Leadership in a Clinical Profession
I am deeply honored, and I humbly thank the past recipients of the Harvey
A. K. Whitney Lecture Award and the Southeastern Michigan Society of
Hospital Pharmacists for choosing me, a practitioner, for this distinction.
I admit to experiencing what Dr. Pauline Clance described as the “imposter phenomenon.”
(1) Even when others proclaim your accomplishments, there is a feeling that
any success you have realized must be due to some mysterious bit of luck or breaks
and hard work but not a result of your own ability. You feel that others may have been
misled into believing that you are more capable and knowledgeable than you really
are and sooner or later the mask will be removed, exposing the real you.
I attribute any professional success I have had to knowing how long it takes to
succeed and being persistent. Even a stopped clock is right twice a day, and after
some years it can boast of a long series of successes.
I claim few personal accomplishments, but I do concede that anyone who survives
being named Joe Smith deserves a little credit.
When Joe Oddis called to give me the great news, which elevated me right up
through the roof, he quickly brought me back to earth with this comment: “Yes, Joe,
it’s a great trip, but there is some baggage that goes with it. You have to deliver the
Whitney Award Lecture.” That was certainly a sobering thought. It has indeed become
a challenge and, I have since come to realize, an opportunity – an opportunity
to raise your level of awareness or concern for some issue that I think is important to
the profession.
It took only a small amount of time and thought to come up with a long list of
problems that the profession needs to address, and the list swelled as I got ideas from
the many friends I have spoken to recently. As the list of problems grew and I was
becoming more depressed, I kept having to remind myself that we have faced problems
like these in the past and have dealt with them rather effectively.
In fact, I feel very good about what the profession has accomplished. In the last 25
years, the profession has changed from one that was product and materials management
oriented to one that is truly clinical and patient oriented. I feel fortunate that the
greater part of my career has taken place during that period of time. So, I have looked
for a subject through which I can express that good feeling about ourselves, one that
has significantly contributed to that success and would symbolize it. And I have chosen
to dedicate my lecture to accredited residency programs.
Harvey Whitney himself was one of our greatest preceptors, and from the welldesigned
internship program he began in the early 1930s at the University of Michigan
Hospital came equally great preceptors such as Don Francke, Paul Parker, Clif
Latiolais, George Phillips, and many others.
One of the most common characteristics among the Whitney Award recipients has
been their contribution to the profession through the preceptorship of residency programs.
Indeed, the first thought that comes to mind when the names of many of them
are mentioned is of their legendary residency programs.
Residency programs and the accreditation process have been a strong force to
bring about change in hospital pharmacy. I believe that residency training is the single
most important activity initiated from within the profession itself that has advanced
hospital pharmacy practice. Changes in practice have often been driven by
influences from outside (e.g., nursing shortages, federal capitation grants for medical
education, Joint Commission on Accreditation of Healthcare Organization standards,
and a more litigious society). But the initiation of residency training and the accreditation
process came from within the practice of hospital pharmacy itself.
This year is the silver anniversary of ASHP–accredited residency programs. Residency
accreditation was initiated in 1962; in early and mid–1963, some site surveys
were conducted; in December 1963, a few programs were accredited. Jefferson’s was
the first program surveyed and among the first accredited, I’m proud to say. Its accreditation,
however, did not go without sharp criticism from the surveyors, John
Oliver and Paul Parker. The program was cited, for example, for continuing to use
cardboard slide boxes to dispense medications, and it did not go unnoticed that the
department had only two dispensing pharmacists for a 736–bed hospital.
It was not uncommon in those days for preceptors to have to justify residency
programs through the provision of a variety of services, and Jefferson was no exception.
Twenty–four–hour service was accomplished by the rotation of residents on night
shifts. As one means of justifying their existence, pharmacy residents provided, in
addition to normal pharmaceutical services, inhalation therapy to all patients from 5
p.m., when the regular therapists went home, until 8 the next morning. Unusual
services did not end there. Since the pharmacy was located in the basement alongside
the morgue, the residents were assigned to release bodies from the morgue to
undertakers during the night shift.
From beginnings that were tied strongly to personal preceptorship by a few of the
profession’s leaders, residency programs have grown in number and have become
highly organized and often specialized to meet the changing needs of the profession.
There are now 196 accredited programs, including 36 advanced clinical residencies
and 35 advanced specialty residencies. More than 3000 pharmacists have completed
accredited residency programs, and over 400 are currently completing them each
year.
