50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Specialized residencies
ar Layar
The future of specialized pharmacy residencies: Time for postgraduate year 3 subspecialty training Dennis K. Helling and Samuel G. Johnson Am J Health-Syst Pharm. 2014; 71:1199-203
T
o optimally position and advance the pharmacy profession, it is necessary to continue to build on the current framework for postgraduate pharmacy training and education. In the rapidly changing health system in the United States, there is a critical need for effective, efficient, and comprehensive medication management by pharmacist clinicians. We discuss here our vision for how specialized residency training will contribute to pharmacy’s role in the coming years. (The opinions and assertions conveyed in this article are those of the authors; the ASHP Commission on Credentialing has not taken any position on these topics.)
Health-system transformation On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act, into law.1 This comprehensive health care reform is driving the payment structure from a fee-for-service model to a pay-foroutcomes model.2 There is increasing pressure from the U.S. government and employer groups to shift the focus of our health care system to
improving outcomes, lowering costs, and increasing overall access to care. As a result, major payers (e.g., United Healthcare) are transitioning away from an exclusive fee-for-service model.3 The shift toward increased collaboration, outcomes-based payment, and new benefit design is driving innovation in how health care is delivered and financed. This pay-for-outcomes model represents a shift toward a payment system that incentivizes improved quality and cost outcomes. A recent Institute of Medicine report underscored the importance of this process with recommendations to “structure payment to reward continuous learning and improvement in the provision of best care at lowest cost.”4 This challenge is one side of the coin, while “opportunity” is the other. Past successes in acute care and ambulatory care pharmacy practice clearly demonstrate that interventions provided by highly trained pharmacist clinicians directly align with a pay-for-quality approach. This underscores the opportunity for highly trained pharmacist clinicians to provide interventions that
Dennis K. Helling, Pharm.D., D.Sc., FCCP, FASHP, FAPhA, is Executive Director Emeritus, Pharmacy Operations and Therapeutics, Kaiser Permanente Colorado, Aurora, and Clinical Professor, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver. Samuel G. Johnson is Clinical Pharmacy Specialist—Applied Pharmacogenomics, Kaiser Permanente Colorado, and Clinical Assistant Professor, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado.
carry tremendous value by increasing quality of care while decreasing costs of care. Furthermore, with clear incentives for the creation of accountable care organizations and patient-centered medical homes, it is critical to establish effective interprofessional and multidisciplinary teams for collaborative care. Thus, there is an intrinsic need for highly trained pharmacist clinicians to deliver comprehensive medication management within these patient-centered care teams. The notion that interprofessional team-based care is central to the theme of patient-centered care dominates the national conversation; however, it is unreasonable to expect health professionals with different training, perspectives, and experience to simply coalesce without a concerted multilevel initiative. Shifting from incidental exposure to deliberate and strategic training as members of interprofessional teams—at undergraduate and postgraduate levels—is imperative. Physicians are increasingly drawn into specialty and subspecialty practices, exacerbating a long-standing shortage of primary care practition-
Address correspondence to Dr. Johnson (samuel.g.johnson@ kp.org). Based on a presentation at the ASHP National Pharmacy Preceptors Conference, Washington, DC, August 23, 2013. The authors have declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved1079-2082/14/0702-1199$06.00. DOI 10.2146/ajhp140115
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ers.5 Pharmacist clinicians have an opportunity to address the care delivery gaps created by this shortage. In addition, pharmacy specialists have an opportunity to augment the delivery of patient-centered care within interprofessional teams.6 To accomplish this, it is critical to build on the success of postgraduate year 2 (PGY2) specialized residencies by expanding into new subspecialty areas and advancing clinical (practicebased) research. Postgraduate pharmacy education Pharmacy education must revise its focus on the needs of tomorrow’s pharmacist clinicians. As professional and clinical competencies improve, expectations for future pharmacy school graduates will begin to overlap with those of current postgraduate year 1 (PGY1) residency graduates, which will serve to elevate future PGY1 residency competencies to overlap with present-day PGY2 residency competencies. A dramatic transformation in pharmacy education has unfolded throughout history, from the traditional “apprenticeships” to the bachelor’s degree in pharmacy and now to the doctor of pharmacy degree. Similar and no less dramatic changes have occurred in postgraduate pharmacy education as residency and fellowship training. None of these changes happened overnight, and none were accomplished by looking in our profession’s rearview mirror. Looking forward Our vision for the profession is to develop, position, and advance pharmacist clinicians in medical subspecialties and to capitalize on emerging areas of therapeutics (e.g., precision medicine). Further, we must design and implement advanced medical subspecialty clinical research agendas, and we must develop, implement, and document the impact of pharmacy practice across a wider array of medical subspecialties. 1200
