American Journal of Pharmaceutical Education 2013; 77 (10) Article 207.
VIEWPOINTS Is it Time to Start Teaching Basic Diagnostics? Frank Romanelli, PharmD, MPH, Mandy Jones, PharmD, PA-C University of Kentucky College of Pharmacy
A pressing movement within the profession, which is being partially propelled by national universal healthcare initiatives, is the drive towards “provider status” for at least some groups of pharmacists.1 Given the long history of our profession, it is startling that in 2013 we find ourselves still advocating for “recognition” as healthcare providers, even within the confines of bureaucratic federal processes. A corollary and perhaps more long and winding road has been the battle for pharmacist prescriptive privileges across the United States.2,3 Some momentum has been made on a state-by-state basis, especially in terms of collaborative care agreements.4 From a medical perspective, the lynch pin in blocking progress in this area is a lack of even basic diagnostic training for most pharmacists.5 Physicians and mid-level practitioners alike have often used the “inability to diagnose” battle cry as a reason to obstruct sometimes even the most tepid efforts by pharmacy to assume greater responsibilities in the care and follow-up of patients. Some might argue that pharmacists graduating from modern doctor of pharmacy (PharmD) degree programs, while often not formally exposed to diagnostic training, do indeed have some level of skill in this area. The movement in professional pharmacy education towards more significant and continuous patient contact exposes students to a greater breadth and depth of clinical training and thinking. Patient assessment, which encompasses skills associated with physical assessment, are now a component of accreditation standards and are instructed to varying degrees within almost every US college and school of pharmacy.6 Patient and physical assessment requires students to think critically, evaluate laboratory and diagnostic testing, develop a sense of inquiry, and process information in a logical, stepwise fashion. Also, the increased emphasis within the profession on authentic assessments, such as objective standardized clinical examinations (OSCEs), continues to force students to practice and refine patient care skills, including information gathering and assimilation, communication, and clinical reasoning. Models of pharmacists effectively utilizing
diagnostic skills to manage uncomplicated disease states exist in various settings including the Veterans Affairs System and within ambulatory care settings. In these settings, pharmacists everyday utilize very basic diagnostic assessment in arriving at recommendations for both prescription and more commonly nonprescription medications and drug products. Despite the aforementioned intentional or unintentional changes to pharmacy curricula, which may have moved professional education closer to instructing some degree of diagnostic skills, there are no reports of existing schools that have explicitly added required curricular work in this area. One school has reported the development of an elective course in very basic clinical reasoning and differential diagnosis.7 A small number of colleges and schools have developed dual degree programs that award both PharmD and master of science in physician assistant studies (MSPAS) credentials. Certainly graduates of these hybrid programs will have gained proficiency in diagnosis. It may be time for the academy to take a more aggressive stand with regards to diagnostic instruction within professional degree programs. The profession has recently seen many retail chains experiment with and implement care models in which either nurse practitioners or physician assistants are placed in close proximity to or within a pharmacy in order to provide basic primary care.8,9 This may represent a missed opportunity for the profession, leaving some wondering why a pharmacist with appropriate training could not provide these services along with a high level of medication therapy management. Implementation of the Affordable Care Act may provide another impetus for change in this direction as many more Americans are expected to become increasingly eligible for covered primary care services. These patients will require some level of care that the current system, devoid of sufficient primary care practitioners, will be stressed to provide. At a minimum, an increased emphasis on diagnostic training will allow pharmacists to more autonomously influence health outcomes and contribute to the general wellbeing of patients.
Corresponding Author: Frank Romanelli, PharmD, MPH. Professor of Pharmacy, University of Kentucky, College of Pharmacy, 789 S. Limestone Rd., Lexington, KY 40536.
1
American Journal of Pharmaceutical Education 2013; 77 (10) Article 207. Movement towards a curriculum with an increased emphasis on diagnosis will likely be met with some opposition by other health care providers. On the surface they will likely find most training to be insufficient in breadth and depth. If the profession were to move in this direction, a critical tenet would be that instruction would be aimed at basic assessment, triage, and diagnostic skills. The objectives for instruction in this area might specifically focus on commonly encountered, uncomplicated primary care disease states (eg, allergic rhinitis, otitis media, rash, etc). It should not be the intent of the academy to advocate for the creation of “pseudo-physicians,” but rather to empower pharmacists with the ability to more impactfully care for patients. The profession should also tactfully limit its sensitivity to noise from other professions and instead focus on collaborative efforts to define its own scope of practice. Any sentiment towards increasing curricular burden within professional degree programs with greater course work must be balanced with deletion of some other existing content. Without an effort to achieve balance in credit hours, programs will become increasingly burdensome for students, limiting time to actually think, reflect, and learn. The evolution of pharmacy practice and future practice models should continue to dictate what is taught and what topical areas could potentially be removed from curricula to provide room for new instruction in the area of basic diagnostics. As previously mentioned the concept of instructing even basic diagnosis within PharmD curricula will likely generate deliberation and controversy both within the profession and from our colleagues in other health care colleges. This is dialogue that needs to occur. In considering provocative proposals such as this, the academy should exhibit mutual respect but not cower from sensible, healthy, and productive debate. Regarding diagnostic instruction and skill building, the time seems right for this discussion given external factors within the health care
system and internal changes within the academy and our profession.
