Specialization and Specialties in Pharmacy Practice: "Gradual Evolution or Intelligent Design?"

The development of specialized practices for pharmacists has quickened considerably in the past two decades as a result of several forces, including the objective of ensuring the rational management of complex pharmacotherapeutic agents and regimens, fundamental changes in the professional curriculum and educational preparation of new pharmacist graduates, and growing recognition of the importance and value of residency training (both general and specialized) in the development and maturation of pharmacists who provide direct patient care services.

When combined with the public policy imperatives of promoting optimal safety, cost-effectiveness, and quality outcomes from the use of medications, the handwriting on the wall is increasingly clear: the role, and performance, of a growing number of pharmacists as the "specialists" on the health care team responsible for the appropriate use of medications, regardless of setting, is all but inevitable.

There is ample evidence of this trend, both in the substantial growth in numbers of pharmacists pursuing certification in one of the five "formal" specialties in pharmacy currently recognized by the Board of Pharmaceutical Specialties (BPS) (see Figure 1) and the proliferation of pharmacist credentialing/certification programs outside the BPS framework in areas such as geriatric pharmacy practice, anticoagulation management, lipid management, and, most recently, HIV/AIDS.¹ Entities both within and outside of pharmacy that understand and seek to serve the health care marketplace have begun to identify needs to which pharmacists, together with their national professional associations, must respond in a comprehensive, coherent, and integrated way. A significant number of the 1300 ACCP members responding to a 2006 College survey expressed strong support for exploring recognition of an array of "specialized" pharmacy practice areas that are not currently encompassed by the BPS framework.

A parallel development has been the growth by more than 75% in the numbers of specialized (PGY-2) residency programs and resident positions within those programs in the 10 years from 1999 to 2008.² Accreditation standards for 22 different PGY-2 residency programs have been approved by the ASHP Commission on Credentialing, the nationally recognized accrediting body for pharmacy residency programs. And while there are PGY-2 residency programs that align exactly with the five BPS-recognized specialties (along with two areas of "added qualifications" within pharmacotherapy), that leaves more than a dozen distinct areas of "specialization" in pharmacy for which a formalized certification process for practitioners seeking to practice that specialty is either nonexistent or outside the current framework of BPS.

ACCP and BPS – A History of Collaboration and Mutual Support

ACCP and its members are strong supporters of both specialization in pharmacy and BPS. ACCP was the sponsoring organization for the petition submitted to BPS in 1988 to recognize pharmacotherapy as a specialty, and the College has continued to work with BPS and its Pharmacotherapy Specialty Council to promote pharmacotherapy specialization and support the professional development and recertification needs of BPS-certified pharmacotherapy specialists. Even more broadly, the College recently published a white paper³ that expresses the vision "... that in 20–30 years, most clinical pharmacy practitioners will be board-certified specialists."

To assist in achieving that vision, the College believes the time has arrived for a profession-wide dialogue on the desirability of and approach to a refined framework for specialty recognition and specialist certification within pharmacy. In February 2007, ACCP Executive Director Michael Maddux and President Stuart Haines wrote to BPS, urging it to take a leadership role in convening such a discussion on the current specialization framework. They noted that:

In its more than 30 years of service to the profession, BPS has provided valuable leadership, guidance, and management in its activities in specialty recognition and pharmacist specialist certification. In that same period, however, the changes in the profession of pharmacy specifically, and health care generally, have been nothing short of revolutionary. The changes over the next 30 years will likely be even more remarkable.

As visionary as the leaders of pharmacy were in 1976 in establishing BPS and its processes, there can be little doubt that changes in the practice of pharmacy are now and will increasingly impact the activities, effectiveness, and credibility of BPS in an increasingly complex and sophisticated health care environment. For that reason, an examination of the existing framework for specialty recognition and specialist certification in pharmacy (a framework that has remained essentially unchanged since BPS' founding) is overdue. Such an examination will assure that pharmacy's framework for specialty recognition and certification is best positioned to meet the needs of the public and the profession in the future.

BPS has responded to this recommendation by working collaboratively within the Council on Credentialing in Pharmacy (CCP) to have CCP organize a profession-wide invitational conference in early 2009 to engage all stakeholders with an interest in pharmacy specialization in a strategic examination of the current framework and potential refinements to meet the needs of the health care system and pharmacists. ACCP's 2008 Board Certification Committee is currently developing a white paper for review and approval by the Board of Regents that will present the College's perspective and recommendations for consideration at the conference.

"Ambulatory Care" – Current Status of a Joint Petition to BPS

Among the areas of pharmacy practice for which PGY-2 residency accreditation standards have been approved but for which no BPS certification process exists is "ambulatory care." BPS, on its own initiative and in conjunction with its educational consultant, Professional Examination Services (PES), conducted a role delineation/task analysis survey of ambulatory care pharmacists (many of them ACCP members) in late 2006. Subsequently, a task group of member and staff representatives of the American Pharmacists Association (APhA), ASHP, and ACCP met in May 2007 to review the data generated by that process and to provide advice to their respective boards concerning the potential involvement of the organizations in the development of a petition to BPS to recognize ambulatory care as a specialty.

Based on the recommendation of staff representatives and ACCP leaders who participated in the May meeting, the ACCP board approved in July the College's participation in the development and submission of a petition in collaboration with APhA and ASHP.

The ACCP board's decision reflects its (1) long-standing support for the professional and public health value of board certification in pharmacy, (2) commitment to expanding opportunities for clinical pharmacists to seek board certification in their area of practice, and (3) belief that ACCP's involvement will help ensure the development of a petition that conforms to the existing criteria for recognition of a specialty and that demonstrates comparability with other currently recognized specialties in pharmacy.

After the petition is submitted to BPS, which is currently projected to occur in November 2008, BPS will conduct its prescribed public process for seeking input from the full range of stakeholders involved in pharmacy specialization and credentialing. Individual ACCP members, as well as the College itself, will, at that point, have the opportunity to provide their perspectives, feedback, and recommendations to BPS concerning the approval or rejection of the petition.

The petition development task group consists of a contract manager for the project and one volunteer member and one staff member from each of the three organizations. The timetable for petition development and submission is currently on schedule, as follows:

November 15, 2007: Issue request for proposals (completed)
January 30, 2008: Deadline for receipt of proposals (completed)
February 29, 2008: Review of proposals and selection of consultant (completed)
March – July 2008: Meetings/work of resource task group (with interim petition drafts)
September 1, 2008: Petition final draft completed
Sept. – Oct. 2008: Petition review/modification/approval by the Associations' boards
November 1, 2008: Submission of petition to BPS by the Associations

The ambulatory care petition development process and the planning for the stakeholders' conference on the specialty recognition and specialist certification framework can and will proceed simultaneously because each will generate information and guidance to assist the profession in its deliberations on both issues.

So ... the question is: gradual evolution or intelligent design? Which approach should pharmacy embrace in its quest to take its specialty recognition and specialist certification framework to the next level to further improve patient care in the use of medications? Please share your thoughts with staff and elected leaders.

Above: Pharmacists Certified by the Board of Pharmaceutical Specialties. Click here to view a PDF of the data.

References

1. The American Academy of HIV Medicine. Available at www.aahivm.org/index.php?option=com_content&task=view&id=632&Itemid=129#1.
2. Source: ASHP Commission on Credentialing. Data presentation at meeting of March 6–9, 2008, Bethesda, MD.
3. ACCP. Future clinical pharmacy practitioners should be board-certified specialists. Pharmacotherapy 2006;26:1816–25.