Specialty training in medicine Pharmacy can draw lessons from the profession of medicine. Physicians are increasingly pursuing careers in specialty and subspecialty practices and training experiences. The Accreditation Council for Graduate Medical Education (ACGME)7 and the American Board of Medical Specialties (ABMS)8 list available programs and certifications for 150 different specialties and subspecialties. After graduation from medical school, the majority of physicians matriculate into three-year general residency programs (e.g., internal medicine). The first year is regarded as an internship year, and completion of that year is the necessary step to obtain independent licensure to practice medicine in most states. For example, upon completion of an internal medicine residency, many physicians elect to pursue specialty training, which requires an additional three or four years. Physicians increasingly then elect to pursue subspecialty training in three-year residency/clinical fellowship programs to increase their knowledge and skills.9 The purpose of such subspecialization is to acquire the technical skills necessary to address complex medical issues. The trend toward training in subspecialties has grown exponentially, as care requirements have become more technically complex. Financial incentives also drive medical students and residents to subspecialize. Along with subspecialization, the trend for physician leaders to combine a medical degree and residencies/fellowships with an additional graduate degree (e.g., master of business administration, master of public health) is also expanding. An important question remains, How far will subspecialization in the medical profession go? There are two elements to balance: (1) the clinical need for more advanced skills and (2) the economic costs and benefits for providing subspecialty care. In
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cities with large and diverse populations, more clinical subspecialization will likely continue to occur; however, this will likely be balanced by the number of patients who need such services within a geographic area as well as the general shortage of health care providers. Growth in pharmacy residencies There has been tremendous growth in postgraduate pharmacy training opportunities, with nearexponential growth in programs offered since 1990. Also of importance is that the growth in PGY2 or specialized residencies has been nearexponential over that time period, with a higher rate of growth than PGY1 or general residencies. Thus, we are already starting to see a shift toward specialization in the pharmacy profession.10 A 2011 report indicated that ASHP accredits over 682 PGY2 programs, including 19 different PGY2 areas with 5 emerging areas and 5 combined PGY1–PGY2 programs.10 The available specialized residencies are listed in Appendix A. One must note that some ASHP specialized residencies are in areas classified by ACGME and ABMS as medical subspecialties (e.g., critical care, oncology, palliative care/pain management). The American College of Clinical Pharmacy (ACCP) lists more than 40 programs (including PGY2 residencies and fellowships) in distinct specialty and subspecialty areas (Appendix B).11 Several residencies and fellowships listed by ACCP are in areas classified by ACGME and ABMS as medical subspecialties. Similarly, the Board of Pharmacy Specialties recognizes 10 specialties in pharmacy practice (including oncology and critical care, which are classified as medical subspecialties by the aforementioned medical organizations),12 with additional petitions and surveys underway (i.e., cardiology and infectious disease) (Appendix C).
50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Specialized residencies
PGY2 training gaps Certainly, an argument could be made that a number of subspecialty accredited residency options already exist. However, a counterargument is that many subspecialty pharmacy practices exist without ASHP-accredited training programs (Appendix D). We believe that the pharmacy profession must develop the necessary steps for formal subspecialty residency/fellowship training with accreditation, consistent with the historical successes of PGY2 residency programs. In addition, the pharmacy profession must clarify some existing PGY2 specialty residencies consistent with the medical profession’s classification of speciality and subspecialty practices. Clinical administrative leadership training Gaps in clinical administrative leadership training also persist. How do we prepare future managers, directors, and vice presidents of clinical pharmacy services to develop, implement, and evaluate new and existing programs? With an unprecedented increase in hospital and health-system mergers, larger and more complex multihospital systems that focus on integrating and optimizing all aspects of pharmacy practice are being created. There is a growing trend for pharmacy clinical leaders to oversee large multihospital and multiclinic health systems.13 Job requirements for such practice leadership positions often include advanced training in business administration or public health. This differentiation is increasingly important for the pharmacy profession to remain competitive for such leadership positions. We recommend that our profession consider developing a more advanced postgraduate training framework that may include graduate degree opportunities. In the words of John Wooden,14 the famous University of California,
Los Angeles, basketball coach and author: “Don’t measure yourself by what you have accomplished, but by what you should have accomplished with your ability.” The chief takeaway from his advice here is that we cannot, as a pharmacy profession, just sit back and rest on our past progress and residency accreditation achievements. We cannot be content now that we have successful PGY1 and PGY2 programs. We are able to accomplish so much more by elevating our competencies. The future of specialized residencies: Postgraduate year 3 subspecialty training Our vision is for an expanded training paradigm that includes two postgraduate year 3 (PGY3) residency/ fellowship options: (1) advanced subspecialty training and clinical research and (2) advanced clinical administrative leadership. While clinical research is an important underpinning of an advanced subspecialty clinical pharmacy specialist, we are not advocating that this framework for PGY3 training supplant current one- or two-year experiences focused solely on research (e.g., pharmacy research fellowships) because they are not traditionally focused on subspecialty clinical practice. However, a number of these current programs could feasibly transition to the PGY3 model to include advanced subspecialty training and clinical research. A similar research requirement would not be required for the advanced clinical administrative leadership track; instead, emphasis on graduate-level business or public health training may be more appropriate. In contrast to a recent commentary on future preparation for clinical scientists in pharmacy,15 we are not proposing a master of science degree within a PGY3 framework in subspecialty areas. While PGY3 graduates may choose to pursue a clinical or translational scientist career, the
