50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Pharmacy residency training
ar Layar
A vision for the future of pharmacy residency training John S. Clark Am J Health-Syst Pharm. 2014; 71:1196-8
A
ny vision for the future of residency training must be strongly connected with a vision for the profession as a whole. This article discusses the trends in health care and in health-system pharmacy that will affect the future of pharmacy residency training, potential changes in the future of pharmacy residencies and in the standards for accreditation, and the future of the relationship between doctor of pharmacy degree (Pharm.D.) programs and residency training. (The opinions and assertions conveyed in this article are those of the author; the ASHP Commission on Credentialing has not taken any position on these topics.) Trends in health care that will affect pharmacy residency training Several broad issues in health care will affect the development of pharmacy residency training and the profession of pharmacy as a whole, including the Patient Protection and Affordable Care Act and continued financial pressure on health care. It is likely that provider status will be attained for pharmacists, which will
give the profession an enhanced opportunity to address cost and quality concerns in health care. Pharmacy residents need to build competencies that are inherent in recognition as a patient care provider. Health care provider organizations continue to consolidate, leading to larger groups of pharmacy residents being trained by individual organizations. Within health care organizations, central coordination and support of residency training are essential in this growth model. Pharmacy students and residents, through their experience with interprofessional patient care teams, will become comfortable with a teambased approach to patient care. Pharmacists will be trained in the future to allow physicians and nurses to be more efficient. Pharmacy residents will be trained to consider their effect on the efficiency, effectiveness, and safety of the health care team. With the promulgation of accountable care organizations and patient-centered medical homes, pharmacy residency training will become increasingly focused on ambulatory care. The transition of focus in health care to prevention
John S. Clark, Pharm.D., M.S., BCPS, FASHP, is Director of Pharmacy Services and Director of Pharmacy Residency Programs, University of Michigan Hospitals and Health Centers, Ann Arbor, and Clinical Assistant Professor, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Chair, Commission on Credentialing, American Society of Health-System Pharmacists (ASHP), Bethesda, MD ([email protected]).
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Am J Health-Syst Pharm—Vol 71 Jul 15, 2014
and wellness will have a profound effect on residency training. Many pharmacy residency programs will offer training primarily at ambulatory care sites. Improving transitions of care will be emphasized by health care provider organizations. The pharmacy profession is uniquely situated to foster smoother transitions for patients, especially with respect to their medication-related problems. Pharmacy departments will establish the involvement of pharmacists as essential to provision of effective and efficient care transitions, which will be given major attention in residency training. Community pharmacy will offer additional clinical services to ambulatory care patients. As community pharmacies support health and wellness programs and focus more sharply on resolving medication-use problems, they will expand postgraduate year 1 (PGY1) residencies as a means of enhancing their capacity for clinical services. Clinical laboratory-based pharmacogenomics test results will be assessed by pharmacy residents in all settings, which will allow for the provision of more patient-specific care.
Based on a presentation at the ASHP National Pharmacy Preceptors Conference, Washington, DC, August 23, 2013. The author has declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0702-1196$06.00. DOI 10.2146/ajhp140113
50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Pharmacy residency training
The health care industry has adopted new information technology much more slowly than have other industries. Pharmacy will increasingly be an advocate for accelerating the adoption of information technology that improves the safety, efficiency, and effectiveness of patient care. In addition, pharmacy personnel will assist in the development, implementation, and monitoring of the effectiveness of new technology. Pharmacy residents will be heavily involved in these matters. Other issues in health care that will continue to affect pharmacy residency training include increased quality demands, higher patient volumes, community health and chronic disease management, pharmacy technician responsibility for the medication-use process, career development ladders for pharmacists, drug shortages, and transformation of the drug research and product development processes. Trends in health-system pharmacy that will affect pharmacy residency training Pharmacists (including pharmacy residents) increasingly will be required to document, through formal credentialing and privileging processes, that their competencies align with their scope of responsibilities. There will be a shift away from nearly-universal pharmacist order review to a situation where many medication orders will be reviewed effectively by technology.1 The reduction in pharmacist time needed for order review will precipitate related changes in residency training. Health care provider organizations increasingly will give pharmacists opportunities to assume roles in areas such as quality improvement, informatics, administration, education, and research. (Many more physicians and nurses than pharmacists have these opportunities now.) Pharmacy residencies need to strengthen
