Millcroft Hospital Pharmacy Leadership Conference - June 1 - 3, 2007

Theme:Scope of Pharmacy Practice - What Will the Future Look Like?

Point/Counterpoint:
A Discussion of the Role of Pharmacy
in the Health Care System of the Future

Moderator: Kevin Hall
Editorial Advisory Board
Hospital Pharmacy in Canada Report
Winnipeg, MB

In the course of discussion, participants returned repeatedly to one central challenge in achieving advanced pharmacy practice: designing a system that is flexible enough to accommodate all practitioners. Some spoke of the need to facilitate the work of “overachievers” in the profession, while also accommodating the traditional community pharmacist who may be content to stay behind the drugstore counter. Presenters and participants demonstrated broad agreement that success in doing so will require more consistent and coherent credentialing, national standards, and initiatives; more comprehensive education and practice philosophies; and extensive work across disciplines.

While credentialing was generally recognized as a necessary component in expanding scope of practice, there were different ideas for the appropriate structure of a credentialing system and for the educational and training components needed to support the structure.

Dr. Gomori stressed the importance of tailoring education and training closely to the particular practice area, to ensure that inter-professional teams blend well and function successfully.

Several participants noted that credentialing is only a first step in the process of advancing practice scope. A residency pharmacy graduate summarized this line of thinking: “A credential gets you in the door, but it’s the relationships you form that move you and your professional practice forward.” When professionals have the right skills, their background is respected, witnessed, and assessed by their peers—this can be “as important a measure as anything that can be accomplished in a formal training structure.”

Koshman and Syme both stressed the need to increase residency training programs as an integral part of the education and credentialing system. Koshman referred to her own undergraduate experience to illustrate the importance of integrating longer and more residencies into basic pharmacy education to help guide students as they make decisions about their future practice. She called for strong formal relationships between hospital pharmacy and undergraduate programs, so that programs are less centred on traditional community practice.

Syme recommended that in light of contemporary issues, efforts to advance practice be strategic. Pharmacists should take advantage of current trends in health care to position themselves to take over roles for which they have the expertise in both hospital and community settings.

Syme underscored the comments of several others in noting that formal curriculum changes must be accompanied by practical “common sense” changes. For example, pharmacology is taught to nurses by nurses and to doctors by doctors. A good first step in building inter-professional cooperation, understanding, and respect would be for pharmacists to teach their discipline to other professionals. She recommended increasing inter-professional education opportunities overall, both in field placements and within the academic curriculum.

The need for flexibility again asserted itself. Dr. Gomori observed that not all pharmacists might be interested in residencies that prepare them for hospital or inter-professional practice. He suggested screening pharmacy students to help select those who might want or be suited to a residency program.

A mechanism for advanced training would allow the system to “grow” practitioners and offer them opportunities suited to their level of expertise, ability, and willingness, Koshman countered. The inability of everyone to do a particular thing should not hold back those who are willing and able.

Group members used the metaphor of “ceiling and floor” to further explore the tensions in creating a system that fits those who want to expand their scope of practice and those who do not. Some group members expressed concern that the “floor effect” is as problematic as the “ceiling effect,” which is known to discourage advancement. A system of regulatory authority will not function if it is built for the “stars” of the profession; it must be built for the basic level. One participant called it the responsibility of hospital pharmacy leaders and administrators to create a system that recognizes and uses the talents of the “stars” while simultaneously moving forward the whole profession.

Others disagreed. Several participants said community pharmacists are “holding back” the advancement of practice. They argued that other disciplines view hospital pharmacists differently from their community colleagues. They recommended leveraging the reputation of hospital pharmacists, Doctors of Pharmacy, and hospital/community residency programs to expand opportunities for advanced practice. One participant stressed the need to proceed “without getting stuck in the mud waiting for our community colleagues to catch up.” Another recommended acknowledging the important role of community pharmacists by enabling practice in that area to move forward differently.

Syme said a truly national representative organization to parallel the Canadian Nurses Association would be useful. The organization could take responsibility for aligning activities across provinces and for using best practice evidence-based models to help advance practice across the country. Participants said such a body does not exist for pharmacists. The Canadian Pharmacists Association (CPhA) is voluntary and the National Association of Pharmacy Regulatory Authorities (NAPRA) does not include Quebec and Ontario. A participant called for the creation of a leadership body to help bridge the gap for advancing inter-professional advanced pharmacy practice without alienating broader pharmacy associations or leaving anyone out of the process.

The issue of job title was revisited. Dr. Gomori echoed the sentiments of participants when he noted that “words are important and small details like titles matter.” He expressed his support for changing the name of advanced practice pharmacists at his Winnipeg clinic to reflect the actual scope of their contributions.

Finally, participants expressed agreement on the importance of clearly defining the roles for advanced practice across disciplines to ensure that overlapping roles are understood and do not become a source of contention. They called for the establishment of appropriate structures to ensure that expertise is used efficiently and effectively in as broad a range of settings as possible.