recent commentary promulgates an alternative framework for doctor of pharmacy plus master of science degrees in clinical translational science without necessarily including PGY1 (or PGY2 or PGY3) residency training. We believe it would be advantageous to use a PGY1–PGY2–PGY3 framework for building advanced subspecialty clinical competencies and research expertise (Figure 1). Consider the following case related to pediatrics. In the new PGY3 framework, the PGY1 residency would provide broad-based entry-level exposure to pharmacy operations, medication-use systems, clinical pharmacy services, and research. The PGY2 residency would focus on general pediatrics training and research experience. The PGY3 residency/ fellowship would provide subspecialty training and advanced clinical research in a specific subspecialty area (e.g., pediatric hematology/ oncology). A similar case can be made for internal medicine/ambulatory care; an example of a PGY3 subspecialty residency/fellowship is geriatrics. In the area of chronic disease management, an example of a focus area for a PGY3 program is endocrinology, diabetes, and metabolism (Figure 1). In advanced clinical administrative leadership, the PGY1 residency would consist of broad-based entrylevel exposure to pharmacy operations, medication-use systems, clinical pharmacy services, and research. The PGY2 residency could vary and feasibly include ambulatory care, internal medicine, or other specialties. Some individuals may choose a PGY2 administrative track (or the PGY1 and PGY2 residencies could be tied to master degree programs in health services administration). The PGY3 residency/fellowship would then provide more advanced business management and leadership training opportunities. Advanced research experience in this track is not as critical as it is in subspecialty
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Figure 1. Proposed new framework for pharmacy residency training, including postgraduate year 3 (PGY3) residencies/fellowships. PGY1 = postgraduate year 1, PGY2 = postgraduate year 2. PGY1 PHARMACY RESIDENCY Broad-basd, Entry-level Exposure to Operations, Systems, Clinical, and Research
ENDOCRINOLOGY, DIABETES, & METABOLISM
PGY2 Specialty Residency Internal Medicine/ Ambulatory Care General Medicine Training & Research Experience
PGY3 Residency/ Fellowship Endocrinology, Diabetes, & Metabolism Advanced Subspecialty Training & Clinical Research
PEDIATRIC HEMATOLOGY/ ONCOLOGY
GERIATRICS
NEPHROLOGY
HOSPICE/ PALLIATIVE CARE
PGY2 Specialty Residency Pediatrics General Pediatrics Training & Research Experience
PGY2 Specialty Residency Internal Medicine/ Ambulatory Care General Medicine Training & Research Experience
PGY2 Specialty Residency Internal Medicine/ Ambulatory Care General Medicine Training & Research Experience
PGY2 Specialty Residency Internal Medicine/ Ambulatory Care General Medicine Training & Research Experience
PGY3 Residency/ Fellowship Nephrology Advanced Subspecialty Training & Clinical Research
PGY3 Residency/ Fellowship Hospice/Palliative Care Medicine Advanced Subspecialty Training & Clinical Research
PGY3 Residency/ Fellowship Pediatric Hematology/Oncology Advanced Subspecialty Training & Clinical Research
PGY3 Residency/ Fellowship Geriatrics Advanced Subspecialty Training & Clinical Research
CLINICAL ADMINISTRATIVE LEADERSHIP
PGY2 Specialty Residency Various* Specialty Training & Research Experience
PGY3 Residency/ Fellowship Advanced Clinical Administrative Leadership Advanced Business Management & Leadership Training**
*Feasibly includes Ambulatory Care, Internal Medicine, or other Specialties. **Some programs may be designed to combine PGY3 Residency/Fellowship with MBA or MPH.
clinical practice. The skills developed in these training programs would be extremely valuable in the evolving health care environment where multihospital and health-system conglomerates are being formed to efficiently deliver care. Conclusion Many facets of evolving health care delivery, including payment reform, patient-centered care, and interprofessional team-based practice, warrant a new framework for pharmacy residency training that builds on the success of the current PGY1– PGY2 system. The practice of pharmacy and medicine is increasingly shifting toward subspecialization due to increasing complexity of new therapeutics, diagnostics, and medical technology. Pharmacy’s postgraduate educational system must keep 1202
up with the advances in the medical profession. There are gaps between current pharmacy PGY2 specialized residencies and current pharmacy practice in subspecialty areas. Thus, it is time to consider updating pharmacy residency training to include PGY3 residency/fellowship training in subspecialties. Further, to meet the pharmacy leadership needs of multihospital health systems, the profession should consider augmenting PGY2 health-system pharmacy administration residencies with a PGY3 residency/fellowship in advanced clinical administrative leadership that includes advanced business management and leadership training and optional graduate course work. The words of the legendary quality-improvement guru W. Edwards Deming16 are most fitting for our profession at this time: “It