their focus on training for strategic leadership from the perspective of the health care organization as a whole, not just from the perspective of the pharmacy department. Potential changes in pharmacy residency programs Radical change in postgraduate year 2 (PGY2) residency training should be considered. Two separate tracks for PGY2 residencies should be adopted. One track would be traditional patient care PGY2 residencies in areas such as ambulatory care, infectious diseases, and pediatrics. Another track would be systemsof-care PGY2 residencies, with a focus on areas such as patient safety, informatics, drug information, and health-system pharmacy administration, guided by unique standards for such residencies. Current PGY2 pharmacy residency training starts with very similar standards for all programs. The requirements for systems-of-care residencies and for direct patient care residencies should each be consistent with the very different nature of specialization in these two areas. A postgraduate year 3 (PGY3) model for pharmacy residency training will likely be developed in the future. How the model will be implemented is, at this time, unclear. Some possibilities include using the PGY3 year as a chief resident year or focusing the training on areas such as leadership, administration, subspecialty clinical practice, research, or teaching. Establishment of PGY3 residency training will increase the credibility of pharmacy among clinical and executive leaders in health care. A continuum of training is likely to be established in pharmacy (a layered learner model), starting as an intern, developing through introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs), advancing into pharmacy residencies,
and eventually becoming practitioner pharmacists (or attending pharmacists). At each training level, the layer above will assist in establishing norms and expectations for the learners. This approach is used in medical training where the attending physician oversees the learners, and at each level there is a responsibility for training the rising level of learners. Pharmacy residents will be more engaged in IPPE and APPE education, at times serving as the primary preceptor. In addition, colleges of pharmacy will see increasing value in the teaching components and site development of residency training and will fund more residency positions. Major residency training sites will create an infrastructure to support the provision of residency training. This support system will allow for the provision of training for 25–50 residents a year. These training sites will be structured to be effective and efficient in the execution of training. The residency program director will be given adequate support, and there will be a formal structure for the training curriculum. Additional personnel will be assigned to the residency, such as coordinators to assist program directors with the documentation required in residency training. Administrative assistants will handle organization of the meetings, travel, and meals associated with the programs. These sites will most likely be associated with integrated health networks, academic medical centers, government hospitals, or corporate operators of hospitals and health systems. There will be more assertive efforts to close the gap between supply and demand for residency training. For PGY1 residencies in 2013, the gap was 1400 positions. Given the goal that by 2020 all pharmacists providing direct patient care will be residency trained,2 this gap needs to be narrowed and eventually eliminated. This can be achieved by each
Am J Health-Syst Pharm—Vol 71 Jul 15, 2014
1197
50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Pharmacy residency training
program adding additional positions and by supporting qualified organizations that lack the confidence to start a residency. Lessons can be taken from the medical model of training for enhancement of capacity. Additional approaches include the application of distance-learning technology, simulations of repetitive experiences, use of nonacute care training sites, developing toolkits for how to start or expand a program, developing a mentoring program for prospective program directors, and providing more preceptor and program development.3 Potential changes in the pharmacy residency standards Several changes in residency accreditation requirements should be considered to improve and simplify training. For example, the standards should be simplified to require less documentation and less resident self-evaluation. Simplification of the standards could make residency training more efficient, allow residents to spend more time with patients, and allow programs to accept more residents. Future requirements for residency training should be clearer about the depth of training in specific types of patient care and the associated procedures. In medical training, a focus on repetition ensures competency for performance of patient care functions. This approach should be taken in the pharmacy residency requirements. There will be growing demand for pharmacy residency accreditation outside of the United States. Pockets
1198