It is in these structured programs that we can best communicate values, philosophy,
and a vision of the profession. The young professional, encouraged by a mentor,
begins a process of introspection in which he tests his own abilities and limits and
develops ethical standards and a philosophy of practice.(2) During this transition from
a theoretical base to a professional practice, the resident also develops an attitude – a
habit, if you will – of lifelong searching and learning. A culture develops around these
residency programs that breeds commitment and exploration, and from the programs
flow highly energized and motivated people with high individual and professional
goals. Those who have been a part of this culture go on to build programs and similar
cultures in other hospitals.
Supplying the profession with mature, highly skilled clinical and managerial practitioners
is, without question, the primary value of residency programs, and assuring
the quality of such programs is the primary purpose of the accreditation process.
However, the importance of residency programs and the accreditation process to the
advancement of professional practice has not been fully appreciated. That culture
that develops around residency programs also breeds innovation and advancement
in hospital pharmacy practice. The residents and others in the department who become
a part of the culture help to keep these programs on the cutting edge of professional
practice.
There is another force at play here that drives these programs to higher levels of
excellence; that is the accreditation process itself. There are many elements to this
dynamic process that make it effective, but the most important, I believe, is the existence
of written standards defining the level of pharmacy practice that must be in
place in that hospital before it can be accredited. The services are defined at a level
that you and I would consider state of the art. Programs strive to meet these standards
and become accredited. Subsequently, the ASHP Commission on Credentialing raises
the level of standards as the state of the art changes, so that by the time the next
survey is conducted the program has new goals to meet, and the cycle repeats itself.
This never–ending challenge to meet higher and higher standards stimulates pharmacies
with residency programs to advance pharmacy services.
We have 25 years of exceptional achievement through residency programs behind
us. What is in store as we go for the golden anniversary? Before I share some thoughts
on the role experiential training might play in the future, I would like to make some
comments on the way we determine what that role will be.
Before we can rationally plan for the educational and training needs of future hospital
pharmacists, we need to identify what it is that they will be doing. Since it takes
5–10 years to get any changes made in our educational system, we ought to be planning
ahead at least that far. Dr. Henry Manasse, Dean of the College of Pharmacy at
the University of Illinois, cautioned recently that:(3)
We must focus our attention on the necessity and mechanism for rational (manpower) planning.
To date, there has not been a rational planning mechanism, and indeed, a consensus does not
exist about the nature of the required manpower force.
If the profession is to be responsive to the manpower needs of the future, a rational
planning process must be developed. Only four times in this century has the profession
made any attempt to examine, analyze, and make recommendations for the
profession in general and pharmaceutical education in particular – the last time being
in 1975. In 1984, there was an APhA task force on Pharmacy Education, but it
limited its recommendations primarily to some specific curriculum changes and the
Pharm.D. degree. Although its scope was limited, that task force did make several
important recommendations.(4) It recommended that the six–year Pharm.D. program
evolve as the desired goal, with the intent that the Pharm.D. become the sole entry-level
degree for the practice of pharmacy. However, the APhA Task Force concluded
that there was relatively little documentation of the utility and effectiveness of
Pharm.D.–degree pharmacists in practice, particularly in community practice, and
recommended an analytical study on this issue. It then offered this advice:
If the profession makes the decision to move to the recommended six–year Pharm.D. degree as the
sole entry degree for practice, that decision must be based on sound, supportable reasons.
It concerns many of us that we are rushing along toward a Pharm.D. for everyone
and have not shown that a sixth year of education improves the quality of professional
practice in community pharmacy – the area into which 59% of our pharmacy graduates
currently go. Pharm.D.–level education (and residencies) have made all the difference
in the world in the quality of services that have evolved in hospital pharmacy,
but evidence of similar improvements in patient care as a direct result of advanced
education is lacking in the community setting. It is surprising to me that this situation
exists when we have the perfect laboratory in which to test the thesis that a sixth year
of education would result over the years in improved patient care in the community
setting.
In California, most graduates of colleges of pharmacy have received the Pharm.D.
degree for more than 25 years. We should be able to find some detectable difference
in the level of professional services in community pharmacy in, for example, San
Francisco versus Philadelphia, where almost no one with a Pharm.D. degree has gone
into community practice. That we have not conducted such a study suggests that we
already know what the results would be.
How we educate and train pharmacists for community practice is important to you
and me as we plan for the education and training of hospital pharmacists – not because
of any inherent need to tie them together but because of the pharmacy school and
hospital resources that are consumed in the education and training of that large portion of
college classes directing themselves towards a future in community practice. Many
schools of pharmacy are finding it difficult to put together the faculty and facilities to meet
the demand from all of the profession for a larger number of graduating pharmacists
and the ever–increasing demand from hospital pharmacy, academia itself, and the
pharmaceutical industry for yet more highly educated and skilled professionals.