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isn’t necessary to change. Survival is not mandatory.” It is time to push our clinical and administrative competencies to a higher level. Medicine continues to elevate competencies by moving aggressively toward subspecialization. Pharmacy has the opportunity to proactively and formally prepare subspecialists who will foster innovation and maintain the profession’s relevance and value in patient care. To draw from U.S. Army Chief of Staff General Eric Shinseki,17 “Pharmacy must recognize that if it doesn’t like change, it will like irrelevance even less.” References 1. U.S. Congress. The Patient Protection and Affordable Care Act. www.gpo.gov/ fdsys/pkg/BILLS-111hr3590enr/pdf/ BILLS-111hr3590enr.pdf (accessed 2013 Sep 16). 2. Silow-Carroll S, Edwards JN, Rodin D. Aligning incentives in Medicaid: how
50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Specialized residencies
Colorado, Minnesota, and Vermont are reforming care delivery and payment to improve health and lower costs. www. commonwealthfund.org/Publications/ Case-Studies/2013/Mar/Alig ningIncentives-in-Medicaid.aspx (accessed 2014 Apr 14). 3. United Healthcare. Shifting from feefor-service to value-based contracting model. Employer information sheet. http://consultant.uhc.com/assets/vbc_ overview_flier.pdf (accessed 2013 Sep 16). 4. Institute of Medicine. Summary recommendations for best care at lower cost: the path to continuously learning health care in America. www.iom.edu/~/media/ Files/Report%20Files/2012/Best-Care/ Best%20Care%20at%20Lower%20Cost_ Recs.pdf (accessed 2013 Sep 16). 5. Health Resources and Services Administration. 20th report of the Council on Graduate Medical Education: advancing primary care. www.hrsa.gov/advisory committe es/bhpr a dv isor y/co g me/ reports/twentiethreport.pdf (accessed 2013 Sep 16). 6. Health Resources and Services Administration. Pharmacists’ contributions to primary care in the U.S.—collaborating to address unmet patient care needs. www.hrsa.gov/publichealth/clinical/ patientsafety/aacpbrief.pdf (accessed 2013 Sep 16). 7. Accreditation Council for Graduate Medical Education. Program and institutional accreditation. www.acgme. org/acgmeweb/tabid/83/Programand InstitutionalGuidelines.aspx (accessed 2013 Jul 28). 8. American Board of Medical Specialties. Specialties and subspecialties. www.abms. org/who_we_help/physicians/specialties. aspx (accessed 2013 Jul 28). 9. American Association of Medical Colleges. The road to becoming a doctor. Student flyer. www.aamc.org/ download/68806/data/ (accessed 2013 Jul 28). 10. Johnson TJ, Teeters JL. Pharmacy residency and the medical training model: is pharmacy at a tipping point? Am J Health-Syst Pharm. 2011; 68:1542-9. 11. American College of Clinical Pharmacy. Directory of residencies, fellowships, and graduate programs. www.accp.com/ resandfel/index.aspx (accessed 2013 Aug 1). 12. Board of Pharmacy Specialties. Homepage. www.bpsweb.org/ (accessed 2013 Sep 16). 13. The consensus of the Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2011; 68:1148-52. 14. BrainyQuote. John Wooden quotes. www.brainyquote.com/quotes/authors/j/ john_wooden.html (accessed 2014 Apr 4).
15. Parker RB, Ellingrod V, Dipiro JT et al. Preparing clinical pharmacy scientists for careers in clinical/translational research: can we meet the challenge?: ACCP Research Affairs Committee commentary. Pharmacotherapy. 2013; 33:e337-46. 16. BrainyQuote. W. Edwards Deming quotes. www.brainyquote.com/quotes/ authors/w/w_edwards_deming.html (accessed 2014 Apr 4). 17. Gunny G’s Marines History and Traditions. Marines turned soldiers. www. network54.com/Forum/220604/thread/ 1073929871/last-1073929871/Marines+ Turned+Soldiers (accessed 2014 Apr 4).
Appendix A—ASHP-accredited postgraduate year 2 (PGY2) specialized residencies PGY2 specialties • Ambulatory care • Cardiology • Critical care • Drug information • Emergency medicine • Geriatrics • Health services administration • Infectious disease • Informatics • Internal medicine • Managed care • Medication safety • Nuclear • Nutrition • Oncology • Palliative care/pain management • Pediatrics • Pharmacotherapy • Solid-organ transplantation Emerging areas • Community • HIV • Nephrology • Pharmacogenomics • Transitional care Combined postgraduate year 1/PGY2 programs • Health services administration/Master of Science • Health services pharmacy administration • Medication systems and operations • Pharmacotherapy • Pharmacy informatics
Appendix B—Summary of American College of Clinical Pharmacy listing of specialty residency and fellowship programs11
• Drug information • Emergency medicine • Family medicine • Geriatrics • HIV/AIDS • Infectious disease • Informatics • Internal medicine • Managed care • Medication safety • Nephrology • Nutrition support • Oncology • Outcomes research • Pain management and palliative care • Pediatrics • Pharmacoeconomics • Pharmacogenomics • Pharmacokinetics • Psychiatry • Toxicology • Translational research • Transplantation
Appendix C—Pharmacy specialties recognized by the Board of Pharmacy Specialties12 • Added qualifications in infectious disease and cardiology • Ambulatory care • Critical care • Nuclear pharmacy • Nutrition support • Oncology • Pediatrics • Pharmacotherapy • Psychiatric pharmacy
Appendix D—Some areas of specialty and subspecialty pharmacy practice for which there are no standards for residency training • Advanced heart failure and cardiac transplantation • Allergy/immunology • Bone marrow transplant • Endocrinology, diabetes, and metabolism • Gastroenterology • Maternal–fetal medicine (women’s health) • Medical toxicology • Neonatology • Neurology • Pediatric hematology/oncology
• Administration • Ambulatory care • Cardiology • Community pharmacy • Critical care • Drug development
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ar Layar
The future of specialized pharmacy residencies: Time for postgraduate year 3 subspecialty training Dennis K. Helling and Samuel G. Johnson Am J Health-Syst Pharm. 2014; 71:1199-203
T
o optimally position and advance the pharmacy profession, it is necessary to continue to build on the current framework for postgraduate pharmacy training and education. In the rapidly changing health system in the United States, there is a critical need for effective, efficient, and comprehensive medication management by pharmacist clinicians. We discuss here our vision for how specialized residency training will contribute to pharmacy’s role in the coming years. (The opinions and assertions conveyed in this article are those of the authors; the ASHP Commission on Credentialing has not taken any position on these topics.)
