konkan said:
Lots of reasons why this occurring, but point is that a 3yr vs 4yr is unlikely to put you at a disadvantage for competing for a residency slot since the supply of residencies vs candidates out there is still pretty equally proportional so that most slots get filled.
So what are those reasons?
Also, it has nothing to do with this thread, but since you and sdn1977 are real pharmacy experts here, what do you think of clinics being opened at pharmacy stores? How (if at all) it will affect retail pharmacist practice? Thanks.
So what are those reasons...Well I've been trying to avoid the "future telling" posts but a small explanation is as follows. One of the biggest hurdles facing pharmacy are outcomes. Similar to the days when the PharmD/BS were possible options people often decided to go the straight BS route b/c they were often likely to get paid as much if not more than their PharmD counterparts. Some conspiracy folks argued that one of the original decisions for going from the BS in Pharmacy to the PharmD were that there was a need for PharmDs out there to teach in pharmacy school. I guess depending on where you lived at the time the bulk of pharmacy academic professors were PhD types more into research and/or a minor part of the curriculum focused on pharmacy practice (i.e. straight to hospital/retail). Obviously increase in the education of the profession is one reason for the one degree, but many reasons lead to any change.
The issue w/ clinical aspirations is that if you want to tell people to do something you have to give them a guaranteed reason why. This is what ASHP is perhaps missing. If you are being told that you have to complete 1-2 yrs of residency training than what do you get in return. Secondly if everyone wants to be clinical then who will doing the staffing portion. Hence the clinical staff model that has everyone do a little bit of everything. The problem w/ this is that whenever you are tied to processing orders, your capacity to process orders becomes the rate limiting step. For instance, if it is real busy than you don't have anytime to look into how to dose somone's gent, vanco, or whatever. Secondly w/ the clinical staff model it is often someone different from one day to the next dosing a med so the practice style and outcome may vary largely from one person's expertise than anothers. Perhaps this isn't as big a deal w/ antibiotic dosing as you typically have a larger room for error (at least w/ vanco), but when you are dosing digoxin, pain management, antisz meds, or doing anticoag then the potential for adverse outcome becomes more significant.
Hopefully by the time all of these new "pharmacy initiatives" take place a real Clinical Pharmacists Practitioner model will be set where clinical pharmacists can prescribe w/ autonomy and bill for services and get reimbursed as opposed to all of these. Basically kind of like what the VA already has, but the amount of people actually functioning in this capacity in the VA is probably still a minority compared to their staffing counterpart. Another problem is that we as pharmacists too often overembelish what it is we really do clinically. Those who are on rotation may better appreciate those who really are practicing "clinical pharmacy" vs those who are "putting up a good front".
The hope w/ real autonomy for clinical pharmacists is that we will get away from some of these collaborative practice models and/or have the actual capacity to be recognized as mid-level health care practitioners. I'm not talking about running out there and diagnosing diabetes insipidus, but we as a profession excel in managing chronic conditions where a diagnosis is alread made so hopefully sooner than later we will gain the right to do so w/ prescribing privliges and a billing/reimbursement system that makes such services sustainable and profitable for the facility in which we practice. Otherwise if you can't obtain reiumbursement for a service than you are always at risk of being cut when times get tough financially within that system. Residency training comes into play by realizing that maybe every pharmacist shouldn't be out there functioning in such a manner. Are we all really trained to do so or do we all really want to do so. If we are all PharmDs than the theory is that one should expect the same competence from everyone b/c of the degree you posess.
So how do you decide who does and who doesn't. Well like everyother profession you need some type of formal post-graduate training. Problem #2: this post graduate training has to be standardized to guarantee federal funding for the programs. Hence the recent issue w/ funding for specialty residencies since the issue was why fund a specialty residency if one can go from Point A (pharm graduate) to Point B (clinical position) w/o residency training. Therefore you have to make residency training mandatory and standardized to assure that everyone is playing by the same standards. Remember most of the "clinical pharmacy" stuff is a knowledge base so one could always argue that you could potentially learn such information through reading on your own. Possibly true, but typically w/o residency training one would likely be short on actual application of such ideas.
Another way to look at it is that in theory a BSN has the same knowledge base as a nurse practioner, just, but the NP is required add'l training to have some autonomy as granted by law. Or even some med residents may have the same knowledge base as their attendings, but until they pass the various tests/licensing they aren't recognized w/ that capacity by law. Clinical pharmacy may ultimately follow a similar path from a standpoint of one would have to have certain experiences (residency training and/or board certification) to have the capacity to write certain orders (possibly, but who knows).
Whether all of this ever translates to retail is anyone's guess, but a long time is probably a good estimate. Either way this is one of the reasons why trying to gauge a pharmacy shortage is so difficult. Who knows what the demand will be on pharmacies in the future. The 1st obvious issue is that people are only getting older making a hirer demand for potential pharmacy services, many hospital pharmacies that previously were only open 12hrs a day (or <24 hrs/day) are now being required by various JCAHO initiatives to maintain 24hr pharmacy services which also increases demand. In addition w/ automation RN staff want the drugs quicker so it may take more pharmacy man power to do so and what happens if facilities start offering clinical pharmacy services 24hrs (i.e. ER pharmacists, inpt anticoag, kinetics services, etc vs being on-call or developing protocols to have staff pharmacist triage issues until the next day shift) vs the typical 9-5. Basically continued increase in demand.
Clinics in pharmacy...why not? I really don't think they will take off that much, but it is anyones guess. One of the downsides to trying to market "clinical or non-dispensing" services in a retail pharmacy setting is that you are often "out of loop" from the whole decision making process. When you or your loved one is sick w/ strep throat the avg person just wants their meds and to be on their respective way.
Not to say that impt interventions can't be made at a community level b/c they certainly can, but there are just some boundaries from general healthcare setup and even others w/i the pharmacy in particular so I'm not sure how clinics in a pharmacy may evolve pass the current drug regimen review and general counseling. For instance, the local pharmacy manager who refuses to believe that there may be something more to offer the local pt population than one's efficiency in "licking and sticking".
I personally see more room for growth in AC clinics and med management clinics just b/c there location is often incorporated w/i a healthcare medical center so labs and facility billing services are already established. In addition, the role within the healthcare system is already established so you are often prescribing your regimen of choice w/ no interaction from MD/NP/PA, but downside is that you are still either signing the MDs signature (via previous approval) or are in someway able to authorize a prescription on their behalf. The problem w/ all of this is that you as a pharmacist aren't getting full credit for your service. The facility obtains some reimbursement for the service, but how much comes back to the pharmacy is another story few if any fully understand.
Basically in the end clinical pharmacy has been doing lot of different things, but nothing terribly new since the early 80s. Their is a great review of the history of clinical pharmacy and clinical pharmacology in Journal of Clinical Pharmacology in ~1980. The main difference is that many more people are doing clinical activities and in various different disciplines than they were 5 or 10 or 20 yrs ago. We as a profession are just trying to get recognized for the services provided. A bit too much on this post though, but hopefully I answered your questions in the midst of all that babbling.
