EDITORIAL:
It is Time to Reconsider Pharmacy Degree and Licensure Requirements
The colleges of pharmacy of the University of California San Francisco and the University of Southern California established 6-year Doctor of Pharmacy (Pharm.D.) degree programs in the early 1950s, and the college of pharmacy at the University of the Pacific provided it as an option to the baccalaureate degree program in pharmacy. These Pharm.D. programs were established before clinical pharmacy became a primary focus of pharmacy educational programs and practice responsibilities. The 4-year baccalaureate degree in pharmacy continued as the entry-level degree required for licensure and practice through the early 1960s, at which time the 5-year baccalaureate degree was adopted as the requirement.
As the authority and opportunities for pharmacists to participate in clinical practice responsibilities became available, some colleges of pharmacy established post-baccalaureate Pharm.D. degree programs as an advanced professional degree option for pharmacists. The Philadelphia College of Pharmacy (PCP) and the colleges of pharmacy at the University of Kentucky and the University of Texas were among the leaders in establishing comprehensive Pharm.D. programs that provided 2-3 years of additional instruction and experience beyond that required in the 5-year baccalaureate program. The class sizes in these programs were limited (e.g., PCP had a maximum of 16 students in a class) and graduates were in high demand to serve as faculty/practitioners in post-baccalaureate Pharm.D. programs being started at other colleges of pharmacy and in clinical pharmacy positions at many hospitals.
The continuing increase in the number of opportunities for pharmacists to expand their professional practice roles and patient-centered responsibilities resulted in discussions of whether the profession should increase the academic requirements required for licensure and practice. Following extended discussion and debate, the profession adopted the Pharm.D. degree as the entry-level degree required for licensure and practice. This Pharm.D. degree requirement is typically six academic years in length and includes approximately one year of clinical and elective practice experiences. Because many of the students in these programs have already earned a 4-year baccalaureate degree in another discipline, their total time commitment to earn the entry-level Pharm.D. degree is at least 8 years.
Advocates for the increased academic requirements asserted that this level of education was necessary for the provision of expanded professional services by pharmacists and implementation of such on a profession-wide basis. Colleges of pharmacy revised their programs and, by the year 2000, were offering a 6-year (2 years of pre-professional studies and 4 years of professional studies) Pharm.D. degree program as the entry-level requirement.
Those who opposed a requirement that all pharmacy graduates earn a Pharm.D. degree (that had previously been viewed as an advanced professional degree) questioned whether there was a need for all pharmacists to earn this degree and whether the status of holding the title of "Doctor" had an excessive influence on the advocacy for the Pharm.D. credential (i.e., would the support for increased educational requirements be as strong if a Master's degree would be awarded upon completion rather than the Pharm.D. degree?).
Upon implementation of the requirement of the Pharm.D. as the entry-level degree for licensure and practice, the 5-year baccalaureate degree programs were discontinued, and the more comprehensive post-baccalaureate Pharm.D. degree programs were downsized to be consistent with the length of the new standard requirement.
Missed opportunities
My experience in pharmacy started as a student in a 4-year baccalaureate degree program. The standards of practice were much more limited than they are now but, even then, pharmacists were widely considered to be overtrained/underutilized. The degree requirements and professional practice opportunities have greatly increased since then, but the characterization of pharmacists being overtrained/underutilized is still valid.
As one whose professional career was in pharmacy education, I am an advocate for advanced education and experience. However, it is very important that opportunities are available or can be readily developed that correspond to those for which academic programs have prepared their graduates. Notwithstanding the increasing dominance of external factors (e.g., high costs of drugs and other healthcare services, PBMs, health insurance companies, government agencies) over which the profession of pharmacy has no or little control or influence, our profession has not demonstrated the commitment and actions needed to advance the practice standards and opportunities in a manner that would be of value for patients and provide fulfilling professional experiences for pharmacists graduating with increased knowledge and skills.
I recognize that there are numerous situations in which innovative and excellent professional roles and services have been developed, and I commend the pharmacists and those who have supported them in these achievements. However, these experiences are isolated rather than a "norm," and are generally unknown to the public, our legislators, and even many pharmacists. Rather, the "norm" for the large majority of community pharmacists and many hospital pharmacists is that their activities are focused primarily on drug distribution responsibilities. The accuracy and quality of dispensing/drug distribution responsibilities are certainly very important, but fall far short of the scope and value of services that pharmacists are able to provide.