Health-system transformation On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act, into law.1 This comprehensive health care reform is driving the payment structure from a fee-for-service model to a pay-foroutcomes model.2 There is increasing pressure from the U.S. government and employer groups to shift the focus of our health care system to
improving outcomes, lowering costs, and increasing overall access to care. As a result, major payers (e.g., United Healthcare) are transitioning away from an exclusive fee-for-service model.3 The shift toward increased collaboration, outcomes-based payment, and new benefit design is driving innovation in how health care is delivered and financed. This pay-for-outcomes model represents a shift toward a payment system that incentivizes improved quality and cost outcomes. A recent Institute of Medicine report underscored the importance of this process with recommendations to “structure payment to reward continuous learning and improvement in the provision of best care at lowest cost.”4 This challenge is one side of the coin, while “opportunity” is the other. Past successes in acute care and ambulatory care pharmacy practice clearly demonstrate that interventions provided by highly trained pharmacist clinicians directly align with a pay-for-quality approach. This underscores the opportunity for highly trained pharmacist clinicians to provide interventions that
Dennis K. Helling, Pharm.D., D.Sc., FCCP, FASHP, FAPhA, is Executive Director Emeritus, Pharmacy Operations and Therapeutics, Kaiser Permanente Colorado, Aurora, and Clinical Professor, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver. Samuel G. Johnson is Clinical Pharmacy Specialist—Applied Pharmacogenomics, Kaiser Permanente Colorado, and Clinical Assistant Professor, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado.
carry tremendous value by increasing quality of care while decreasing costs of care. Furthermore, with clear incentives for the creation of accountable care organizations and patient-centered medical homes, it is critical to establish effective interprofessional and multidisciplinary teams for collaborative care. Thus, there is an intrinsic need for highly trained pharmacist clinicians to deliver comprehensive medication management within these patient-centered care teams. The notion that interprofessional team-based care is central to the theme of patient-centered care dominates the national conversation; however, it is unreasonable to expect health professionals with different training, perspectives, and experience to simply coalesce without a concerted multilevel initiative. Shifting from incidental exposure to deliberate and strategic training as members of interprofessional teams—at undergraduate and postgraduate levels—is imperative. Physicians are increasingly drawn into specialty and subspecialty practices, exacerbating a long-standing shortage of primary care practition-
Address correspondence to Dr. Johnson (samuel.g.johnson@ kp.org). Based on a presentation at the ASHP National Pharmacy Preceptors Conference, Washington, DC, August 23, 2013. The authors have declared no potential conflicts of interest. Copyright © 2014, American Society of Health-System Pharmacists, Inc. All rights reserved1079-2082/14/0702-1199$06.00. DOI 10.2146/ajhp140115
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ers.5 Pharmacist clinicians have an opportunity to address the care delivery gaps created by this shortage. In addition, pharmacy specialists have an opportunity to augment the delivery of patient-centered care within interprofessional teams.6 To accomplish this, it is critical to build on the success of postgraduate year 2 (PGY2) specialized residencies by expanding into new subspecialty areas and advancing clinical (practicebased) research. Postgraduate pharmacy education Pharmacy education must revise its focus on the needs of tomorrow’s pharmacist clinicians. As professional and clinical competencies improve, expectations for future pharmacy school graduates will begin to overlap with those of current postgraduate year 1 (PGY1) residency graduates, which will serve to elevate future PGY1 residency competencies to overlap with present-day PGY2 residency competencies. A dramatic transformation in pharmacy education has unfolded throughout history, from the traditional “apprenticeships” to the bachelor’s degree in pharmacy and now to the doctor of pharmacy degree. Similar and no less dramatic changes have occurred in postgraduate pharmacy education as residency and fellowship training. None of these changes happened overnight, and none were accomplished by looking in our profession’s rearview mirror. Looking forward Our vision for the profession is to develop, position, and advance pharmacist clinicians in medical subspecialties and to capitalize on emerging areas of therapeutics (e.g., precision medicine). Further, we must design and implement advanced medical subspecialty clinical research agendas, and we must develop, implement, and document the impact of pharmacy practice across a wider array of medical subspecialties. 1200