of interest are already developing around the world, such as Saudi Arabia and India. The probability is high that accreditation in these areas will accelerate over the next five years. Accreditation teams must be prepared to provide their service on an international scale. The future of pharmacy will include further development of residents as scientific professionals. There will be greater focus on evidence-based decision-making, scholarly activity, and research. Increasingly, residency-trained pharmacists will be expected to be change agents in patient care. The accreditation requirements must ensure that residents are prepared for this expectation. Skills development for future residents will emphasize attributes in the affective domain, including emotional intelligence, caring, professionalism, communication skills, health disparity recognition and response, health literacy, and leadership. These skills, combined with clinical expertise, will strengthen pharmacists’ relationships with patients and with clinical and executive leaders in health care. Relationship between Pharm.D. education and residency training Plans should be developed to more seamlessly transition between Pharm.D. programs and residency training. Working with the Accreditation Council for Pharmacy Education (ACPE), the American Society of Health-System Pharmacists and its residency partners should continue to enhance this transition. This
Am J Health-Syst Pharm—Vol 71 Jul 15, 2014
would be an opportune initiative because ACPE is currently revising the accreditation standards for Pharm.D. programs. Similarly, residency training as an explicit method of preparing for certification in a specialty recognized by the Board of Pharmacy Specialties should be enhanced. Conclusion Residents’ training must focus on the skills that will be needed to care for patients in the future. Preceptors are an influential factor in the future of our profession because they will drive change in residency training. Several broad trends in health care (including funding constraints) and in health-system pharmacy will influence the nature of pharmacy residencies. There is an important current opportunity to enhance the connection between pharmacy education and pharmacy residency programs. Strong leadership and preceptor development will be needed to continue to expand the training, roles, and responsibilities of pharmacy residents in the long-term interest of improving the medication-related outcomes of patient care. References 1. Flynn AJ. Opportunity cost of pharmacists’ nearly universal prospective order review. Am J Health-Syst Pharm. 2009; 66:668-70. 2. American Society of Health-System Pharmacists. ASHP policy 0701: requirement for residency. www.ashp.org/DocLibrary/ BestPractices/EducationPositions.aspx (accessed 2013 Jul 1). 3. Expanding the number of positions for pharmacy residents: highlights from the Pharmacy Residency Capacity Stakeholders’ Conference. Am J Health-Syst Pharm. 2011; 68:1843-9.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ar Layar
A vision for the future of pharmacy residency training John S. Clark Am J Health-Syst Pharm. 2014; 71:1196-8
A
ny vision for the future of residency training must be strongly connected with a vision for the profession as a whole. This article discusses the trends in health care and in health-system pharmacy that will affect the future of pharmacy residency training, potential changes in the future of pharmacy residencies and in the standards for accreditation, and the future of the relationship between doctor of pharmacy degree (Pharm.D.) programs and residency training. (The opinions and assertions conveyed in this article are those of the author; the ASHP Commission on Credentialing has not taken any position on these topics.) Trends in health care that will affect pharmacy residency training Several broad issues in health care will affect the development of pharmacy residency training and the profession of pharmacy as a whole, including the Patient Protection and Affordable Care Act and continued financial pressure on health care. It is likely that provider status will be attained for pharmacists, which will
give the profession an enhanced opportunity to address cost and quality concerns in health care. Pharmacy residents need to build competencies that are inherent in recognition as a patient care provider. Health care provider organizations continue to consolidate, leading to larger groups of pharmacy residents being trained by individual organizations. Within health care organizations, central coordination and support of residency training are essential in this growth model. Pharmacy students and residents, through their experience with interprofessional patient care teams, will become comfortable with a teambased approach to patient care. Pharmacists will be trained in the future to allow physicians and nurses to be more efficient. Pharmacy residents will be trained to consider their effect on the efficiency, effectiveness, and safety of the health care team. With the promulgation of accountable care organizations and patient-centered medical homes, pharmacy residency training will become increasingly focused on ambulatory care. The transition of focus in health care to prevention
John S. Clark, Pharm.D., M.S., BCPS, FASHP, is Director of Pharmacy Services and Director of Pharmacy Residency Programs, University of Michigan Hospitals and Health Centers, Ann Arbor, and Clinical Assistant Professor, University of Michigan College of Pharmacy, Ann Arbor; at the time of writing, he was Chair, Commission on Credentialing, American Society of Health-System Pharmacists (ASHP), Bethesda, MD ([email protected]).
