- Email: [email protected]
Community Pharmacy Residency Programs, 1997–1998
RESEARCH
Community Pharmacy Residency Programs, 1997-1998 Jenene Robin Spencer, JoLaine R. Draugalis, and Richard N. Herrier
Objective: To obtain a descriptive "snapshot" of community pharmacy residency programs active in 1997-1998. Design: Survey (telephone interview) of community pharmacy residency program directors. Methods: An advance letter to residency directors stated the purpose of the study and requested written information on their residency program. Using a scripted questionnaire, telephone interviews were conducted with each residency director. Results: Descriptive statistics were used to portray the data. There were 13 active community pharmacy residency programs with 20 filled residency sites nationwide at the time of the study. Results revealed that 9 (69%) programs were funded by multiple sources, 3 programs were funded solely by the affiliated college, and 1 program was funded solely by the affiliated pharmacy. Of the 10 residency programs that had been in existence for longer than 1 year, 7 (70%) had the same funding source as they did the first year. Respondents provided descriptions of the residency programs, along with insight into the challenges of creating such programs. At the time of publication (November 1999), there were 50 active community residency sites within the 21 active community pharmacy residency programs. Several other programs are planned for implementation in July
2000. Conclusion: In general, community pharmacy residency programs continue to grow in number, and funding has been sustained due to the programs' successful outcomes. The results of this study provide a framework for the improvement of existing community pharmacy residency programs and the development of additional ones. JAm Pharm Assoc. 1999;39:798-802.
To prepare their students to provide pharmaceutical care, the majority of colleges of pharmacy in the United States either currently offer or are converting to doctor of pharmacy (PharmD) entry-level degree programs. Students from these programs graduate with extensive skills in pharmacotherapeutics and diseasestate management. However, pharmacy graduates still require specialized education and training to develop appropriate skill levels in the provision of patient care. A residency is one means of obtaining specialized professional skills. A pharmacy residency is a directed postgraduate training program l that gives new pharmacists an overview of a defined area of pharmacy practice and helps them develop marketable Received August 28, 1998, and in revised form January 7, 1999, and April 23, 1999. Accepted for publication May 5, 1999. Jenene Robin Spencer, PharmD, is residency preceptor, Fry's Food and Drug Stores, Tucson, Ariz. She was the community pharmacy resident for Fry's from July 1998 through June 1999. JoLaine R. Draugalis, PhD, is assistant dean and professor; Richard N. Herrier, PharmD, is assistant professor, Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson. Correspondence: Jenene Robin Spencer, PharmD, Fry's Food and Drug Stores, 11408 N. Silver Pheasant Loop, Tucson, AZ 85737. Fax: 520-7447841. E-mail: [email protected]. See related articles on pages 748 and 750.
798
Journal of the American Phannaceutical Association
skills in a short time. 2 Historically, residencies have been based in a hospital setting. However, residency programs based in the community pharmacy have also been successful in training pharmacy graduates. These programs nurture highly skilled practitioners who can provide professional leadership and develop innovative, advanced practices in the community setting. 1 While a residency does require additional time for the preceptor and staff, there are also advantages for the pharmacy. These include additional manpower (the resident) to develop and implement reimbursable pharmaceutical care programs, additional resources from affiliated colleges of pharmacy, and motivation for existing pharmacy staff to maintain or augment existing competencies in order to efficiently mentor the resident. The philosophy of postgraduate residency training programs is to provide the resident with opportunities to "learn by doing" while being closely supported by one or more mentors. This application-based, mentor-supported training leads to "the beginning of a completely new and higher plane of professionalization aimed at developing not only cognitive skills, but also a sense of true self-knowledge and worth."3 Upon completion of a community pharmacy residency, the resident is intended to have the training, experience, and self-confidence necessary to enter a new practice environment and provide leadership in the development and implementation of progressive pharmaceutical care services.
NovemberlDecember 1999
Vol. 39, No.6
Residency Programs
Funding and the development of program guidelines have been crucial to the development of such programs, as discussed by arducci.4 The American Pharmaceutical Association (APhA) recently updated their guidelines,S and the National Community Pharmacists Association (NCPA)6 has also adopted their own guidelines for a community pharmacy residency program. Furthermore, APhA and the American Society of Health-System Pharmacists (ASHP) recently finalized a process for accreditation of community pharmacy residency programs.
Objective This project compiled a descriptive "snapshot" of established community pharmacy residency programs for the 1997-1998 year.
Methods A survey was performed of all community pharmacy residency directors for the programs active during the 1997-1998 year. The original list of residency directors was compiled from information obtained from APhA, NCP A, and the American College of Apothecaries (ACA). If, during the interview, it was found that other residency programs existed (a process known as snowball sampling), efforts were made to contact those directors, as well. Advance letters were sent stating the purpose of the project, describing the telephone interview, and requesting the director's participation as well as written information on each residency program. Telephone interviews were then scheduled and conducted with each residency director. Each interview lasted approximately 20 to 30 minutes. A scripted questionnaire based on standard reference texts was used to guide the interview. 7-9 The variables were the characteristics of the residency programs. Descriptive statistics were used to portray the data.
