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Last year, I attended a summit on team-based care at the American College of Cardiology in Washington, DC. Very few of my fellow attendees from other health professions were aware of the training generally expected of pharmacists practicing in a cardiology setting, and I was encouraged to write an entry on the topic. At the same time, editorials like this from the Courier-Post make it clear that the public remains equally unaware of even the minimum expectations for pharmacists entering practice today.
Although the training and expectations of clinical pharmacists practicing in cardiology are rapidly evolving, the following information is a summary of the current paradigm (also depicted in the figure below – click to enlarge):
Pharmacists complete a minimum of two years of undergraduate education prior to being accepted into pharmacy school. Although the required coursework differs by school, many programs expect up to three years of undergraduate coursework in areas similar to those required of students applying to medical school (e.g., biology, physical and organic chemistry, calculus, anatomy and physiology, etc.). An undergraduate degree gradually became an expectation of medical school applicants in response to market demand and a similar trend is occurring in pharmacy. Currently, the number of pharmacy school applicants with undergraduate degrees is approaching 70%.
Most schools also require that applicants complete the Pharmacy College Admissions Test (PCAT), which is analogous to the examination for medical school applicants (i.e., the Medical College Admissions Test or MCAT). The PCAT covers reading, writing, verbal ability, biology, chemistry, and quantitative analysis. More information on pharmacy school applicants can be found here.
Pharmacy School Education
General Curriculum & Didactic Training
Pharmacy is a doctorate-level degree program that focuses on the safe and effective use of medication therapy. At some schools, the curriculum begins with the pathophysiologic basis of disease and then transitions to therapeutics. Others design the curriculum in a modular fashion, where the pathophysiologic and therapeutic aspects of each disease state are covered together in blocks. To complement the core therapeutics curriculum, students also complete coursework in public health, law, management, pharmacoeconomics, and pharmacogenomics, among other subjects.
Professional Skills Development
Concurrent to the didactic curriculum are skills-based courses that focus on the fundamentals of professional pharmacy practice, including the preparation, delivery, and dispensing of drugs; patient assessment, including physical examination; and patient communication. Many schools use objective structured clinical examinations (OSCEs) to assess student competence in these areas and a growing number use simulations as well as actual patients as part of skills-based courses.
During the first three years of the curriculum, students complete introductory pharmacy practice experiences (IPPEs), which altogether constitute 5% of the curriculum. In IPPEs, students integrate their knowledge and skills into practice, often through interactions with patients. At a minimum, IPPEs are completed in both community and hospital/health-system settings.
Advanced pharmacy practice experience (APPEs, often called “rotations”) are the capstone of the pharmacy curriculum and constitute 25% of total coursework. In APPEs, students are assigned, often in blocks of 4-6 weeks, to a variety of practice settings, including acute and critical care (i.e., general practice as well as specialties such as cardiology and infectious diseases), ambulatory care (i.e., clinic-based management of chronic disease), community pharmacy, managed care, administration, and more. In APPEs, students gain experience in the pharmacist patient care process and often serve as extenders of care by performing activities such as medication histories, medication reconciliation, and patient education. Literature evaluation is also emphasized as students learn how to integrate evidence-based medicine into practice. Finally, in concert with their preceptor, students also gain experience in the optimization of medication therapy for individual patients.
After obtaining their Doctor of Pharmacy (PharmD) degree, graduates must complete the North American Pharmacist Licensure Examination (NAPLEX), which assesses their competency to practice pharmacy, and the Multistate Pharmacy Jurisprudence Examination (MPJE or “law exam”), which assesses their knowledge of federal drug law as well as the laws governing pharmacy for the state in which they intend to practice.
Postgraduate Residency Training
Approximately one-third of graduates pursue postgraduate residency training, as it is quickly becoming an expectation for positions involving direct patient care in both ambulatory and acute care settings. The process is highly competitive; in 2014, less than two-thirds of applicants entering the match process successfully obtained residency positions. Whereas training programs in many professions consist of on-the-job training, pharmacy residency programs must meet rigorous educational standards in order to be accredited nationally. Postgraduate Year 1 (PGY1) residencies may be completed in community, hospital/health system, or managed care settings. Many graduates then pursue a Postgraduate Year 2 (PGY2) residency in a specialty area such as cardiology, infectious diseases, oncology, or solid organ transplantation. Most cardiology pharmacists complete PGY2 training in cardiology, although some complete residencies in internal medicine or critical care. Some also pursue research fellowships, either alone or before/after residency training.
Board Certification & Other Credentials
Many pharmacists practicing in direct patient care roles obtain board certification from the Board of Pharmacy Specialties (BPS). To become a Board Certified Pharmacotherapy Specialist (BCPS), a pharmacist must practice for three years (with the majority of their experience being in the management of pharmacotherapy) or complete a PGY1 residency, and then achieve a passing score on the BCPS board examination. Board certification in cardiology first became available in the fall of 2018, and certifications are also available in a variety of other specialty practice areas, such as nutrition support, oncology, critical care, and pediatrics.
Cardiology clinical pharmacists who practice in specific settings may also pursue credentials offered by other certifying organizations, such as Clinical Lipid Specialist (CLS) or Certified Anticoagulation Care Provider (CACP).
Recently the profession has collectively advocated that pharmacists be recognized by the Centers for Medicare and Medicaid Services (CMS) as health care providers, whose services should be paid for in a fashion similar to other providers (either as fee-for-service in the current model or as part of the team-based approach emphasized in value-based care models). Incumbent to obtaining these privileges is the burden of proof that pharmacists possess the knowledge and skills necessary for providing valuable clinical services as well as a willingness to accept accountability for medication-related health outcomes. Overall, clinical pharmacists in the area of cardiology have a doctorate-level education and have completed years of postgraduate residency training; many have obtained board certification and/or additional credentials. Although they are often considered as being integral members of the health care team by their colleagues in other health professions, their practice remains limited by a lack of recognition among payers. To truly move forward, the latter has to change.
Note: This is an updated version of an entry originally posted on Dr. Reed’s personal blog, The Unit.
Brent N. Reed, PharmD, BCPS-AQ Cardiology, FAHA
Dr. Reed is an assistant professor in the Department of Pharmacy Practice and Science at the University of Maryland School of Pharmacy, and practices as a clinical pharmacy specialist in advanced heart failure at the University of Maryland Medical Center in Baltimore, MD. Follow him on Twitter @brentnreed
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