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Determining Excellence of a Pharmacist Opening Statements

Hello, Pharmacy Learning Network listeners. Welcome to Great Debates in Pharmacy: Determining Excellence of a Pharmacist. I'm your moderator, Julie Gould, associate digital editor of Pharmacy Learning Network.

I am joined today by Drs. Randolph Fugit and Mark Munger.

Dr. Fugit is an internal medicine ‑‑ infectious diseases clinical specialist at the Denver Veterans Affairs Medical Center, as well as associate clinical professor in the Department of Pharmacy Practice, College of Pharmacy, at the University of Colorado Health Sciences Center.

He is also director of the Antimicrobial Stewardship program at the Denver VA Medical Center.

Dr. Fugit received his Doctor of Pharmacy degree from the University of New Mexico College of Pharmacy.

Upon graduation, he completed a clinical pharmacy practice residency at the Albuquerque Veterans Affairs Medical Center, in which his focus was on internal medicine, infectious diseases, gastroenterology, and ambulatory care.

Dr. Fugit is a board‑certified pharmacotherapy specialist and maintains an active clinical practice in the Department of Internal Medicine at the Denver Veterans Affairs Medical Center.

Finally, Dr. Fugit is a member of the Pharmacy Learning Network editorial board.

Dr. Munger graduated from Oregon State University with a BS in Pharmacy, received his PharmD from the University of Illinois in Chicago, and completed a clinical cardiovascular pharmacology research fellowship from Case Western Reserve University School of Medicine in Cleveland, Ohio.

His current position is Professor of Pharmacotherapy and Adjunct Professor of Internal Medicine ‑‑ Cardiology at the University of Utah, where he joined the faculty in 1991.

He is also an associate dean for college affairs at the University of Utah College of Pharmacy and is a fellow in the University of Utah Academy of Health Science Educators.

Dr. Munger is a fellow in the American College of Clinical Pharmacy, the American College of Cardiology, and the Heart Failure Society of America.

He has served as chairman for the University of Utah Institutional Review Board, chairman and member of the Utah State Board of Pharmacy, chairman of Utah State Department of Digital Health Commission, and the Utah State Controlled Substances Advisory Board.

He currently serves as a member of the Utah State Cannabinoid Product Safety Board.

Dr. Munger is also a member of the Pharmacy Learning Network editorial board and writes a monthly blog.

In December, Dr. Munger wrote a blog post titled, "What Makes an Outstanding Pharmacist?" He questions if national board certification should be the only way to judge a pharmacist's ability to practice in a proficient, caring manner.

During this debate, Dr. Munger and Dr. Fugit discuss two topics. In round one, our speakers discuss, "What determines excellence in a pharmacist?" In round two, they discuss the question, "Can board certification be justified?"

Dr. Fugit, your opening statement?

Dr. Randolph Fugit:  Yes. Thank you, Julie, for that kind introduction.

My esteemed colleague, Dr. Munger, wrote a wonderful piece on PLN Blogs defining what he felt made for an outstanding pharmacist.

I truly feel this manuscript was well constructed and carefully thought out. However, I do feel there are some major points that were missed and should be addressed. I agree with him. This is a very difficult‑to‑define issue as to what makes an outstanding pharmacist, especially without subjective observations by the pharmacist's own colleagues, their managers, and perhaps even their patients.

How these individuals are perceived and viewed on a daily basis is important, but what mechanisms exist or basically allow us to grade or determine excellence? How can you measure compassion, common sense, communication skills, or even empathy? How does an individual who has never encountered this outstanding pharmacist know that they're truly outstanding?

How can we compare an academic pharmacist with dozens of publications, a multitude of research experience, or even a fellow of every professional medical society known to our practice to, say, a community pharmacist who ensures every prescription is accurately filled?

Ensures that every patient has full understanding of the medication they are about to consume? Is obviously loved by his patients for the time he spends with them?

What about the hospital pharmacist, who carefully reviews every patient's pharmacotherapy plan and makes those life‑saving decisions to change their medications based on their knowledge of clinical guidelines or even the recent literature?

No. It is impossible, but depending on who you ask, all would suggest that each of these individuals are outstanding pharmacists. That would be by their respective peers, or even perhaps their peers would suggest they're terrible pharmacists based on their own personal biased perceptions.

The fact is, bias can be introduced anytime you have a subjective analysis. As you know, every pharmacist must pass an entry‑level board examination prior to being qualified to practice pharmacy. Does this not make them outstanding? I don't think so, as it is impossible to measure the type of care that this pharmacist will be able to deliver.

How is competency assessed after this exam? By the number of CEs obtained during the current year? What measures do exist to ensure a pharmacist remains relevant, contemporary, and even qualified to practice at a higher level?

The bottom line is knowledge matters. I'm not saying that care, compassion, empathy for our patients are not important. Heck, that's the reason we went into pharmacy in the first place. It was to provide care for our patients, but improving the outcomes and livelihood of our patients is the bottom line and is paramount.

What is one way we can ensure that we remain a relevant caregiver to our patients?