Results Study Participants Initially, we contacted 16 residency directors. Of the 16 programs, 3 were excluded because they were not community pharmacy residency programs but ASHP-accredited ambulatory care or pharmacy practice programs. The remaining 13 community pharmacy residency directors agreed to participate in the interview. They provided the information sought in the initial contact and requested a copy of the study results.
RESEARCH
years (± SD) in existence was 2.5 ± 1.6 year (range, 1 to 6 years). Two of the other three residency programs had existed for 2 or more years but had not had a resident during the previous year (1996-97), and one program has existed since 1986 but had not had a resident since 1991. All but two residency programs (85%) started out with a single residency site for the fIrst year. The other two programs commenced with two sites. Seven of the 13 active programs (54%) had 1 residency site available and filled that site with a resident during 1997-1998. Two programs had one site available, but did not fIll it with a resident. One program had two sites available, both fIlled with residents. Three programs had a variable number of sites available depending on the number of applicants and the availability of funding. Interestingly, one program varied between one to nine sites each year. A total of 20 residency sites were filled during 1997-1998. Of the 13 residency programs, 4 (31 %) trained their frrst resident in 1997-1998. Of the other 9 programs that had been in existence longer than 1 year, 4 programs had had 2 residents overall complete the program, while 3 programs had 6, 7, and 26 residents overall complete the program. Not surprisingly, the oldest residency program (established in 1991) had had the largest number of residents (26) complete the program. Overall, 47 residents had completed a community pharmacy residency within these 13 programs. It is unknown how many residents had completed other community pharmacy residency programs that were in existence prior to 1997-1998. Table 1 lists the distribution of the 47 previous residents' current positions. About one-half of the residents (51 %) have remained in community practice.
Residency Structure Eight of the 13 active programs (62%) were structured around a single practice site. Four had separate rotations among several pharmacies throughout the year, and one offered the option of a residency at either a single site or multiple sites. Elective rotations offered Table 1. Previous Community Pharmacy Residents' Positions in 1997-1998 (n = 47) Current Position
No.(%)
Chain community pharmacist
11 (23.4)
Unknown
7 (14.9)
Faculty member
6 (12.8)
Independent community pharmacist
6 (12.8)
Chain pharmacy manager
5 (10.6)
4 (8.5)
Hospital pharmacist Independent owner
",'
2 (4.3)
Industry pharmacist
2 (4.3)
Hospice pharmacist
1 (2.1)
Residency History
Long-term care pharmacist
1 (2.1)
Of the 13 active community pharmacy residency programs, at the time of the study 10 had had at least 1 resident for all years of the program's existence. Of those 10, the average number of
Postgraduate fellow
1 (2.1)
Student
1 (2.1)
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RESEARCH
Residency Programs
Table 2. Goals of the 13 Residency Programs Active in 1997-1998 (n = 86) No. (%)
Goal Category Gain skills to provide pharmaceutical care in the community pharmacy s'~tting Gain skills- in
ownership/managem~nt
Gain skills in education
~ , ,~- .
30 (34.9) 14(16.3) 11(12.8)
quarterly) meetings with the residency preceptor and/or director.
Stipends/Benefits The average stipend for the residencies was $25,800. All but one program had a benefits package, with costs ranging from $800 to $8,000. Only one program failed to mention fmancial support for travel expenses, and five programs had available funding for other miscellaneous needs, including research, computers, office, graduate course, moving, and project implementation expenses.
Gain skills in research
7 (8.1)
Gain skills in drug information
5 (5.8)
Promote the profession
4 (4.7)
Gain skills in long-term/home care
4 (4.7)
Gain skills in communication
3 (3.5)
Accreditation
Gain skills in leadership
2 (2.3)
Become involved in the community
2 (2.3)
All others
4 (4.7)
At the time this study was conducted, none of the programs was accredited, because no formal process for accrediting community pharmacy residencies existed. Most of the programs followed a combination of APhA, NCPA, and ACA guidelines for community pharmacy residencies.
included family practice, pediatric allergy, pulmonary, diabetes education, home health, long-term care, cardiology, pediatrics, neurology, anticoagulation, drug information, HIV, geriatrics, psychology, and dialysis.
Funding Nine of the 13 active programs (69%) were funded by multiple sources, including colleges, pharmaceutical companies, wholesalers, grants, and the pharmacies affiliated with the residency program. Three programs (23%) were funded solely by the affiliated college. One program was funded solely by the pharmacy affiliated with the program, and this resident spent 100% of their time at that specific pharmacy. Of the 10 residency programs that had existed for longer than 1 year, 7 (70%) had the same funding source as they did the rust year of the program. Ten of the 13 programs (85%) initially started with a I-year commitment from the funding source. One program had a 3-year commitment, and two programs had a "multiple-year" or "long-term" commitment. In general, the residency directors stated that their programs continue to grow and funding has been sustained due to the programs' record of success.
Goals Four of the 13 programs (31 %) had 1 comprehensive goal; 8 (62%) had between 2 and 8 goals, and 1 program had 29 specific goals. Table 2 lists the goals of the residency programs.