It seems irresponsible for us to be caught up in this snowball that is gaining force
and propelling us toward a Pharm.D. for everyone without better evidence that the
vast resources that will be consumed in so doing will be justified in terms of our better
serving important societal needs. The importance of resolving this issue alone speaks
strongly to the need for the profession to develop a mechanism for rational manpower
planning.
Another problem we face that calls for rational manpower planning is the widespread
shortage of pharmacists. Over the last 11 years (1977–1987), a time when all sectors
of the profession have been expanding rapidly, the total number of pharmacy
graduates has declined from 8200 per year to 6073 – a decrease of 2127 (26%). The problem
can only increase because we are not now graduating, nor have we for several years,
even enough pharmacists to replace those retiring or otherwise leaving the profession.
On one hand, we have created exciting, challenging jobs requiring highly skilled
specialized professionals; on the other hand, the manpower problem is compounded
by the fact that there is a continuing and pervasive use of overly qualified manpower
in boring, unsatisfying jobs. As the users of health care become more organized,
more and more pressure will be put on the health care industry to become more
efficient. This is another reason for community and hospital pharmacy to reevaluate
the way manpower is trained and utilized.
This is a major issue and one that needs to be addressed immediately. One approach
would be to assemble representatives from appropriate sectors of pharmacy
in a Hilton Head–type consensus–building conference on pharmacy manpower. However,
if all were drawn together, I believe that they should separate into at least two
groups to deal with the issues according to the unique needs for manpower and training
of community and hospital pharmacy.
If given the opportunity to work with educators and other stakeholders to develop
appropriate programs in which to educate and train future hospital pharmacists, what
programs would we prescribe? To answer that question, we first have to define what
our roles will be. Fortunately, we have already taken that step. At the Hilton Head
Conference, we agreed that it is a fundamental purpose of the profession to serve as a
force for safe and appropriate use of drugs and that a fundamental goal is to promote
optimal use of drugs. We went further to say that we should continue to have ultimate
responsibilities for drug distribution and drug control activities, but that those functions
should be carried out by technicians.
The consensus and commitment made at this conference have since been reaffirmed
in a number of similar conferences at regional, state, and local levels. I believe
that we had an understanding as we came to those conclusions as to what those clinical
roles will be. If those clinical activities are the primary and fundamental roles of
hospital pharmacists, then the basic goal of our instructional and training programs
should be to impart to pharmacists the knowledge and skills needed to fill those roles.
As schools of pharmacy are currently structured, I believe that the only way this
can be accomplished is through a six– or seven–year program. It appears that in the
near future that level of education will become a reality, at least for hospital pharmacy,
as schools continue to convert to the six–year, entry–level Pharm.D. program. If
we can accept for a moment that that will be the basic educational background of
hospital pharmacists in the future, what, if any, additional experiential training will
be needed? The APhA Task Force on Pharmacy Education concluded that “mastery
of the subject areas in the proposed core curriculum will enable a person to become a
pharmacist, not to be a pharmacist at the time of initial entry into practice.”
General residencies in hospital pharmacy have in the past successfully fulfilled this
experiential need for many hospital pharmacists, as I mentioned earlier. In some
programs, an emphasis has been placed on either management experience or clinical
experience, but, by and large, generalists have emerged who could in fact go on to
provide leadership in one or more areas of practice. This served well to bridge the
gap between theory and practice when most graduates were B.S. or M.S. graduates,
but how should our entry–level residency programs change to meet the needs of those
who will be beginning a career in the near future?
What has changed about the practice is that we have become a clinical profession.
We are in the process of changing educational programs to meet the needs of a clinical
profession, and it seems reasonable that we must change the entry–level experiential
program to meet the needs as well. We then need to strengthen within the experiential
program the clinical knowledge and skills beyond those acquired in the Pharm.D.
program. A resident should be able to mature in clinical practice under the preceptorship
of an experienced clinical pharmacist. However, since this is an entry–level experience,
the residency must also provide meaningful training in the other components
of hospital pharmacy service: administration, drug distribution and control, drug information
services, etc. Pharm.D. graduates must come to understand how clinical
services are integrated with other pharmacy services to best meet the needs of a given
institution. In a clinical profession, advancement of clinical practice must be the single
most important mission, but all pharmacists in an institution must understand and
be able to give support to all important goals of the pharmacy department.