Specialty training in medicine Pharmacy can draw lessons from the profession of medicine. Physicians are increasingly pursuing careers in specialty and subspecialty practices and training experiences. The Accreditation Council for Graduate Medical Education (ACGME)7 and the American Board of Medical Specialties (ABMS)8 list available programs and certifications for 150 different specialties and subspecialties. After graduation from medical school, the majority of physicians matriculate into three-year general residency programs (e.g., internal medicine). The first year is regarded as an internship year, and completion of that year is the necessary step to obtain independent licensure to practice medicine in most states. For example, upon completion of an internal medicine residency, many physicians elect to pursue specialty training, which requires an additional three or four years. Physicians increasingly then elect to pursue subspecialty training in three-year residency/clinical fellowship programs to increase their knowledge and skills.9 The purpose of such subspecialization is to acquire the technical skills necessary to address complex medical issues. The trend toward training in subspecialties has grown exponentially, as care requirements have become more technically complex. Financial incentives also drive medical students and residents to subspecialize. Along with subspecialization, the trend for physician leaders to combine a medical degree and residencies/fellowships with an additional graduate degree (e.g., master of business administration, master of public health) is also expanding. An important question remains, How far will subspecialization in the medical profession go? There are two elements to balance: (1) the clinical need for more advanced skills and (2) the economic costs and benefits for providing subspecialty care. In
Am J Health-Syst Pharm—Vol 71 Jul 15, 2014
cities with large and diverse populations, more clinical subspecialization will likely continue to occur; however, this will likely be balanced by the number of patients who need such services within a geographic area as well as the general shortage of health care providers. Growth in pharmacy residencies There has been tremendous growth in postgraduate pharmacy training opportunities, with nearexponential growth in programs offered since 1990. Also of importance is that the growth in PGY2 or specialized residencies has been nearexponential over that time period, with a higher rate of growth than PGY1 or general residencies. Thus, we are already starting to see a shift toward specialization in the pharmacy profession.10 A 2011 report indicated that ASHP accredits over 682 PGY2 programs, including 19 different PGY2 areas with 5 emerging areas and 5 combined PGY1–PGY2 programs.10 The available specialized residencies are listed in Appendix A. One must note that some ASHP specialized residencies are in areas classified by ACGME and ABMS as medical subspecialties (e.g., critical care, oncology, palliative care/pain management). The American College of Clinical Pharmacy (ACCP) lists more than 40 programs (including PGY2 residencies and fellowships) in distinct specialty and subspecialty areas (Appendix B).11 Several residencies and fellowships listed by ACCP are in areas classified by ACGME and ABMS as medical subspecialties. Similarly, the Board of Pharmacy Specialties recognizes 10 specialties in pharmacy practice (including oncology and critical care, which are classified as medical subspecialties by the aforementioned medical organizations),12 with additional petitions and surveys underway (i.e., cardiology and infectious disease) (Appendix C).
50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Specialized residencies
PGY2 training gaps Certainly, an argument could be made that a number of subspecialty accredited residency options already exist. However, a counterargument is that many subspecialty pharmacy practices exist without ASHP-accredited training programs (Appendix D). We believe that the pharmacy profession must develop the necessary steps for formal subspecialty residency/fellowship training with accreditation, consistent with the historical successes of PGY2 residency programs. In addition, the pharmacy profession must clarify some existing PGY2 specialty residencies consistent with the medical profession’s classification of speciality and subspecialty practices. Clinical administrative leadership training Gaps in clinical administrative leadership training also persist. How do we prepare future managers, directors, and vice presidents of clinical pharmacy services to develop, implement, and evaluate new and existing programs? With an unprecedented increase in hospital and health-system mergers, larger and more complex multihospital systems that focus on integrating and optimizing all aspects of pharmacy practice are being created. There is a growing trend for pharmacy clinical leaders to oversee large multihospital and multiclinic health systems.13 Job requirements for such practice leadership positions often include advanced training in business administration or public health. This differentiation is increasingly important for the pharmacy profession to remain competitive for such leadership positions. We recommend that our profession consider developing a more advanced postgraduate training framework that may include graduate degree opportunities. In the words of John Wooden,14 the famous University of California,
Los Angeles, basketball coach and author: “Don’t measure yourself by what you have accomplished, but by what you should have accomplished with your ability.” The chief takeaway from his advice here is that we cannot, as a pharmacy profession, just sit back and rest on our past progress and residency accreditation achievements. We cannot be content now that we have successful PGY1 and PGY2 programs. We are able to accomplish so much more by elevating our competencies. The future of specialized residencies: Postgraduate year 3 subspecialty training Our vision is for an expanded training paradigm that includes two postgraduate year 3 (PGY3) residency/ fellowship options: (1) advanced subspecialty training and clinical research and (2) advanced clinical administrative leadership. While clinical research is an important underpinning of an advanced subspecialty clinical pharmacy specialist, we are not advocating that this framework for PGY3 training supplant current one- or two-year experiences focused solely on research (e.g., pharmacy research fellowships) because they are not traditionally focused on subspecialty clinical practice. However, a number of these current programs could feasibly transition to the PGY3 model to include advanced subspecialty training and clinical research. A similar research requirement would not be required for the advanced clinical administrative leadership track; instead, emphasis on graduate-level business or public health training may be more appropriate. In contrast to a recent commentary on future preparation for clinical scientists in pharmacy,15 we are not proposing a master of science degree within a PGY3 framework in subspecialty areas. While PGY3 graduates may choose to pursue a clinical or translational scientist career, the