Evaluation Tools All programs had an evaluation process for the resident. Eight of 13 (62%) used a standard evaluation tool that was based on the goals and objectives of the residency program. Ten of 13 programs (77%) mentioned as evaluation tools periodic (monthly or
800
Journal of the American Phannaceutical Association
Discussion The residency directors provided important information regarding program funding and structure. Most of the community pharmacy residency programs were funded by a combination of sources. Interestingly, most programs did not have a confrrmed commitment guaranteeing funding for upcoming years. Rather, funding sources continued to support the programs on a year-toyear basis depending on the outcomes of each program. To increase funding-and therefore stability-future research might examine the contribution of residency-generated funding; for example, one avenue would be to develop a reimbursable diabetes education program and use that income to support the residency. The existing programs incorporated a wide variety of structures. Structural components that were fairly consistent among the different programs included the use of an evaluation process for the resident, the amount of the stipend, and the provision of benefits and financial support for travel. Components that varied among the programs were number and type of residency goals, number of sites available, percentage of time spent at various practice locations, and availability and type of elective rotations. The directors also provided insight into the challenges of creating a community pharmacy residency program. In addition to designing and implementing innovative and reimbursable pharmaceutical care programs, residents must also master the basics of community pharmacy practice and management, and learn to face specific challenges, such as reimbursement and resistance to change from health care professionals, including some pharmacists. Additionally, because of the inherent need for continuity of care in the community setting, residents must learn to effectively communicate and develop trusting relationships with patients. Other factors presented challenges to residents. First, there are relatively few pharmaceutical care models for the community set-
NovemberlDecember 1999 ' ')
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Residency Programs
ring. Although a growing number of community pharmacies are tarting to implement the practice of pharmaceutical care, the majority still rely primarily on dispensing functions. It appears, however, that there soon will be a breakthrough in reimbursement and billing for certain pharmaceutical care services. According to the Balanced Budget Act of 1997, providers will be reimbursed in the near future for training diabetes patients in self-care, provided that the patient's physician deems this training necessary.I0 These providers must meet standards that will be developed by the Health Care Financing Administration or standards of the National Diabetes Advisory Board or an organization representing patients with diabetes. Unfortunately, pharmacists were not included as providers in the fIrst phase of this program. However, pharmacists are lobbying to be recognized as one of these providers. Although reimbursement is an important consideration, residents provide value-added services to pharmacies, whether or not they can seek reimbursement for their services. Second, because most of these community-based programs are relatively new, they do not have preceptors with years of experience, tested evaluation tools, or goals and objectives that have been refIned through experience. Third, managed health care is altering the community pharmacy practice through its reimbursement policies for dispensing and cognitive services, and pharmacists must constantly adjust their practice to meet these demands. Surprisingly, 2 of the 16 residency programs originally contacted were not training residents at the time the study was conducted. Furthermore, 3 of the remaining 13 programs had not had a resident in the past year. A lack of interest from students, rather than an absence of funding, was cited by several residency directors as the cause of the problem. Multiple factors may contribute to students' lack of interest. First, in contrast to most hospital-based residency programs, community pharmacy residency programs were not accredited by an administrative body and therefore were not standardized. This lack of an accreditation process appears to have been a limiting factor in their continued success and growth. For instance, some programs reported only one general comprehensive goal, whereas others had more detailed objectives. Although most programs likely strive for most, if not all, of the goals listed in Table 2, the lack of official, written, standardized goals may weaken the credibility of the programs. Fortunately, this problem has been recognized by national pharmacy organizations. APhA announced at its 1999 APhA Annual Meeting in San Antonio, Texas, that it had finalized an appropriate accreditation process with ASHP. Second, a greater effort needs to be exerted in promoting these programs to students and practicing pharmacists. Many, if not most, students and pharmacists are not aware of the excellent opportunities or even the purpose of community pharmacy residency programs. Many may not realize these programs exist. Residency directors need to promote the unique opportunities, challenges, and rewards within community pharmacy. Fortunately, APhA is currently developing new recruitment strategies, includirlg Internetbased residency information and promotions at APhA Academy of
Vol. 39, No.6
NovemberlDecember 1999
RESEARCH
Students of Pharmacy (APhA-ASP) Midyear Regional Meeting .4 Third, although this information i anecdotal, there appears to be a misconception by students and faculty members that there are no opportunities in the community setting to practice clinical skills. By preparing and motivating graduates to practice the clinical skills they learn in school at any chosen pharmacy site, colleges of pharmacy can and should ensure that graduates feel confident with any career choice they make. Finally, completion of an ASHP-accredited residency is recognized as a key step in advancement within a variety of practice settings. A similar reward system has not yet been widely established in the community practice setting.
Recent Developments According to APhA's listing of affiliated residency programs, five new community pharmacy residency programs became available for the 1998-1999 year. The total number of residency sites within each residency program varies. Currently, as of November 1999, there is a total of 50 active community residency sites within the 21 active community pharmacy residency programs (2 programs are in redevelopment). Because of the dynamic nature of such programs, this information is rapidly changing. For instance, several other programs are planned to be available in July 2000, as well.
Conclusion These descriptive results may provide a framework for the improvement of existing community pharmacy residency programs as well as the development of additional ones. Community pharmacy residency programs need standardized goals and an accreditation process. Residency directors need more effective recruitment methods to attract motivated and determined students interested in the community pharmacy setting. Although there are challenges involved in creating and improving community pharmacy residency programs, residents provide an excellent stimulus for pharmacy to evolve in the provision of pharmaceutical care. The authors declare no conflicts of interest or financial interests in any product or service mentioned in the manuscript, including grants, employment, gifts, and honoraria.
