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The conversation around requirement for a residency has been interesting to follow but somewhat disappointing from my admittedly biased perspective. However I am glad to see that several Connect users and bloggers have outlined the way to get involved in the ASHP policy making processes and if more members do so because of these discussions, there will have been at least one valuable outcome. In the end though, we have a democratic process and after all comments are heard, the majority does rule.

I would like to take the opportunity to provide commentary related to these issues but want to first disclose various relationships so that readers can consider my background and potential internal biases on the issues. As the lead author of ACCP’s paper on “requirements” for residency for those graduates intending to enter direct patient care practices, I would encourage those commenting and reading the posts in this blog to read that paper (referenced below) as it provides considerable background on the thinking of ACCP and its Board of Regents. I was also a member of the House of Delegates when ASHP passed the 2007 resolution on the requirement for residencies by 2020. I am currently a member of the ASHP Commission on Credentialing and a past president of ASHP and ACCP. The comments made below are mine and it should not be construed that they are written as a representative of any of these affiliations.

I completed a post-BS PharmD program, did not do a residency and, despite that, have had a wonderful career. However, if it could be done over again, I would seek a residency because it is my sincere belief that doing one would have made me a much better clinician who was better able to care for my patients during the time I provided direct patient care. It would have also made me a better educator.

There are a wide variety of topics discussed in this blog and several, but not all, will be addressed in some detail. The key areas discussed will be: 1) why this movement toward residencies is critical and who it is meant to benefit; 2) what residency “equivalency” means or should mean; 3) hiring practices and the supply of pharmacists; and 4) the profession’s response to the need for more residency positions.

1. Why Residencies are Critical for Providing Direct Patient Care and the Profession

First and foremost, the reason for having pharmacy graduates that will provide direct patient care (estimated at about 75% of the population of pharmacists in our ACCP paper) undertake a residency is simple, it is for our patients. Though I believe doing a residency will also result in a much more fulfilling career for our graduates, it really isn’t about them, it is about our ability to help patients manage increasingly complex medication therapy. More than 50 years ago visionary pharmacist Donald Franke said something like “we treat patients with medications that have the power of atomic weapons but act as if they were bows and arrows.” I think medication therapy has become tremendously more complex than it was 50 years ago and doing a residency after graduation is the best way possible to be prepared to help our patients manage these therapies. I also firmly believe that residency training does a much better job at preparing pharmacists for the intensity of life-long learning than do the colleges and schools of pharmacy, and I have worked in them ever since graduating with my PharmD degree.

2. What Residency Equivalency Means

I believe this “requirement” for graduates to pursue a residency is an important move forward for the profession that is readily recognized by all other health care professionals as something that develops critical knowledge and patient care skills. It will continue to build respect for our role as patient care providers recognized by patients, health professionals, and payers. In no way is the movement meant to disenfranchise current clinicians.

Many individuals have distinguished themselves as clinicians by being fortunate enough to have had great support at their institutions to forge new practices and given the time to educate themselves in general and specialty practice. These individuals are of clear value in providing direct patient care and are well respected on the interprofessional teams where they provide this care.

An ACCP committee developed a document on residency equivalency. Though this does not appear to have been used by a substantial number of individuals, it is available for those wishing to consider the approach to demonstrate their background. However, pharmacy practice experience over time does not equal residency equivalency unless the pharmacist has been practicing and gaining skills in the areas considered required for residents. I also believe that a pharmacist who completed a PGY1 residency but has not practiced or maintained their skills would not be an ideal candidate for a position involving direct patient care. I personally would never consider applying for a clinical position having been out of practice for many years.

ASHP has a policy on this issue that indicates there are no objective means to determine equivalency. (Residency Equivalency-1109: To acknowledge the distinct role of ASHP-accredited residency training in preparing pharmacists to be direct patient care providers; further, To recognize the importance of clinical experience in developing practitioner expertise; further, To affirm that there are no objective means to convert or express clinical experience as equivalent to or a substitute for the successful completion of an ASHP-accredited residency.)