1196
Am J Health-Syst Pharm—Vol 71 Jul 15, 2014
and wellness will have a profound effect on residency training. Many pharmacy residency programs will offer training primarily at ambulatory care sites. Improving transitions of care will be emphasized by health care provider organizations. The pharmacy profession is uniquely situated to foster smoother transitions for patients, especially with respect to their medication-related problems. Pharmacy departments will establish the involvement of pharmacists as essential to provision of effective and efficient care transitions, which will be given major attention in residency training. Community pharmacy will offer additional clinical services to ambulatory care patients. As community pharmacies support health and wellness programs and focus more sharply on resolving medication-use problems, they will expand postgraduate year 1 (PGY1) residencies as a means of enhancing their capacity for clinical services. Clinical laboratory-based pharmacogenomics test results will be assessed by pharmacy residents in all settings, which will allow for the provision of more patient-specific care.
Based on a presentation at the ASHP National Pharmacy Preceptors Conference, Washington, DC, August 23, 2013. The author has declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/14/0702-1196$06.00. DOI 10.2146/ajhp140113
50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Pharmacy residency training
The health care industry has adopted new information technology much more slowly than have other industries. Pharmacy will increasingly be an advocate for accelerating the adoption of information technology that improves the safety, efficiency, and effectiveness of patient care. In addition, pharmacy personnel will assist in the development, implementation, and monitoring of the effectiveness of new technology. Pharmacy residents will be heavily involved in these matters. Other issues in health care that will continue to affect pharmacy residency training include increased quality demands, higher patient volumes, community health and chronic disease management, pharmacy technician responsibility for the medication-use process, career development ladders for pharmacists, drug shortages, and transformation of the drug research and product development processes. Trends in health-system pharmacy that will affect pharmacy residency training Pharmacists (including pharmacy residents) increasingly will be required to document, through formal credentialing and privileging processes, that their competencies align with their scope of responsibilities. There will be a shift away from nearly-universal pharmacist order review to a situation where many medication orders will be reviewed effectively by technology.1 The reduction in pharmacist time needed for order review will precipitate related changes in residency training. Health care provider organizations increasingly will give pharmacists opportunities to assume roles in areas such as quality improvement, informatics, administration, education, and research. (Many more physicians and nurses than pharmacists have these opportunities now.) Pharmacy residencies need to strengthen
their focus on training for strategic leadership from the perspective of the health care organization as a whole, not just from the perspective of the pharmacy department. Potential changes in pharmacy residency programs Radical change in postgraduate year 2 (PGY2) residency training should be considered. Two separate tracks for PGY2 residencies should be adopted. One track would be traditional patient care PGY2 residencies in areas such as ambulatory care, infectious diseases, and pediatrics. Another track would be systemsof-care PGY2 residencies, with a focus on areas such as patient safety, informatics, drug information, and health-system pharmacy administration, guided by unique standards for such residencies. Current PGY2 pharmacy residency training starts with very similar standards for all programs. The requirements for systems-of-care residencies and for direct patient care residencies should each be consistent with the very different nature of specialization in these two areas. A postgraduate year 3 (PGY3) model for pharmacy residency training will likely be developed in the future. How the model will be implemented is, at this time, unclear. Some possibilities include using the PGY3 year as a chief resident year or focusing the training on areas such as leadership, administration, subspecialty clinical practice, research, or teaching. Establishment of PGY3 residency training will increase the credibility of pharmacy among clinical and executive leaders in health care. A continuum of training is likely to be established in pharmacy (a layered learner model), starting as an intern, developing through introductory pharmacy practice experiences (IPPEs) and advanced pharmacy practice experiences (APPEs), advancing into pharmacy residencies,
