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Since starting my residency a few weeks ago, I have gotten to interact with many third and fourth year pharmacy students passing through the hospital on rotations.  In talking with them, I perceive a great deal of insecurity from them about the future and the role that they will play in it.  And this is understandable because pharmacy was one thing when we entered pharmacy school, and now it appears to be morphing into something entirely different.  We are breaking new ground as a profession in rather uncertain, chaotic times.  Remember the days when pharmacy was bulletproof?  When all the graduates had jobs? When tuition didn’t cost you almost as much as an entire house?  Well, some of my older readers may remember those halcyon days, but my classmates and I certainly can’t remember what we have never known.  The economy is driving some of these changes, but so is the changing face of healthcare in this country.  We, as a profession, are at an important crossroads in determining what the face of pharmacy will look like in the future with the Pharmacy Practice Model Initiative (PPMI) and with clinical practice models changing all over the country.  It is an exciting time, to be sure, but a little bit unsettling, too, particularly for new graduates trying to find their place in a profession trying to find its place. 

When I talk to students about their post-graduation plans, I consistently hear variations on the same theme:  “It is either residency or retail.”  Many of the students who I have spoken will also add that they don’t really like/want to do retail, so they are “settling on a residency” as their only other option.  And many of them don’t seem very jazzed about doing a residency, either.  When I ask them why, they say, “I am just not sure it is for me, but I know I hate retail, so….”  Oh dear.  Can it be that pharmacy schools are advising their students so poorly that the entire profession comes down to only two (not so very attractive) options? One student told me she didn’t really want to do a residency (she was actually interested in compounding pharmacy), but that she would only pursue compounding pharmacy if “the whole residency thing didn’t work out.”  My advice to her was to follow her heart (Most people don’t go after residencies as a back-up option.).  Life is too short to invest yourself in a path that isn’t true.   I don’t think she is going to listen to me, though.  She is convinced that her choices are “residency or retail,” and that’s it. 

I think we are on rather shaky ground if some of our best and brightest students have such a myopic view of their future options in this profession.  What about long term care, managed care, academia, research, policy, community pharmacy, or (gasp!) a hospital job that doesn’t require a residency?  Now I know that ASHP is a big proponent of residencies, and I don’t mean to be controversial in this blog about this point because I certainly understand ASHP’s position in promoting clinical competency among the next generation of practitioners.  I, myself, am doing a residency. I chose this path deliberately:  not because it was expected or required, but because it was what I wanted to do.  I wanted to carve out another year of my life in the pursuit of intense clinical study in order to take my clinical skills to the next level.  But the important point is that I did not choose this path because it was the lesser of two evils. I explored my options in pharmacy school, and discovered early on in my conversations with pharmacists, preceptors, and faculty what I wanted, so I was able to make this decision confidently and without hesitation.

A residency was the right choice for me.  But I also recognize that it isn’t necessarily the right choice for others.  You can certainly build and acquire a formidable clinical skillset without a residency.  It may take a few years, but there are very many pharmacists who have done this successfully.  I look at the pharmacists who I admire the most and honestly, very few of them did residencies.  (!) Yet these pharmacists are more knowledgeable about clinical matters than I probably will ever be—no matter how many residencies I do or how many years I spend in the profession. I don’t believe you need a residency to practice at the top of your license:  Above all, you just need the willingness to learn.  I think this message gets drowned out in pharmacy schools sometimes, as students are pushed into residencies as “the only way” to get a hospital job.  However, I know lots of graduates who have gotten hospital jobs without residencies.  Maybe they aren’t practicing at the level 1 trauma center in the biggest town in the state, but they ARE practicing.  Don’t lose sight of the fact that hospital jobs are still out there sans residency, if that is the path you wish to take.  People feel bottled into the choice, and it ends up making them unhappy.  So don’t be discouraged, there is life inside and outside a residency.  Choose what is right for you.  For the right reasons.

Eventually ASHP may make residencies mandatory, but in the interim, there are not nearly enough positions to accommodate interest at either the PGY1 and PGY2 level. This means that not everyone who wants a residency will get one in the foreseeable future.  And I think residencies will be (must be) remade in the future to accommodate more students, which will change how they are structured and executed in terms of form and function.  Today’s residencies and tomorrow’s residencies will likely look very different from each other, much like the specialty residencies that pioneering pharmacists did a few years ago (when there were no PGY1s).  Not better or worse, just different.  For those students who are passionate about residencies, I say, don’t give up.  Go after what you want:  no matter what.  Even if the odds aren’t in your favor.   In the end, you will arrive at where you want to be. 

Retail pharmacy gets a bad rap.  I know ASHP is a health-system pharmacy organization, and we don’t usually advocate for the retail side of the profession.  There still continues to be cross over from the retail side to the hospital side and vice versa, so I think we need to do better educating students that there still is ebb and flow across these boundaries.  Retail pharmacists can be excellent clinicians, too.  And likewise, hospital pharmacists can function very well in a retail/community pharmacy environment.  But the important point being lost on students is that there is a lot of opportunity to make a difference in patient care in retail pharmacy, particularly if you work in a community setting.  The retail pharmacy I worked for in the little town next to the little town where I live set up flu clinics and immunized over 2000 people this past year locally and regionally in Oregon.  Not all retail pharmacies are the same any more than all hospitals are the same.  Many of the retail/ community pharmacists I know have closer relationships with their patients/ customers than the hospital pharmacists I know have.  And isn’t that why many of us are drawn into patient care in the first place?

And for those students who still aren’t thrilled about their options, I urge you to branch out beyond the “residency or retail” theme.  Network at local, state, and national meetings.  Pick the brains of the residents who went to your school or who work at the hospitals where you are on rotation.  Bend the ears of pharmacists and preceptors you meet through your internships and externships. Talk to the professors you admire about their career path and how they got to be where they are in the profession.  Seek out shadowing opportunities in areas of pharmacy that interest you.  Don’t settle on anything you aren’t passionate about.  If all else fails, don’t be afraid to make your own way.  It is your future and only you can decide what you will make of it.