References 1. Wenzl off NJ. Community pharmacy residency: 10 steps toward implementing your own program. Am Pharfn. 1987;NS27(12):874-8. 2. Murer MM. Community pharmacy residencies refine career goals. Am Pharm. 1991;NS31(11):3G-3. 3. Pierpaoli PG. Mentoring. Am J Hosp Pharm. 1992;49:2175-8. 4. Narducci WA. Revised CPRP guidelines increase opportunities for postgraduate education in pharmaceutical care. J Am Pharm Assoc. 1998;38(4):436-9. 5. APhA CPRP Advisory Committee. Community Pharmacy Residency Program Guidelines. Washington, DC: American Pharmaceutical Association; 1997.
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Residency Programs
6. National Community Pharmacists Association. Guidelines for Accreditation of Community Pharmacy Residencies. Alexandria, Va; 1996.
9. Fowler, FJ. Survey Research Methods. Newbury Park, Ca: SAGE Publications; 1988.
7. Salant P, Dillman DA. How to Conduct Your Own Survey. New York, NY: John Wiley & Sons; 1994. 8. Fink, A, Kosecoff, J. How to Conduct Surveys: A Step-by-Step Guide. Newbury Park, Ca: SAGE Publications; 1985.
10. Medicare reforms affect hospitals, outpatient settings. Am J HealthSyst Pharm. 1997;54:2433.
- - PHARMACY THROUGH THE AGES
Coming Full Circle Until the 19th century, the vast majority of pharmacists gained their admission into the profession through apprenticeship. The apprentice, according to 1859-1860 APhA President Samuel Colcord, was "one who is bound by covenant to serve a person with a view to learn his art, mystery, or occupation in which his master is bound to instruct him."l The system of apprenticeship had its origin centuries earlier in Europe. An aspiring Italian pharmacist in 1565 was required to serve 5 years as an apprentice, 3 years as a clerk, and then pass a rigid examination. An apprenticeship of 6 years was required in Germany, followed by an examination. The 1617 charter of the Society of Apothecaries of London required 7 years of apprenticeship. 3 By the early 19th century, the system of binding apprentices through indenture was replaced by an arrangement where young people would serve a master for a predetermined compensation during a defInite period of time. Soon after APhA was founded in 1852, there was a call for the Association to establish a uniform system of apprenticeship.4 It was determined that the "preceptorship of the master should instruct the apprentice in all details of the store and laboratory, and extend to the minutiae of every operation of manufacturing and dispensing." Furthermore, it was proposed that apprentices "should be allowed to leave their employers before the expiration of four years' time for the purpose of completing their education and graduating from some regular school of pharmacy."5 Even so, others, like William Procter Jr., felt that "students could learn practical pharmacy only through the apprenticeship process.,,6 By the end of the 19th century, pharmaceutical educators were beginning to doubt the value of the apprenticeship system. Edward Kremers wrote in 1894 that, "it becomes the duty of schools of pharmacy to raise the standard of their course." He added, "such a procedure would generally do away with the apprentice, which would be a matter of rejoice and not of regret."7 As various states followed the 1905 lead of New York in requiring graduation in pharmacy for licensure, and after the American Association of Colleges of Pharmacy's adoption of the mandatory 2-year pharmacy curriculum in 1907, it was no longer possible to qualify as a pharmacist exclusively through apprenticeship. Yet, many felt that a new college graduate was still not fully competent, and that apprenticeship permitted a maturing of skill in actual practice that cannot take place in an academic institution. 3 In 1940 the National Association of Boards of Pharmacy generated the fIrst national guidelines for supervised practical experience required for licensure, but it was not until 1953 that the trade-based term "apprenticeship" was replaced with the profession-based term "internship."8 In 1968 APhA urged that internship (1 year of training subsequent to graduation) be replaced by externship (6 months of training prior to graduation), and in 1974 the American Council on Pharmaceutical Education decided that the "experiences students gain in clinical courses (including clerkships and extemships) should be of such caliber so as to serve in lieu of the internship requirement for licensure."9 Today, all U.S. states require candidates for licensure to obtain practical internship experience acquired under the supervision of a licensed practitioner (usually 1,500 hours with 400 concurrent hours obtained in traditional internship supervised by the college, in clinical pharmacy programs, or in demonstration projects). 10 So, as Kremers and Urdang put it, in the course of a century, supervised experience has come full circle. George Griffenhagen, Pharmacist, Vienna, Va. References 1. Colcord SM. On apprenticeship. ProcAm PharmAssoc.1872;20:418--5. 3. Sonnedecker G. Kremers and Urdang's History of Pharmacy; 1976. 4. Becker C. Apprenticeship. Proc Arner Pharm Assoc. 1877;25:452-3. 5. Parrish E. The education of apprentices. Proc Am Pharm Assoc. 1873;21: 175-8. 6. Higby GJ. In Service to American Pharmacy: The Professional Life of William Procter, Jr.; 1992:125-8. 7. Kremers E. The apprenticeship system. Proc Am Pharm Assoc. 1894;42:399-421. 8. National Association of Boards of Pharmacy. Proc Natl Assoc Boards Pharm. 1969;214:530. 9. Externship and internship. JAm Pharm Assoc. 1968;NS8:388--9. 10. Survey of Pharmacy Laws. Park Ridge, III: National Association of Boards of Pharmacy; 1998-1999; 1999.