Let me summarize the changes that are implied in this recommendation for an entry-level
residency program in hospital pharmacy. The first is that training in clinical
(general) practice become the focus of the program. Second, a Pharm.D. degree should
be a prerequisite for entry into the program. Third, the training program should provide
meaningful experience in the other important services and in the overall management
of the department. And fourth, this generalist entry–level residency should be a
prerequisite for advanced specialized residency programs. It is this level of training that
we should set our sights on for all pharmacists who are preparing for a future in hospital
pharmacy practice. As educators and practitioners in a clinical profession, we have the
moral and ethical responsibility to students and young pharmacists to develop qualified
sites for such training programs and to guide future hospital pharmacists into them.
Beyond this entry-level training program, there is a growing need for highly specialized
clinical training programs. We already have 35 such programs, but my sense
is that we need many more. I believe that there is now a much greater demand for
highly specialized clinicians than we can supply, and the demand will likely increase.
Having described the education and training scenario that I think is needed to prepare
the general and highly specialized clinical practitioners for tomorrow’s hospital pharmacy
practice, I’ll push your indulgence a little further and propose a training program
for highly specialized managers in a clinical profession. And the scenario will not be
that much different from the first, since I believe that managers and leaders in a clinical
profession require a solid foundation in clinical practice. Although we are already a
clinical profession, we need leaders who can guide a pharmacy staff to assume new roles
and higher professional responsibilities. Those leaders need personal clinical experience
if they are to appreciate fully the scope and depth of a pharmacist’s clinical potential.
Such understanding is essential to be able to visualize the potential and take advantage
of opportunities that develop as the environment changes. Only by having faced
clinical challenges and enjoyed the success of meaningful contribution to the resolution
of clinical problems can one visualize the purpose and generate value in those
activities. The leaders of a clinical profession must be committed to – almost obsessed
with – the idea of clinical practice. And, most important, they will need to project
that idea into images that create excitement in other people about that activity.
Those pharmacists who are qualified and interested in developing their future along
managerial lines should complete the programs described in the above scenario
through the post–Pharm.D., entry–level residency program. And then, just as their
counterparts who want to prepare for specialized clinical practice enter specialized
clinical residencies, management–oriented pharmacists should enter a specialized residency
in administration in which they acquire the knowledge and skills needed to
accomplish the human resource management responsibilities of a clinical department.
ASHP, through specialty administrative practice groups, must foster the advancement
of this specialty practice and encourage the development of training programs
to support it. Just as we need clinical specialty practice groups to focus efforts on
advancing clinical specialties, we need an administrative specialty practice group
composed of our best–trained and specialized managers to focus on advancing our
management capabilities.
The purpose of my comments has been twofold. First, I asked you to recognize and
be proud of the fact that we have reached a milestone in one of the most constructive
areas of our professional activity – residency training and the accreditation process.
Second, I asked you to explore with me some ideas for the kind of education and
experiential training that we are going to need as we grow and mature as a clinical
profession. I made the point earlier that factors in the external environment have
contributed significantly to our phenomenal growth but that at least one major contributing
factor – residency training and accreditation – came from within. Having
expanded our thinking to include didactic training, I would like to add that the second
major contributor to that success that has come from within the profession is clinical
training through Pharm.D. programs. The combined efforts of schools of pharmacy
and hospital pharmacies have given many pharmacists clinical knowledge and skills.
The knowledge and the expertise to apply it in the patient care environment are
what have driven the changes that brought us to the point of having a clinical profession.
Schools of pharmacy are building on that success and are preparing to supply us
with more graduates with clinical knowledge. I would ask that we devote adequate
effort and resources to developing quality residency training sites and promoting them
to pharmacy graduates so that when we arrive at the golden anniversary of accredited
residency training programs, we shall have as much pride in them as we have today.
It gives me great pleasure to express my thanks to the many who share this Award.
It occurred to me recently that if I were to share the very generous honorarium that
goes with this Award with all those who contributed significantly to it, we would each
receive about 10 cents. Many have helped me along the way. Those who deserve the
greatest share, however, are those professionally committed, creative colleagues at
Jefferson with whom I have had the pleasure and good fortune to work. Many are
more intelligent and highly skilled than I; all are willing to share their strength and
talent for the cause, always with cheer, optimism, and great expectations of each
other. To those very exceptional people, my most sincere thanks!
I’ll close with this thought from George Bernard Shaw:
I’m not a teacher; only a fellow–traveller of whom you asked the way. I pointed ahead –
ahead of myself as well as of you.
***
Any references cited in this lecture are available in the PDF version.
Originally published in Am J Hosp Pharm. 1988; 45: 1675-81.
© 1988, American Society of Health-System Pharmacists, Inc. All rights reserved.
Posted with permission.