The academic requirements to become licensed and to practice pharmacy have increased by two years since the early 1960s. Is it valid to think that the primary responsibility (i.e., dispensing/drug distribution) of most pharmacists has essentially not changed over that period of time? If so, why haven't the practice standards and "norms" increased in a manner that corresponds to the increased academic requirements? Is it not the responsibility of our associations, boards, and colleges of pharmacy to accomplish the high expectations associated with increased academic requirements?
It can't be anticipated that recent graduates of the longer academic programs will be able to increase the practice standards and opportunities themselves when the entire profession has not been able to do so over decades. It is already evident that chain pharmacies, PBMs, health insurance companies, physician organizations, and others will oppose expanded practice roles for pharmacists and the accompanying increased costs. If our profession hopes to retain any control of its destiny, we must take appropriate and urgent actions!
The consequences of going all Pharm.D.
It was approximately 25 years ago that the profession of pharmacy adopted the Pharm.D. degree as the entry-level requirement for licensure and practice. How has the profession assessed the outcomes of such an important change? Oh, wait! Has such an assessment actually been conducted? Have the increased time, energy, cost, and college debt incurred by Pharm.D. graduates been "rewarded" with professionally-fulfilling employment opportunities and higher salaries? Do these graduates recommend that their siblings, children, and friends pursue pharmacy as a career? How many recent graduates feel disillusioned and even betrayed by the college and profession that recruited them, only to discover that so many of the employment "opportunities" are stressful experiences that jeopardize their mental and physical health? Can requiring all pharmacy graduates to complete a 6-year Pharm.D. degree program be justified by documented benefits for the public, patients, and the profession of pharmacy over the last 25 years? What are those benefits?
One important consequence of the profession going all Pharm.D. is that the colleges that had developed more comprehensive 7-8 year post-baccalaureate Pharm.D. programs discontinued them. These programs were a pharmacy success story that enabled their graduates to accept and/or develop advanced practice responsibilities on a gradual basis for the smaller number of pharmacists who completed these programs.
During the discussion and implementation of the all Pharm.D. decision, the essentially exclusive attention of the profession was devoted to the increases in the academic requirements. The profession failed to make a similar commitment to increase the practice standards and opportunities that would accommodate and utilize the advanced training of thousands of pharmacy graduates each year who were entering a healthcare environment/"market place" that was not prepared for, or even receptive to, an expansion of their professional role and responsibilities. The result was that most of the graduates of the 6-year Pharm.D. program accepted positions with responsibilities that were being fulfilled capably by graduates of 5-year and 4-year baccalaureate programs.
With respect to the characterization of pharmacists being overtrained, underutilized, or both, the experience of the last 25 years suggests that the profession of pharmacy is not able to increase the utilization of the advanced knowledge and skills of pharmacy graduates on a widespread basis. Is there not then a responsibility to consider reducing the academic requirements currently necessary to become a pharmacist, over which the profession of pharmacy does have control? Are any pharmacy associations, boards, or colleges even discussing this, or is the status quo considered sufficient?
The academic requirements for pharmacist licensure should be revised
In my opinion, the current responsibilities of mail-order pharmacists, a large majority of community pharmacists, many hospital pharmacists, and some pharmacists in other areas of pharmacy practice do not require six years of college-level education or a doctoral degree. I believe that the profession, the public, and patients can be better served by revisions in the academic requirements. However, I also anticipate that there will be few or no pharmacy leaders who will be willing to actively consider revisions. Accordingly, I am proposing the following recommendations with the hope that they will stimulate discussion and action.
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A 4-year baccalaureate degree program should be adopted as the entry-level degree for pharmacy licensure and practice. I am confident that a well-designed 4-year program will be sufficient for pharmacists to fulfill current practice responsibilities, as well as additional expanded responsibilities that can be realistically expected to be achieved by 2040.
- An optional 3-year post-baccalaureate Pharm.D. degree program that includes a one-year pharmacy residency should be provided for pharmacists who wish to pursue advanced/specialized professional responsibilities.