REFERENCES 1. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice. A report to the US Surgeon General. Office of the Chief Pharmacist. US Public Health Service. December 2011. http://www.accp.com/docs/positions/misc/ Improving_Patient_and_Health_System_Outcomes.pdf. Accessed November 20, 2013. 2. Makowsky L, Guirguis LM, Hughes CA, et al. Factors influencing pharmacists adoption of prescribing: qualitative application of the diffusions of innovations theory. Implementation Sci. 2013;8: Article 109. 3. Emmerton L, Marriott J, Bessell T, et al. Pharmacists and prescribing rights: review of international developments. J Pharm Sci. 2005;8:217–228. 4. Consortium recommendations for advancing pharmacists' patient care services and collaborative practice agreements. JAPhA. 2013; 53(2):e132–141. 5. Accreditation Council for Pharmacy Education, American Association of Colleges of Pharmacy, American College of Clinical Pharmacy, American Pharmacists Association, American Society of Consultant Pharmacists, National Association of Boards of Pharmacy, National Alliance of State Pharmacy Associations. Recommendations: AMA scope of practice data series: Pharmacists. http://www.accp.com/docs/positions/commentaries/AMA%20Scope %20of%20Practice%20Pharmacists% 20-%20Joint%20Pharmacy% 20Organization%20Recommendations.pdf Accessed October 2, 2013. 6. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. February 14, 2011. https://www. acpe-accredit.org/pdf/S2007Guidelines2.0_ChangesIdentifiedInRed.pdf. Accessed November 20, 2013. 7. Fuentes D. An elective course in differential diagnosis. Am J Pharm Educ. 2011;75(9) Article 185. 8. Ferris AH, McAndrew TM, Scearer D, et al. Embracing the convenient care concept. Postgrad Med 2010;122:79. Cassel C. Retail clinics and drugstore medicine. JAMA. 2012;307:2151–2.
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VIEWPOINTS Is it Time to Start Teaching Basic Diagnostics? Frank Romanelli, PharmD, MPH, Mandy Jones, PharmD, PA-C University of Kentucky College of Pharmacy
A pressing movement within the profession, which is being partially propelled by national universal healthcare initiatives, is the drive towards “provider status” for at least some groups of pharmacists.1 Given the long history of our profession, it is startling that in 2013 we find ourselves still advocating for “recognition” as healthcare providers, even within the confines of bureaucratic federal processes. A corollary and perhaps more long and winding road has been the battle for pharmacist prescriptive privileges across the United States.2,3 Some momentum has been made on a state-by-state basis, especially in terms of collaborative care agreements.4 From a medical perspective, the lynch pin in blocking progress in this area is a lack of even basic diagnostic training for most pharmacists.5 Physicians and mid-level practitioners alike have often used the “inability to diagnose” battle cry as a reason to obstruct sometimes even the most tepid efforts by pharmacy to assume greater responsibilities in the care and follow-up of patients. Some might argue that pharmacists graduating from modern doctor of pharmacy (PharmD) degree programs, while often not formally exposed to diagnostic training, do indeed have some level of skill in this area. The movement in professional pharmacy education towards more significant and continuous patient contact exposes students to a greater breadth and depth of clinical training and thinking. Patient assessment, which encompasses skills associated with physical assessment, are now a component of accreditation standards and are instructed to varying degrees within almost every US college and school of pharmacy.6 Patient and physical assessment requires students to think critically, evaluate laboratory and diagnostic testing, develop a sense of inquiry, and process information in a logical, stepwise fashion. Also, the increased emphasis within the profession on authentic assessments, such as objective standardized clinical examinations (OSCEs), continues to force students to practice and refine patient care skills, including information gathering and assimilation, communication, and clinical reasoning. Models of pharmacists effectively utilizing
diagnostic skills to manage uncomplicated disease states exist in various settings including the Veterans Affairs System and within ambulatory care settings. In these settings, pharmacists everyday utilize very basic diagnostic assessment in arriving at recommendations for both prescription and more commonly nonprescription medications and drug products. Despite the aforementioned intentional or unintentional changes to pharmacy curricula, which may have moved professional education closer to instructing some degree of diagnostic skills, there are no reports of existing schools that have explicitly added required curricular work in this area. One school has reported the development of an elective course in very basic clinical reasoning and differential diagnosis.7 A small number of colleges and schools have developed dual degree programs that award both PharmD and master of science in physician assistant studies (MSPAS) credentials. Certainly graduates of these hybrid programs will have gained proficiency in diagnosis. It may be time for the academy to take a more aggressive stand with regards to diagnostic instruction within professional degree programs. The profession has recently seen many retail chains experiment with and implement care models in which either nurse practitioners or physician assistants are placed in close proximity to or within a pharmacy in order to provide basic primary care.8,9 This may represent a missed opportunity for the profession, leaving some wondering why a pharmacist with appropriate training could not provide these services along with a high level of medication therapy management. Implementation of the Affordable Care Act may provide another impetus for change in this direction as many more Americans are expected to become increasingly eligible for covered primary care services. These patients will require some level of care that the current system, devoid of sufficient primary care practitioners, will be stressed to provide. At a minimum, an increased emphasis on diagnostic training will allow pharmacists to more autonomously influence health outcomes and contribute to the general wellbeing of patients.
