ASHP has reached out to other organizations interested in residency training and has developed joint standards for residency programs in community care, managed care, and pharmacotherapy. The APhA, AMCP, and ACCP now have individuals on the Commission on Credentialing to represent each respective organization. The ASHP is to be commended for the leadership they have played in bringing residency education and training to its current state. Their stakeholders conference was an important professionwide step in further developing consensus on residency education and training. As residency programs grow and become a prerequisite for practice in a variety of practice settings, a more formalized professionwide organizational structure will be needed to provide oversight, establish goals, and approve standards for residency programs. This organizational structure will undoubtedly evolve over time. The ASHP Commission on Credentialing could become freestanding from ASHP or an existing (e.g., Council on Credentialing in Pharmacy) or new organization could be formed to fulfill this role. Conclusion In the near future, pharmaceutical educators and pharmacists need to debate and make a decision on whether the structure of pharmaceutical education should require pharmacists to obtain both a doctor of pharmacy degree and postgraduate residency education and training as a prerequisite to practice. It is now clear that pharmacy graduates planning a career as a clinical pharmacist or clinical pharmacy specialist in any practice setting should complete at least 1 year of residency training. It is less clear whether the profession will achieve its vision for all pharmacy practitioners to engage in

CHANGING THE STRUCTURE OF PHARMACEUTICAL EDUCATION Miller

February 22, 2006. 18. American Society of Health-Systems Pharmacy. Required and elective educational outcomes, educational goals, and educational objectives for postgraduate year one (PGY1) pharmacy residency programs. Available from http://www.

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ashp.org/rtp/PDF/PGY1%20Req%20&%20Elec%20Out%20%2B %20G&O.pdf. Accessed February 22, 2006. 19. American Society of Hospital Pharmacists. Definitions of pharmacy residencies and fellowships. Am J Hosp Pharm 1987;44:11424.