The ASHP standards for residents and preceptors provide clear goals and objectives that must be met by residency programs and residents to be accredited. Any pharmacist who wants to do a self-evaluation of whether they are at or beyond these requirements can readily examine them and work to document how they meet the criteria. I would encourage all interested individuals to examine the extensive goals and objectives that must be met to become an accredited program.

3. Hiring Practices and The Supply of Pharmacists

Though opportunities to develop skills equivalent to those acquired during a PGY1 may continue to occur, it is rare that we have the luxury of time to do so during jobs these days and new hires are expected to be ready to practice at a high level very shortly after commencing their position. Without the broad education and skill development that occurs in residency training, many will be quite unprepared to provide patient care at the level they need to and potentially may be relegated to more technical functions that fall below their educational development during college. Employers will certainly recognize this when it comes to hiring recent graduates and will seek PGY1 trained individuals. On the other hand, I believe an employer would be very short sighted to disregard skills developed by seasoned practitioners who gained their skills on-the-job over time. However, it is incumbent on any applicant for clinical positions to demonstrate their patient care skills. An employer would also be very short sighted to assume that just because a pharmacist did a PGY1 some time in the past that they have maintained the skills and knowledge gained during their program. Thus, every potential employee must be prepared to demonstrate that they have at least maintained and preferably advanced their knowledge and skills. There are a variety of ways to do this including letters of reference that address specific patient care skills desired for the new position, maintaining a portfolio of patient care experiences, and becoming board certified (and maintaining the certification).

As we all know, the economy has suffered pretty dramatically since 2008 due to a wide variety of circumstances. This has certainly impacted many areas of health care. With that said, the impending retirement of millions of baby-boomers is still upon us and they will need the services of pharmacists and other health care providers.

When we wrote the ACCP paper it was projected that there would be about 10,000 graduates by 2020. This has obviously changed considerably with the increases in class sizes of existing colleges and schools and the near doubling of pharmacy colleges and schools from as short a time ago as 1980 when I began practice (well I guess it wasn’t that short a time ago but you get the idea). Much of this increase in volume of graduates was due to the shortage of pharmacists that occurred in the late 1990s and through at least 2009, when employers were forced to pay outrageous bonuses and other inducements just to get pharmacists with any level of skill to provide essential services. Though this certainly benefited all of our wallets, the system was out of balance. Employers now can fill many if not most of their positions and the balance appears to be shifting, I hope not too far in the other direction. Such is the cycle of supply and demand I guess.

4. The Profession’s Response to the Need for More Residencies

Since the publication of the ACCP position and ASHP’s Policy on Residencies, there has been tremendous work accomplished to increase the number of programs and the number of residency positions available. The growth is dramatic in both PGY1 and PGY2 positions programs and this shows no sign of letting up. However, much work remains to be done if we are to come close to the goal by 2020. I am deeply saddened when highly qualified candidates interested in residencies are unable to get them and with approximately one-third of interested individuals unable to match to a program, it is clear we have our work cut out for us. Those who do not match should not despair but rather do everything possible to attain similar skills and knowledge and demonstrate that they have achieved them. Many of us have pulled ourselves upward and none of us can stop our education after graduation.

We set lofty and important goals to move the profession forward. I don’t know if we will get where we want to be by 2020 in terms of the number of residency positions, but I know the profession will do its best to come as close as possible. This is an important commitment and I hope each person that would qualify as a preceptor works to create new programs and positions. Each new resident that graduates is one more potential preceptor and/or residency program director as well. We need to marshal the forces.

For those that did not complete a residency but provide direct patient care, continue to learn and demonstrate the skills and knowledge that show your value to our patients and your employers. Seek opportunities like board certification and certifications of other types related to patient care.

In the end it is always about our patients.

Reference

Murphy JE, Nappi J, Bosso J, et al. American College of Clinical Pharmacy’s vision of the future: postgraduate pharmacy residency training as a prerequisite for direct patient care practice. Pharmacotherapy. 2006; 26(5):722-33.