recent commentary promulgates an alternative framework for doctor of pharmacy plus master of science degrees in clinical translational science without necessarily including PGY1 (or PGY2 or PGY3) residency training. We believe it would be advantageous to use a PGY1–PGY2–PGY3 framework for building advanced subspecialty clinical competencies and research expertise (Figure 1). Consider the following case related to pediatrics. In the new PGY3 framework, the PGY1 residency would provide broad-based entry-level exposure to pharmacy operations, medication-use systems, clinical pharmacy services, and research. The PGY2 residency would focus on general pediatrics training and research experience. The PGY3 residency/ fellowship would provide subspecialty training and advanced clinical research in a specific subspecialty area (e.g., pediatric hematology/ oncology). A similar case can be made for internal medicine/ambulatory care; an example of a PGY3 subspecialty residency/fellowship is geriatrics. In the area of chronic disease management, an example of a focus area for a PGY3 program is endocrinology, diabetes, and metabolism (Figure 1). In advanced clinical administrative leadership, the PGY1 residency would consist of broad-based entrylevel exposure to pharmacy operations, medication-use systems, clinical pharmacy services, and research. The PGY2 residency could vary and feasibly include ambulatory care, internal medicine, or other specialties. Some individuals may choose a PGY2 administrative track (or the PGY1 and PGY2 residencies could be tied to master degree programs in health services administration). The PGY3 residency/fellowship would then provide more advanced business management and leadership training opportunities. Advanced research experience in this track is not as critical as it is in subspecialty
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50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Specialized residencies
Figure 1. Proposed new framework for pharmacy residency training, including postgraduate year 3 (PGY3) residencies/fellowships. PGY1 = postgraduate year 1, PGY2 = postgraduate year 2. PGY1 PHARMACY RESIDENCY Broad-basd, Entry-level Exposure to Operations, Systems, Clinical, and Research
ENDOCRINOLOGY, DIABETES, & METABOLISM
PGY2 Specialty Residency Internal Medicine/ Ambulatory Care General Medicine Training & Research Experience
PGY3 Residency/ Fellowship Endocrinology, Diabetes, & Metabolism Advanced Subspecialty Training & Clinical Research
PEDIATRIC HEMATOLOGY/ ONCOLOGY
GERIATRICS
NEPHROLOGY
HOSPICE/ PALLIATIVE CARE
PGY2 Specialty Residency Pediatrics General Pediatrics Training & Research Experience
PGY2 Specialty Residency Internal Medicine/ Ambulatory Care General Medicine Training & Research Experience
PGY2 Specialty Residency Internal Medicine/ Ambulatory Care General Medicine Training & Research Experience
PGY2 Specialty Residency Internal Medicine/ Ambulatory Care General Medicine Training & Research Experience
PGY3 Residency/ Fellowship Nephrology Advanced Subspecialty Training & Clinical Research
PGY3 Residency/ Fellowship Hospice/Palliative Care Medicine Advanced Subspecialty Training & Clinical Research
PGY3 Residency/ Fellowship Pediatric Hematology/Oncology Advanced Subspecialty Training & Clinical Research
PGY3 Residency/ Fellowship Geriatrics Advanced Subspecialty Training & Clinical Research
CLINICAL ADMINISTRATIVE LEADERSHIP
PGY2 Specialty Residency Various* Specialty Training & Research Experience
PGY3 Residency/ Fellowship Advanced Clinical Administrative Leadership Advanced Business Management & Leadership Training**
*Feasibly includes Ambulatory Care, Internal Medicine, or other Specialties. **Some programs may be designed to combine PGY3 Residency/Fellowship with MBA or MPH.
clinical practice. The skills developed in these training programs would be extremely valuable in the evolving health care environment where multihospital and health-system conglomerates are being formed to efficiently deliver care. Conclusion Many facets of evolving health care delivery, including payment reform, patient-centered care, and interprofessional team-based practice, warrant a new framework for pharmacy residency training that builds on the success of the current PGY1– PGY2 system. The practice of pharmacy and medicine is increasingly shifting toward subspecialization due to increasing complexity of new therapeutics, diagnostics, and medical technology. Pharmacy’s postgraduate educational system must keep 1202
up with the advances in the medical profession. There are gaps between current pharmacy PGY2 specialized residencies and current pharmacy practice in subspecialty areas. Thus, it is time to consider updating pharmacy residency training to include PGY3 residency/fellowship training in subspecialties. Further, to meet the pharmacy leadership needs of multihospital health systems, the profession should consider augmenting PGY2 health-system pharmacy administration residencies with a PGY3 residency/fellowship in advanced clinical administrative leadership that includes advanced business management and leadership training and optional graduate course work. The words of the legendary quality-improvement guru W. Edwards Deming16 are most fitting for our profession at this time: “It