802
Journal of the American Phannaceutical Association
NovemberlDecember 1999
Vol. 39, No.6
Community Pharmacy Residency Programs, 1997-1998 Jenene Robin Spencer, JoLaine R. Draugalis, and Richard N. Herrier
Objective: To obtain a descriptive "snapshot" of community pharmacy residency programs active in 1997-1998. Design: Survey (telephone interview) of community pharmacy residency program directors. Methods: An advance letter to residency directors stated the purpose of the study and requested written information on their residency program. Using a scripted questionnaire, telephone interviews were conducted with each residency director. Results: Descriptive statistics were used to portray the data. There were 13 active community pharmacy residency programs with 20 filled residency sites nationwide at the time of the study. Results revealed that 9 (69%) programs were funded by multiple sources, 3 programs were funded solely by the affiliated college, and 1 program was funded solely by the affiliated pharmacy. Of the 10 residency programs that had been in existence for longer than 1 year, 7 (70%) had the same funding source as they did the first year. Respondents provided descriptions of the residency programs, along with insight into the challenges of creating such programs. At the time of publication (November 1999), there were 50 active community residency sites within the 21 active community pharmacy residency programs. Several other programs are planned for implementation in July
2000. Conclusion: In general, community pharmacy residency programs continue to grow in number, and funding has been sustained due to the programs' successful outcomes. The results of this study provide a framework for the improvement of existing community pharmacy residency programs and the development of additional ones. JAm Pharm Assoc. 1999;39:798-802.
To prepare their students to provide pharmaceutical care, the majority of colleges of pharmacy in the United States either currently offer or are converting to doctor of pharmacy (PharmD) entry-level degree programs. Students from these programs graduate with extensive skills in pharmacotherapeutics and diseasestate management. However, pharmacy graduates still require specialized education and training to develop appropriate skill levels in the provision of patient care. A residency is one means of obtaining specialized professional skills. A pharmacy residency is a directed postgraduate training program l that gives new pharmacists an overview of a defined area of pharmacy practice and helps them develop marketable Received August 28, 1998, and in revised form January 7, 1999, and April 23, 1999. Accepted for publication May 5, 1999. Jenene Robin Spencer, PharmD, is residency preceptor, Fry's Food and Drug Stores, Tucson, Ariz. She was the community pharmacy resident for Fry's from July 1998 through June 1999. JoLaine R. Draugalis, PhD, is assistant dean and professor; Richard N. Herrier, PharmD, is assistant professor, Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson. Correspondence: Jenene Robin Spencer, PharmD, Fry's Food and Drug Stores, 11408 N. Silver Pheasant Loop, Tucson, AZ 85737. Fax: 520-7447841. E-mail: [email protected]. See related articles on pages 748 and 750.
798
Journal of the American Phannaceutical Association
skills in a short time. 2 Historically, residencies have been based in a hospital setting. However, residency programs based in the community pharmacy have also been successful in training pharmacy graduates. These programs nurture highly skilled practitioners who can provide professional leadership and develop innovative, advanced practices in the community setting. 1 While a residency does require additional time for the preceptor and staff, there are also advantages for the pharmacy. These include additional manpower (the resident) to develop and implement reimbursable pharmaceutical care programs, additional resources from affiliated colleges of pharmacy, and motivation for existing pharmacy staff to maintain or augment existing competencies in order to efficiently mentor the resident. The philosophy of postgraduate residency training programs is to provide the resident with opportunities to "learn by doing" while being closely supported by one or more mentors. This application-based, mentor-supported training leads to "the beginning of a completely new and higher plane of professionalization aimed at developing not only cognitive skills, but also a sense of true self-knowledge and worth."3 Upon completion of a community pharmacy residency, the resident is intended to have the training, experience, and self-confidence necessary to enter a new practice environment and provide leadership in the development and implementation of progressive pharmaceutical care services.
NovemberlDecember 1999
Vol. 39, No.6
Residency Programs
Funding and the development of program guidelines have been crucial to the development of such programs, as discussed by arducci.4 The American Pharmaceutical Association (APhA) recently updated their guidelines,S and the National Community Pharmacists Association (NCPA)6 has also adopted their own guidelines for a community pharmacy residency program. Furthermore, APhA and the American Society of Health-System Pharmacists (ASHP) recently finalized a process for accreditation of community pharmacy residency programs.
Objective This project compiled a descriptive "snapshot" of established community pharmacy residency programs for the 1997-1998 year.
Methods A survey was performed of all community pharmacy residency directors for the programs active during the 1997-1998 year. The original list of residency directors was compiled from information obtained from APhA, NCP A, and the American College of Apothecaries (ACA). If, during the interview, it was found that other residency programs existed (a process known as snowball sampling), efforts were made to contact those directors, as well. Advance letters were sent stating the purpose of the project, describing the telephone interview, and requesting the director's participation as well as written information on each residency program. Telephone interviews were then scheduled and conducted with each residency director. Each interview lasted approximately 20 to 30 minutes. A scripted questionnaire based on standard reference texts was used to guide the interview. 7-9 The variables were the characteristics of the residency programs. Descriptive statistics were used to portray the data.