- This proposed 2-degree structure should be designed to provide more flexibility and options both within pharmacy (e.g., Ph.D. programs in the pharmaceutical sciences, as well as other disciplines) and beyond pharmacy (e.g., medicine, law) as the career interests of student pharmacists become more focused. This structure would also address the important current concern of reduced applicants and enrollments in colleges of pharmacy by providing a shorter and less costly college experience. It would also be expected to increase the number of pharmacy technicians who would be motivated to extend their training in a pharmacy degree program.
There are also other important issues and implications relating to revisions of the academic requirements but these can await subsequent discussion. Your comments are welcomed.
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EDITORIAL:
A New Year – An Old Theme: Pharmacy Needs a More Effective Organizational Structure
I have written numerous editorials voicing my strong opinion that our profession needs a more effective organizational structure. I have recommended specific merger possibilities (e.g., APhA and ASHP; The Pharmacist Activist, January 2013), as well as a single association that would unite the many current national pharmacy associations (i.e., The United Pharmacists of America; The Pharmacist Activist, January 2016). However, I am not aware of any focused effort of any pharmacy organization to consider changes in the current structure. As with the pharmacy degree and licensure requirements addressed in the preceding editorial, the organizational structure is exclusively determined within the profession, and is not dependent on decisions and policies made by those outside the profession. Therefore, the basic questions are whether pharmacists feel that the roles and responsibilities of the profession are optimally protected, recognized, and advanced by the existing organizations and structure and, if not, whether there is sufficient resolve to make changes.
I do not question the value of the services provided by the current associations for their memberships. My concern is whether the current associations, individually or together, are sufficiently protecting and advancing the practice roles and responsibilities of the entire profession, in addition to the specific interests of their memberships.
Some pharmacy association leaders assert that the communication and collaboration among the associations have never been better than they are now. There has been an increased number of statements from "coalitions" of pharmacy associations, some of which also include other interested associations with similar views regarding the topic and actions being requested. Depending on the topic being addressed, the associations that comprise a coalition will vary, and the number of associations "signing" such statements ranges from several to several hundred. I sometimes wonder how a message received from a large coalition of organizations is perceived by legislators and other recipients. A potential exists that a message received from a long list of associations, most or maybe all of which are unknown to recipients of the message, could raise questions or cause confusion that can divert attention from the importance of the topic for which agreement/support is being requested.
Notwithstanding the increased number of coalitions, it is my opinion that the national pharmacy associations are more fragmented, duplicative, and competitive than they are collaborative and synergistic.
Priorities
Until approximately 50 years ago, independent pharmacies and their pharmacist owners were the identity and face of our profession for the public. However, the rapid growth in the number and prescription volumes of chain and mail-order pharmacies, combined with the domination and crushing financial impact of the PBMs and health insurance companies have resulted in the closure of thousands of independent pharmacies.
LARGE CHAIN AND MAIL-ORDER PHARMACIES ARE BECOMING THE PUBLIC IDENTITY OF OUR PROFESSION! They are not committed to or fulfilling the professional roles and responsibilities of our profession! Pharmacists in other practice sites or specialties are essentially invisible and unknown to much of the public and are not in a position to become the public identity of our profession.
Priority must be given to protecting the remaining independent pharmacies and to re-establishing their widespread geographical distribution and financial viability. The NCPA, APhA, and NACDS (National Association of Chain Drug Stores) have provided leadership in the development and advocacy for legislation that will accomplish PBM reform, and are closer than ever to achieving substantial success. There is bipartisan support for these legislative proposals and momentum must be extended.
The NCPA is the largest and most effective advocate for independent pharmacies. However, there are several smaller national pharmacy associations, such as the American Society of Consultant Pharmacists (ASCP), the American College of Apothecaries (ACA), and the Alliance for Pharmacy Compounding (APC) whose memberships include independent pharmacists. To provide advocacy, programs, and services for independent pharmacists in the most effective and efficient manner, the NCPA should explore collaborative initiatives, including merger/acquisition, with these associations. The APhA membership also includes many independent pharmacists and increased collaborative working relationships on their behalf should also be pursued by NCPA and APhA.
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