and eventually becoming practitioner pharmacists (or attending pharmacists). At each training level, the layer above will assist in establishing norms and expectations for the learners. This approach is used in medical training where the attending physician oversees the learners, and at each level there is a responsibility for training the rising level of learners. Pharmacy residents will be more engaged in IPPE and APPE education, at times serving as the primary preceptor. In addition, colleges of pharmacy will see increasing value in the teaching components and site development of residency training and will fund more residency positions. Major residency training sites will create an infrastructure to support the provision of residency training. This support system will allow for the provision of training for 25–50 residents a year. These training sites will be structured to be effective and efficient in the execution of training. The residency program director will be given adequate support, and there will be a formal structure for the training curriculum. Additional personnel will be assigned to the residency, such as coordinators to assist program directors with the documentation required in residency training. Administrative assistants will handle organization of the meetings, travel, and meals associated with the programs. These sites will most likely be associated with integrated health networks, academic medical centers, government hospitals, or corporate operators of hospitals and health systems. There will be more assertive efforts to close the gap between supply and demand for residency training. For PGY1 residencies in 2013, the gap was 1400 positions. Given the goal that by 2020 all pharmacists providing direct patient care will be residency trained,2 this gap needs to be narrowed and eventually eliminated. This can be achieved by each
Am J Health-Syst Pharm—Vol 71 Jul 15, 2014
1197
50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Pharmacy residency training
program adding additional positions and by supporting qualified organizations that lack the confidence to start a residency. Lessons can be taken from the medical model of training for enhancement of capacity. Additional approaches include the application of distance-learning technology, simulations of repetitive experiences, use of nonacute care training sites, developing toolkits for how to start or expand a program, developing a mentoring program for prospective program directors, and providing more preceptor and program development.3 Potential changes in the pharmacy residency standards Several changes in residency accreditation requirements should be considered to improve and simplify training. For example, the standards should be simplified to require less documentation and less resident self-evaluation. Simplification of the standards could make residency training more efficient, allow residents to spend more time with patients, and allow programs to accept more residents. Future requirements for residency training should be clearer about the depth of training in specific types of patient care and the associated procedures. In medical training, a focus on repetition ensures competency for performance of patient care functions. This approach should be taken in the pharmacy residency requirements. There will be growing demand for pharmacy residency accreditation outside of the United States. Pockets
1198
of interest are already developing around the world, such as Saudi Arabia and India. The probability is high that accreditation in these areas will accelerate over the next five years. Accreditation teams must be prepared to provide their service on an international scale. The future of pharmacy will include further development of residents as scientific professionals. There will be greater focus on evidence-based decision-making, scholarly activity, and research. Increasingly, residency-trained pharmacists will be expected to be change agents in patient care. The accreditation requirements must ensure that residents are prepared for this expectation. Skills development for future residents will emphasize attributes in the affective domain, including emotional intelligence, caring, professionalism, communication skills, health disparity recognition and response, health literacy, and leadership. These skills, combined with clinical expertise, will strengthen pharmacists’ relationships with patients and with clinical and executive leaders in health care. Relationship between Pharm.D. education and residency training Plans should be developed to more seamlessly transition between Pharm.D. programs and residency training. Working with the Accreditation Council for Pharmacy Education (ACPE), the American Society of Health-System Pharmacists and its residency partners should continue to enhance this transition. This
Am J Health-Syst Pharm—Vol 71 Jul 15, 2014
would be an opportune initiative because ACPE is currently revising the accreditation standards for Pharm.D. programs. Similarly, residency training as an explicit method of preparing for certification in a specialty recognized by the Board of Pharmacy Specialties should be enhanced. Conclusion Residents’ training must focus on the skills that will be needed to care for patients in the future. Preceptors are an influential factor in the future of our profession because they will drive change in residency training. Several broad trends in health care (including funding constraints) and in health-system pharmacy will influence the nature of pharmacy residencies. There is an important current opportunity to enhance the connection between pharmacy education and pharmacy residency programs. Strong leadership and preceptor development will be needed to continue to expand the training, roles, and responsibilities of pharmacy residents in the long-term interest of improving the medication-related outcomes of patient care. References 1. Flynn AJ. Opportunity cost of pharmacists’ nearly universal prospective order review. Am J Health-Syst Pharm. 2009; 66:668-70. 2. American Society of Health-System Pharmacists. ASHP policy 0701: requirement for residency. www.ashp.org/DocLibrary/ BestPractices/EducationPositions.aspx (accessed 2013 Jul 1). 3. Expanding the number of positions for pharmacy residents: highlights from the Pharmacy Residency Capacity Stakeholders’ Conference. Am J Health-Syst Pharm. 2011; 68:1843-9.
Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
