Should residencies be required by 2020? The argument against.
It is my understanding that there will be a resolution introduced at the American Association of Colleges of Pharmacy annual meeting in July to require a residency for all pharmacists who provide direct patient care by the year 2020. The American Society of Health-System Pharmacists and the American College of Clinical Pharmacy have both endorsed such a resolution within their organizations so clearly the idea has some supporters. I am not among them and I will be speaking against the resolution in Orlando. I would like to share with you my reasoning. 
 
I am generally a strong supporter of voluntary residencies. I believe that residencies are an important means of developing specialists who deal with complex patients and may speed up the post-graduate development of a fully functional professional. Entry-level is just that, ie, a practitioner with the basic skills to perform the work of a generalist pharmacist in most settings. Newly graduated pharmacists will reinforce and further develop their skills on the job. A residency is one way that the development of further confidence and competence can occur. It is, I believe, not the only way. 
 
One premise behind the proposal to require residencies is that current PharmD education does not prepare pharmacists to provide direct patient care. I disagree. I can not speak for the graduates of all colleges and schools of pharmacy but certainly the graduates I see are not only able to provide medication therapy management, but are indeed taking positions where this is the principal practice. Minnesota is now reimbursing for medication therapy management for Medicaid patients and Blue Cross/Blue Shield has recently announced payment for pharmacist-delivered diabetes management. These reimbursements, which are at a rate sufficient to support a pharmacist's salary, are driving the practice and employers are seeking PharmD graduates—without a residency—to provide the care. Fairview Health Services instituted pharmaceutical care practices in their clinics several years ago and employed pharmacists with a wide variety of backgrounds—some even experienced BS graduates—and all have been successful in providing care. The highly successful Asheville project, which is held as an example that is being replicated across the nation by the American Pharmacists Association Foundation, was instituted with pharmacists with a variety of educational backgrounds. 
 
Residencies should not be used for remediation for what schools and colleges have failed to accomplish. If indeed the graduates of some or all of our schools are missing some critical skills now, we must engage in educational improvement, so that pharmacists are graduating with knowledge, patient care skills, and health improvement skills. Individuals who think our graduates are lacking need to let us know what additional skills are necessary to meet their expectations. Curriculum reform is underway in many schools, and as more entering students are beginning their pharmacy education with a baccalaureate degree in hand, we have the flexibility to reconsider which courses are prepharmacy and which must occur in the PharmD curriculum. We have the opportunity to improve the education we deliver to PharmD graduates to meet the stated mission of producing graduates capable of providing direct patient care. Better assessment tools, including outcome OSCEs (observed structured clinical examinations), will help us know for sure the capabilities of our graduates. The accreditation standards embrace the patient care mission; they must be enforced. 
 
If indeed the profession is going to make the transition to a medication therapy management-providing profession, we will need all pharmacists to be able to practice in this manner. This may mean re-education for some. Projects such as the Asheville project suggest that this additional education can be successfully acquired by pharmacists with a variety of degrees and does not require an educational program as long or as disruptive as a 1-year residency. Our experience in Minnesota, where pharmacists who graduated prior to 1996 are required to complete a certificate program before they can be reimbursed by the state for medication therapy management, is that this training can be accomplished in well under a year without disrupting the pharmacist's employment. 
 
Announcing the intention to require a residency will be discouraging to current practitioners and suggests that they are not able to change their practices to incorporate medication therapy management. We can not afford to send that message. 
 
Furthermore, students and the health care system (and ultimately patients, employers, and taxpayers) would have to bear the cost of a required residency year for all pharmacists. Our students are graduating with significant debt and health care costs are soaring. There is every indication that the federal government is less and less willing to support required medical residencies. I do not foresee this changing by 2020 and we would not have until 2020 to start a significant building of new residencies to support the requirement by that time. To ask our graduates to take on additional debt, or at least to forestall earning a full salary for another year, seems to require more evidence of the necessity of the additional training for the protection and benefit of patients' health than I can find. As a responsible component of the overall health care system, we have the obligation to make our educational process as efficient and cost effective as possible. 
 
I welcome the debate around the proposed resolution. It is important that we honestly examine the capabilities of our graduates and the outcomes of our educational processes. If there are deficiencies, we need to correct them. If we don't know the answer, we need to redouble our efforts to get assessment tools in place to measure the capabilities. We can do all this while supporting the creation of residencies for graduates who do want to pursue them and for specialized roles in pharmacy. But I think that building toward required residencies diverts attention and dollars from fulfilling the mission of PharmD education and, therefore, I will vote no.