Results Study Participants Initially, we contacted 16 residency directors. Of the 16 programs, 3 were excluded because they were not community pharmacy residency programs but ASHP-accredited ambulatory care or pharmacy practice programs. The remaining 13 community pharmacy residency directors agreed to participate in the interview. They provided the information sought in the initial contact and requested a copy of the study results.
RESEARCH
years (± SD) in existence was 2.5 ± 1.6 year (range, 1 to 6 years). Two of the other three residency programs had existed for 2 or more years but had not had a resident during the previous year (1996-97), and one program has existed since 1986 but had not had a resident since 1991. All but two residency programs (85%) started out with a single residency site for the fIrst year. The other two programs commenced with two sites. Seven of the 13 active programs (54%) had 1 residency site available and filled that site with a resident during 1997-1998. Two programs had one site available, but did not fIll it with a resident. One program had two sites available, both fIlled with residents. Three programs had a variable number of sites available depending on the number of applicants and the availability of funding. Interestingly, one program varied between one to nine sites each year. A total of 20 residency sites were filled during 1997-1998. Of the 13 residency programs, 4 (31 %) trained their frrst resident in 1997-1998. Of the other 9 programs that had been in existence longer than 1 year, 4 programs had had 2 residents overall complete the program, while 3 programs had 6, 7, and 26 residents overall complete the program. Not surprisingly, the oldest residency program (established in 1991) had had the largest number of residents (26) complete the program. Overall, 47 residents had completed a community pharmacy residency within these 13 programs. It is unknown how many residents had completed other community pharmacy residency programs that were in existence prior to 1997-1998. Table 1 lists the distribution of the 47 previous residents' current positions. About one-half of the residents (51 %) have remained in community practice.
Residency Structure Eight of the 13 active programs (62%) were structured around a single practice site. Four had separate rotations among several pharmacies throughout the year, and one offered the option of a residency at either a single site or multiple sites. Elective rotations offered Table 1. Previous Community Pharmacy Residents' Positions in 1997-1998 (n = 47) Current Position
No.(%)
Chain community pharmacist
11 (23.4)
Unknown
7 (14.9)
Faculty member
6 (12.8)
Independent community pharmacist
6 (12.8)
Chain pharmacy manager
5 (10.6)
4 (8.5)
Hospital pharmacist Independent owner
",'
2 (4.3)
Industry pharmacist
2 (4.3)
Hospice pharmacist
1 (2.1)
Residency History
Long-term care pharmacist
1 (2.1)
Of the 13 active community pharmacy residency programs, at the time of the study 10 had had at least 1 resident for all years of the program's existence. Of those 10, the average number of
Postgraduate fellow
1 (2.1)
Student
1 (2.1)
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Residency Programs
Table 2. Goals of the 13 Residency Programs Active in 1997-1998 (n = 86) No. (%)
Goal Category Gain skills to provide pharmaceutical care in the community pharmacy s'~tting Gain skills- in
ownership/managem~nt
Gain skills in education
~ , ,~- .
30 (34.9) 14(16.3) 11(12.8)
quarterly) meetings with the residency preceptor and/or director.
Stipends/Benefits The average stipend for the residencies was $25,800. All but one program had a benefits package, with costs ranging from $800 to $8,000. Only one program failed to mention fmancial support for travel expenses, and five programs had available funding for other miscellaneous needs, including research, computers, office, graduate course, moving, and project implementation expenses.
Gain skills in research
7 (8.1)
Gain skills in drug information
5 (5.8)
Promote the profession
4 (4.7)
Gain skills in long-term/home care
4 (4.7)
Gain skills in communication
3 (3.5)
Accreditation
Gain skills in leadership
2 (2.3)
Become involved in the community
2 (2.3)
All others
4 (4.7)
At the time this study was conducted, none of the programs was accredited, because no formal process for accrediting community pharmacy residencies existed. Most of the programs followed a combination of APhA, NCPA, and ACA guidelines for community pharmacy residencies.
included family practice, pediatric allergy, pulmonary, diabetes education, home health, long-term care, cardiology, pediatrics, neurology, anticoagulation, drug information, HIV, geriatrics, psychology, and dialysis.
Funding Nine of the 13 active programs (69%) were funded by multiple sources, including colleges, pharmaceutical companies, wholesalers, grants, and the pharmacies affiliated with the residency program. Three programs (23%) were funded solely by the affiliated college. One program was funded solely by the pharmacy affiliated with the program, and this resident spent 100% of their time at that specific pharmacy. Of the 10 residency programs that had existed for longer than 1 year, 7 (70%) had the same funding source as they did the rust year of the program. Ten of the 13 programs (85%) initially started with a I-year commitment from the funding source. One program had a 3-year commitment, and two programs had a "multiple-year" or "long-term" commitment. In general, the residency directors stated that their programs continue to grow and funding has been sustained due to the programs' record of success.
Goals Four of the 13 programs (31 %) had 1 comprehensive goal; 8 (62%) had between 2 and 8 goals, and 1 program had 29 specific goals. Table 2 lists the goals of the residency programs.