Corresponding Author: Frank Romanelli, PharmD, MPH. Professor of Pharmacy, University of Kentucky, College of Pharmacy, 789 S. Limestone Rd., Lexington, KY 40536.
1
American Journal of Pharmaceutical Education 2013; 77 (10) Article 207. Movement towards a curriculum with an increased emphasis on diagnosis will likely be met with some opposition by other health care providers. On the surface they will likely find most training to be insufficient in breadth and depth. If the profession were to move in this direction, a critical tenet would be that instruction would be aimed at basic assessment, triage, and diagnostic skills. The objectives for instruction in this area might specifically focus on commonly encountered, uncomplicated primary care disease states (eg, allergic rhinitis, otitis media, rash, etc). It should not be the intent of the academy to advocate for the creation of “pseudo-physicians,” but rather to empower pharmacists with the ability to more impactfully care for patients. The profession should also tactfully limit its sensitivity to noise from other professions and instead focus on collaborative efforts to define its own scope of practice. Any sentiment towards increasing curricular burden within professional degree programs with greater course work must be balanced with deletion of some other existing content. Without an effort to achieve balance in credit hours, programs will become increasingly burdensome for students, limiting time to actually think, reflect, and learn. The evolution of pharmacy practice and future practice models should continue to dictate what is taught and what topical areas could potentially be removed from curricula to provide room for new instruction in the area of basic diagnostics. As previously mentioned the concept of instructing even basic diagnosis within PharmD curricula will likely generate deliberation and controversy both within the profession and from our colleagues in other health care colleges. This is dialogue that needs to occur. In considering provocative proposals such as this, the academy should exhibit mutual respect but not cower from sensible, healthy, and productive debate. Regarding diagnostic instruction and skill building, the time seems right for this discussion given external factors within the health care
system and internal changes within the academy and our profession.
REFERENCES 1. Giberson S, Yoder S, Lee MP. Improving patient and health system outcomes through advanced pharmacy practice. A report to the US Surgeon General. Office of the Chief Pharmacist. US Public Health Service. December 2011. http://www.accp.com/docs/positions/misc/ Improving_Patient_and_Health_System_Outcomes.pdf. Accessed November 20, 2013. 2. Makowsky L, Guirguis LM, Hughes CA, et al. Factors influencing pharmacists adoption of prescribing: qualitative application of the diffusions of innovations theory. Implementation Sci. 2013;8: Article 109. 3. Emmerton L, Marriott J, Bessell T, et al. Pharmacists and prescribing rights: review of international developments. J Pharm Sci. 2005;8:217–228. 4. Consortium recommendations for advancing pharmacists' patient care services and collaborative practice agreements. JAPhA. 2013; 53(2):e132–141. 5. Accreditation Council for Pharmacy Education, American Association of Colleges of Pharmacy, American College of Clinical Pharmacy, American Pharmacists Association, American Society of Consultant Pharmacists, National Association of Boards of Pharmacy, National Alliance of State Pharmacy Associations. Recommendations: AMA scope of practice data series: Pharmacists. http://www.accp.com/docs/positions/commentaries/AMA%20Scope %20of%20Practice%20Pharmacists% 20-%20Joint%20Pharmacy% 20Organization%20Recommendations.pdf Accessed October 2, 2013. 6. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. February 14, 2011. https://www. acpe-accredit.org/pdf/S2007Guidelines2.0_ChangesIdentifiedInRed.pdf. Accessed November 20, 2013. 7. Fuentes D. An elective course in differential diagnosis. Am J Pharm Educ. 2011;75(9) Article 185. 8. Ferris AH, McAndrew TM, Scearer D, et al. Embracing the convenient care concept. Postgrad Med 2010;122:79. Cassel C. Retail clinics and drugstore medicine. JAMA. 2012;307:2151–2.
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