The bottom line is, again, never stop learning. Never stop ensuring that you possess the most contemporary knowledge base possible. How can that be achieved and documented? One option, in my opinion, is through advanced board certification in that pharmacist's chosen area of practice.

In Dr. Munger's commentary on the outstanding pharmacist, he suggests that specialty board certification should not be considered a gold standard in determining a pharmacist is capable of practicing at an advanced level.

I agree, it will never alone define an outstanding pharmacist. I do feel it represents a pharmacist who is willing to take the extra step towards bettering themselves, towards ensuring that they are the best providers for their patients, providing their patients with the best care possible, and being able to practice within the ability of a higher‑level pharmacist.

To me, that certainly is the path towards becoming an outstanding pharmacist. Let's face it. The pharmacy job market is tightening up. Employers need a way to quickly identify potential candidates for their open positions.

Most candidates will already have a PharmD degree. Since schools are now pushing for graduates to obtain a residency, what sets them apart for that clinical position?

Prior to calling any references to determine if the candidate is an outstanding pharmacist, I do believe board certification will somewhat stand out.

Again, in his blog, Dr. Munger states every pharmacist needs to have competency, but is certification the only way to judge ability to practice in a proficient, caring manager? He says no. I agree that this is not the only way, but give me another, easier way to rapidly determine competency in a specific specialty.

Given this and the fact that board certification requires a significant amount of baseline knowledge to prepare and pass the individual exams, as well as maintaining an up‑to‑date knowledge base to recertify, these pharmacists are thus required to maintain a level of expertise at all times within that specialty.

These are the reasons why I feel the specialty board certification is one way to help identify what I believe as the outstanding pharmacist.

Julie:  Dr. Munger, your opening statement?

Dr. Mark Munger:  I want to thank the Pharmacy Learning Network and especially Julie Gould for the invitation to participate in this podcast.

Pharmacy is a noble profession with a rich history. The pharmacy profession dates to the 17th century when King James established the first pharmacy guild. During the past century, pharmacy has evolved from a guild‑like occupation to a recognized profession with a specialized body of knowledge, a code of ethics and standards, a regulatory framework, and a social covenant to serve the public.

The public facade of pharmacy is the community pharmacist. In the past, a community pharmacist practicing in an independent pharmacy, delivering considerate, effective, professional service and patient care, would be very busy. Those days are gone.

They're replaced by large community pharmacy corporate conglomerates focused on prescription volume and revenue due to shrinking dollar margins per prescription. This change has ushered more depersonalization of the community pharmacist, focused mostly on business efficiency with minimal delivery of care.

The value of a pharmacist has been stated to be, by a national pharmacist organization, prescription medication dispensing, providing clinical services, managing chronic disease states, and increasing medication adherence rates.

These are laudable outcomes related to the value proposition of quality plus service divided by cost, but do they make an outstanding pharmacist in the 21st century?

Currently, the primary way the pharmacy profession judges you and I to be an outstanding pharmacist is almost solely based on recall knowledge. Why? Because it's easier. It's more efficient and less prone to litigation. Recall knowledge is judged by a certification exam across numerous healthcare professions, including pharmacy. This is big business.

New requirements for maintaining medical board certifications, which affect more than 250,000 physicians nationwide, are estimated to be $5.7 billion ‑‑ that's with a B ‑‑ over the next 10 years. Most of the cost is estimated to be from physicians fulfilling requirements, such as completing online modules rather than fees.

We are having physicians and pharmacists take valuable time away from patient care and other related activities, and reduce their quality of life, for what? To pass a recall test? Is that really what makes an outstanding pharmacist? I state that the answer to that question is no. I hope this is not where we have evolved to.

Interestingly, the process of judging a student pharmacist on knowledge recall begins in our admission process to colleges and schools of pharmacy. Most admission processes are based on grades. What are grades based on, in most courses? You guessed it ‑‑ recall knowledge, mostly in science‑based courses.

I acknowledge that most colleges of pharmacy request applicants demonstrate leadership qualities through demonstration of volunteer work, school activities, and employment, but the primary admission scoring rubric remains heavily leveraged on the GPA score in pre‑pharmacy coursework.

Knowledge recall. The profession sows what it reaps as student pharmacists progress in their careers through the college learning environment to being a pharmacy practitioner, judged all along their career by knowledge recall. Is knowledge recall what qualifies a pharmacist's value to their patient?

Is it demonstrating disease state and medical knowledge, or the service he or she provides through communicating compassion and empathy to a patient or caregiver who is suffering from chronic debilitating pain, a new cancer diagnosis, has suffered a myocardial infarction, or as simple as a bug bite requiring over‑the‑counter medications?

Providing effective communication in an empathetic manner, with an ultimate goal to heal, engages patients. When you engage a patient, they become actively involved in their own care. They realize and define their own health‑related goals. We must align our patient goals, not business goals, in order to aspire to be an outstanding pharmacist.

An outstanding pharmacist is more about their value to the patient than the knowledge they elicit on a national exam. It is about communication, providing empathy, in essence, helping to heal, which is uniquely human.

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