Evaluation Tools All programs had an evaluation process for the resident. Eight of 13 (62%) used a standard evaluation tool that was based on the goals and objectives of the residency program. Ten of 13 programs (77%) mentioned as evaluation tools periodic (monthly or
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Discussion The residency directors provided important information regarding program funding and structure. Most of the community pharmacy residency programs were funded by a combination of sources. Interestingly, most programs did not have a confrrmed commitment guaranteeing funding for upcoming years. Rather, funding sources continued to support the programs on a year-toyear basis depending on the outcomes of each program. To increase funding-and therefore stability-future research might examine the contribution of residency-generated funding; for example, one avenue would be to develop a reimbursable diabetes education program and use that income to support the residency. The existing programs incorporated a wide variety of structures. Structural components that were fairly consistent among the different programs included the use of an evaluation process for the resident, the amount of the stipend, and the provision of benefits and financial support for travel. Components that varied among the programs were number and type of residency goals, number of sites available, percentage of time spent at various practice locations, and availability and type of elective rotations. The directors also provided insight into the challenges of creating a community pharmacy residency program. In addition to designing and implementing innovative and reimbursable pharmaceutical care programs, residents must also master the basics of community pharmacy practice and management, and learn to face specific challenges, such as reimbursement and resistance to change from health care professionals, including some pharmacists. Additionally, because of the inherent need for continuity of care in the community setting, residents must learn to effectively communicate and develop trusting relationships with patients. Other factors presented challenges to residents. First, there are relatively few pharmaceutical care models for the community set-
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ring. Although a growing number of community pharmacies are tarting to implement the practice of pharmaceutical care, the majority still rely primarily on dispensing functions. It appears, however, that there soon will be a breakthrough in reimbursement and billing for certain pharmaceutical care services. According to the Balanced Budget Act of 1997, providers will be reimbursed in the near future for training diabetes patients in self-care, provided that the patient's physician deems this training necessary.I0 These providers must meet standards that will be developed by the Health Care Financing Administration or standards of the National Diabetes Advisory Board or an organization representing patients with diabetes. Unfortunately, pharmacists were not included as providers in the fIrst phase of this program. However, pharmacists are lobbying to be recognized as one of these providers. Although reimbursement is an important consideration, residents provide value-added services to pharmacies, whether or not they can seek reimbursement for their services. Second, because most of these community-based programs are relatively new, they do not have preceptors with years of experience, tested evaluation tools, or goals and objectives that have been refIned through experience. Third, managed health care is altering the community pharmacy practice through its reimbursement policies for dispensing and cognitive services, and pharmacists must constantly adjust their practice to meet these demands. Surprisingly, 2 of the 16 residency programs originally contacted were not training residents at the time the study was conducted. Furthermore, 3 of the remaining 13 programs had not had a resident in the past year. A lack of interest from students, rather than an absence of funding, was cited by several residency directors as the cause of the problem. Multiple factors may contribute to students' lack of interest. First, in contrast to most hospital-based residency programs, community pharmacy residency programs were not accredited by an administrative body and therefore were not standardized. This lack of an accreditation process appears to have been a limiting factor in their continued success and growth. For instance, some programs reported only one general comprehensive goal, whereas others had more detailed objectives. Although most programs likely strive for most, if not all, of the goals listed in Table 2, the lack of official, written, standardized goals may weaken the credibility of the programs. Fortunately, this problem has been recognized by national pharmacy organizations. APhA announced at its 1999 APhA Annual Meeting in San Antonio, Texas, that it had finalized an appropriate accreditation process with ASHP. Second, a greater effort needs to be exerted in promoting these programs to students and practicing pharmacists. Many, if not most, students and pharmacists are not aware of the excellent opportunities or even the purpose of community pharmacy residency programs. Many may not realize these programs exist. Residency directors need to promote the unique opportunities, challenges, and rewards within community pharmacy. Fortunately, APhA is currently developing new recruitment strategies, includirlg Internetbased residency information and promotions at APhA Academy of
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Students of Pharmacy (APhA-ASP) Midyear Regional Meeting .4 Third, although this information i anecdotal, there appears to be a misconception by students and faculty members that there are no opportunities in the community setting to practice clinical skills. By preparing and motivating graduates to practice the clinical skills they learn in school at any chosen pharmacy site, colleges of pharmacy can and should ensure that graduates feel confident with any career choice they make. Finally, completion of an ASHP-accredited residency is recognized as a key step in advancement within a variety of practice settings. A similar reward system has not yet been widely established in the community practice setting.
Recent Developments According to APhA's listing of affiliated residency programs, five new community pharmacy residency programs became available for the 1998-1999 year. The total number of residency sites within each residency program varies. Currently, as of November 1999, there is a total of 50 active community residency sites within the 21 active community pharmacy residency programs (2 programs are in redevelopment). Because of the dynamic nature of such programs, this information is rapidly changing. For instance, several other programs are planned to be available in July 2000, as well.
Conclusion These descriptive results may provide a framework for the improvement of existing community pharmacy residency programs as well as the development of additional ones. Community pharmacy residency programs need standardized goals and an accreditation process. Residency directors need more effective recruitment methods to attract motivated and determined students interested in the community pharmacy setting. Although there are challenges involved in creating and improving community pharmacy residency programs, residents provide an excellent stimulus for pharmacy to evolve in the provision of pharmaceutical care. The authors declare no conflicts of interest or financial interests in any product or service mentioned in the manuscript, including grants, employment, gifts, and honoraria.