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isn’t necessary to change. Survival is not mandatory.” It is time to push our clinical and administrative competencies to a higher level. Medicine continues to elevate competencies by moving aggressively toward subspecialization. Pharmacy has the opportunity to proactively and formally prepare subspecialists who will foster innovation and maintain the profession’s relevance and value in patient care. To draw from U.S. Army Chief of Staff General Eric Shinseki,17 “Pharmacy must recognize that if it doesn’t like change, it will like irrelevance even less.” References 1. U.S. Congress. The Patient Protection and Affordable Care Act. www.gpo.gov/ fdsys/pkg/BILLS-111hr3590enr/pdf/ BILLS-111hr3590enr.pdf (accessed 2013 Sep 16). 2. Silow-Carroll S, Edwards JN, Rodin D. Aligning incentives in Medicaid: how
50 YEARS OF PHARMACY RESIDENCY ACCREDITATION Specialized residencies
Colorado, Minnesota, and Vermont are reforming care delivery and payment to improve health and lower costs. www. commonwealthfund.org/Publications/ Case-Studies/2013/Mar/Alig ningIncentives-in-Medicaid.aspx (accessed 2014 Apr 14). 3. United Healthcare. Shifting from feefor-service to value-based contracting model. Employer information sheet. http://consultant.uhc.com/assets/vbc_ overview_flier.pdf (accessed 2013 Sep 16). 4. Institute of Medicine. Summary recommendations for best care at lower cost: the path to continuously learning health care in America. www.iom.edu/~/media/ Files/Report%20Files/2012/Best-Care/ Best%20Care%20at%20Lower%20Cost_ Recs.pdf (accessed 2013 Sep 16). 5. Health Resources and Services Administration. 20th report of the Council on Graduate Medical Education: advancing primary care. www.hrsa.gov/advisory committe es/bhpr a dv isor y/co g me/ reports/twentiethreport.pdf (accessed 2013 Sep 16). 6. Health Resources and Services Administration. Pharmacists’ contributions to primary care in the U.S.—collaborating to address unmet patient care needs. www.hrsa.gov/publichealth/clinical/ patientsafety/aacpbrief.pdf (accessed 2013 Sep 16). 7. Accreditation Council for Graduate Medical Education. Program and institutional accreditation. www.acgme. org/acgmeweb/tabid/83/Programand InstitutionalGuidelines.aspx (accessed 2013 Jul 28). 8. American Board of Medical Specialties. Specialties and subspecialties. www.abms. org/who_we_help/physicians/specialties. aspx (accessed 2013 Jul 28). 9. American Association of Medical Colleges. The road to becoming a doctor. Student flyer. www.aamc.org/ download/68806/data/ (accessed 2013 Jul 28). 10. Johnson TJ, Teeters JL. Pharmacy residency and the medical training model: is pharmacy at a tipping point? Am J Health-Syst Pharm. 2011; 68:1542-9. 11. American College of Clinical Pharmacy. Directory of residencies, fellowships, and graduate programs. www.accp.com/ resandfel/index.aspx (accessed 2013 Aug 1). 12. Board of Pharmacy Specialties. Homepage. www.bpsweb.org/ (accessed 2013 Sep 16). 13. The consensus of the Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2011; 68:1148-52. 14. BrainyQuote. John Wooden quotes. www.brainyquote.com/quotes/authors/j/ john_wooden.html (accessed 2014 Apr 4).
15. Parker RB, Ellingrod V, Dipiro JT et al. Preparing clinical pharmacy scientists for careers in clinical/translational research: can we meet the challenge?: ACCP Research Affairs Committee commentary. Pharmacotherapy. 2013; 33:e337-46. 16. BrainyQuote. W. Edwards Deming quotes. www.brainyquote.com/quotes/ authors/w/w_edwards_deming.html (accessed 2014 Apr 4). 17. Gunny G’s Marines History and Traditions. Marines turned soldiers. www. network54.com/Forum/220604/thread/ 1073929871/last-1073929871/Marines+ Turned+Soldiers (accessed 2014 Apr 4).
Appendix A—ASHP-accredited postgraduate year 2 (PGY2) specialized residencies PGY2 specialties • Ambulatory care • Cardiology • Critical care • Drug information • Emergency medicine • Geriatrics • Health services administration • Infectious disease • Informatics • Internal medicine • Managed care • Medication safety • Nuclear • Nutrition • Oncology • Palliative care/pain management • Pediatrics • Pharmacotherapy • Solid-organ transplantation Emerging areas • Community • HIV • Nephrology • Pharmacogenomics • Transitional care Combined postgraduate year 1/PGY2 programs • Health services administration/Master of Science • Health services pharmacy administration • Medication systems and operations • Pharmacotherapy • Pharmacy informatics
Appendix B—Summary of American College of Clinical Pharmacy listing of specialty residency and fellowship programs11
• Drug information • Emergency medicine • Family medicine • Geriatrics • HIV/AIDS • Infectious disease • Informatics • Internal medicine • Managed care • Medication safety • Nephrology • Nutrition support • Oncology • Outcomes research • Pain management and palliative care • Pediatrics • Pharmacoeconomics • Pharmacogenomics • Pharmacokinetics • Psychiatry • Toxicology • Translational research • Transplantation
Appendix C—Pharmacy specialties recognized by the Board of Pharmacy Specialties12 • Added qualifications in infectious disease and cardiology • Ambulatory care • Critical care • Nuclear pharmacy • Nutrition support • Oncology • Pediatrics • Pharmacotherapy • Psychiatric pharmacy
Appendix D—Some areas of specialty and subspecialty pharmacy practice for which there are no standards for residency training • Advanced heart failure and cardiac transplantation • Allergy/immunology • Bone marrow transplant • Endocrinology, diabetes, and metabolism • Gastroenterology • Maternal–fetal medicine (women’s health) • Medical toxicology • Neonatology • Neurology • Pediatric hematology/oncology
• Administration • Ambulatory care • Cardiology • Community pharmacy • Critical care • Drug development
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