References 1. Wenzl off NJ. Community pharmacy residency: 10 steps toward implementing your own program. Am Pharfn. 1987;NS27(12):874-8. 2. Murer MM. Community pharmacy residencies refine career goals. Am Pharm. 1991;NS31(11):3G-3. 3. Pierpaoli PG. Mentoring. Am J Hosp Pharm. 1992;49:2175-8. 4. Narducci WA. Revised CPRP guidelines increase opportunities for postgraduate education in pharmaceutical care. J Am Pharm Assoc. 1998;38(4):436-9. 5. APhA CPRP Advisory Committee. Community Pharmacy Residency Program Guidelines. Washington, DC: American Pharmaceutical Association; 1997.
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6. National Community Pharmacists Association. Guidelines for Accreditation of Community Pharmacy Residencies. Alexandria, Va; 1996.
9. Fowler, FJ. Survey Research Methods. Newbury Park, Ca: SAGE Publications; 1988.
7. Salant P, Dillman DA. How to Conduct Your Own Survey. New York, NY: John Wiley & Sons; 1994. 8. Fink, A, Kosecoff, J. How to Conduct Surveys: A Step-by-Step Guide. Newbury Park, Ca: SAGE Publications; 1985.
10. Medicare reforms affect hospitals, outpatient settings. Am J HealthSyst Pharm. 1997;54:2433.
- - PHARMACY THROUGH THE AGES
Coming Full Circle Until the 19th century, the vast majority of pharmacists gained their admission into the profession through apprenticeship. The apprentice, according to 1859-1860 APhA President Samuel Colcord, was "one who is bound by covenant to serve a person with a view to learn his art, mystery, or occupation in which his master is bound to instruct him."l The system of apprenticeship had its origin centuries earlier in Europe. An aspiring Italian pharmacist in 1565 was required to serve 5 years as an apprentice, 3 years as a clerk, and then pass a rigid examination. An apprenticeship of 6 years was required in Germany, followed by an examination. The 1617 charter of the Society of Apothecaries of London required 7 years of apprenticeship. 3 By the early 19th century, the system of binding apprentices through indenture was replaced by an arrangement where young people would serve a master for a predetermined compensation during a defInite period of time. Soon after APhA was founded in 1852, there was a call for the Association to establish a uniform system of apprenticeship.4 It was determined that the "preceptorship of the master should instruct the apprentice in all details of the store and laboratory, and extend to the minutiae of every operation of manufacturing and dispensing." Furthermore, it was proposed that apprentices "should be allowed to leave their employers before the expiration of four years' time for the purpose of completing their education and graduating from some regular school of pharmacy."5 Even so, others, like William Procter Jr., felt that "students could learn practical pharmacy only through the apprenticeship process.,,6 By the end of the 19th century, pharmaceutical educators were beginning to doubt the value of the apprenticeship system. Edward Kremers wrote in 1894 that, "it becomes the duty of schools of pharmacy to raise the standard of their course." He added, "such a procedure would generally do away with the apprentice, which would be a matter of rejoice and not of regret."7 As various states followed the 1905 lead of New York in requiring graduation in pharmacy for licensure, and after the American Association of Colleges of Pharmacy's adoption of the mandatory 2-year pharmacy curriculum in 1907, it was no longer possible to qualify as a pharmacist exclusively through apprenticeship. Yet, many felt that a new college graduate was still not fully competent, and that apprenticeship permitted a maturing of skill in actual practice that cannot take place in an academic institution. 3 In 1940 the National Association of Boards of Pharmacy generated the fIrst national guidelines for supervised practical experience required for licensure, but it was not until 1953 that the trade-based term "apprenticeship" was replaced with the profession-based term "internship."8 In 1968 APhA urged that internship (1 year of training subsequent to graduation) be replaced by externship (6 months of training prior to graduation), and in 1974 the American Council on Pharmaceutical Education decided that the "experiences students gain in clinical courses (including clerkships and extemships) should be of such caliber so as to serve in lieu of the internship requirement for licensure."9 Today, all U.S. states require candidates for licensure to obtain practical internship experience acquired under the supervision of a licensed practitioner (usually 1,500 hours with 400 concurrent hours obtained in traditional internship supervised by the college, in clinical pharmacy programs, or in demonstration projects). 10 So, as Kremers and Urdang put it, in the course of a century, supervised experience has come full circle. George Griffenhagen, Pharmacist, Vienna, Va. References 1. Colcord SM. On apprenticeship. ProcAm PharmAssoc.1872;20:418--5. 3. Sonnedecker G. Kremers and Urdang's History of Pharmacy; 1976. 4. Becker C. Apprenticeship. Proc Arner Pharm Assoc. 1877;25:452-3. 5. Parrish E. The education of apprentices. Proc Am Pharm Assoc. 1873;21: 175-8. 6. Higby GJ. In Service to American Pharmacy: The Professional Life of William Procter, Jr.; 1992:125-8. 7. Kremers E. The apprenticeship system. Proc Am Pharm Assoc. 1894;42:399-421. 8. National Association of Boards of Pharmacy. Proc Natl Assoc Boards Pharm. 1969;214:530. 9. Externship and internship. JAm Pharm Assoc. 1968;NS8:388--9. 10. Survey of Pharmacy Laws. Park Ridge, III: National Association of Boards of Pharmacy; 1998-1999; 1999.
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