September 30, 2009

Expanding APPEs – Meeting Future Needs

by Jennifer Thompson, Pharm.D., BCOP - Oncology Clinical Specialist, University of Maryland Medical Center

Due to the current pharmacist shortage and predictions of increased demand for pharmacy services, there has been rising pressure to create and expand PharmD programs. Subsequently, this creates more demand for personnel (preceptors) and resources (rotation sites) for advanced pharmacy practice experiences (APPEs) within the PharmD curriculum which is critical for the successful training of future pharmacists. This topic is of personal interest to me as an APPE preceptor at an acute care institution with several pharmacy residency programs. I will attempt to explore the topic stepwise by discussing a recent needs analysis, the standards, and my evaluation.

Brackett and colleagues performed an APPE organizational needs analysis for pharmacy schools based in the states of Georgia and Alabama (See: Am J Pharm Educ 2009; 73 (5) Article 82). The analysis was performed through the collaboration of the Southeastern Pharmacy Experiential Education Consortium (SPEEC) which includes: Auburn University Harrison School of Pharmacy, Mercer University College of Pharmacy and Health Sciences, South University School of Pharmacy, and The University of Georgia College of Pharmacy. The authors performed a gap analysis by comparing past APPE needs to forecasted future needs. Data regarding APPE class size for the 2006-2007 academic year, number of non-community APPEs needed per class, and total non-community APPE availability was gathered from the Experiential Education Management Systems database. Each SPEEC institution’s experiential learning director estimated needs for the 2010-2011 APPE year based upon their knowledge of anticipated changes in class size or curriculum. The 2006-2007 non-community APPE needs and availabilities were 3,590 and 4,427 sites, respectively, with a surplus availability of 837. Combined projected 2010-2011 non-community APPEs were estimated at 4,309. Assuming 2006-2007 non-community availability remained unchanged, the surplus declined to 118. The authors discussed many limitations to their analysis and acknowledge that they may have overestimated the APPE surplus. Indeed, they anticipate if they had separated required and elective rotations, accounted for rescheduling variables, and worked within a less complex system this surplus might evaporate.

Part of the motivation for Brackett and colleagues to conduct their research was the Accreditation Council for Pharmacy Education (ACPE) revised accreditation standards and guidelines for the PharmD degree adopted in 2006. These standards require that APPEs comprise a minimum of 25% of the curriculum and be at least 1440 hours in length. Standards set for preceptors include: they should be oriented to goals and objectives of the APPE PharmD curriculum and should be well versed in teaching methodologies that enhance learning. Preceptors need to be aware of students' prior knowledge and experience relative to the rotation's objectives so that they may tailor the rotation to maximize the educational experience. (See: ACPE. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree.)

Based on the analysis and standards described, one can summarize that expanding APPE availability is complex. I applaud the efforts of Brackett and his peers. The methods and the results can perhaps be extrapolated to other geographic regions. The top two factors on my mind are balancing the increasing numbers of PharmD students with limited availabilities in acute care settings combined with the economic crisis faced by many health systems. Hospital practitioners with the required skills and training may not have adequate time to precept students during APPE, especially if they also have institutional obligations to pharmacy residency training. Practitioners’ workloads need to reflect their educational commitments. As schools and colleges of pharmacy adapt to the new ACPE standards, scheduling students for APPE rotations should be synchronized and balanced with residency schedules. We can also empower residents to co-precept students.

As described in the ACPE Standards, schools and colleges of pharmacy need to review objectives and instructional activities and assess learning environments. The college or school must ensure that preceptors receive orientation, especially for first-time preceptors. Effective communication regarding student performance and expectations is critical. The defined procedures should be unambiguous and adhere to the task standards. Another method of standardization is through collaboration by consortiums of schools and colleges of pharmacy. Pooling resources between academia and practice sites could assist with preceptor development. Schools or colleges should provide structured feedback to preceptors based on their student evaluations and identify areas the require further development. I believe a combination of these strategies can assist us in meeting the projected APPE needs. By sharing resources and skills through partnerships between educators and practitioners and educational consortiums, future pharmacists and patients will ultimately benefit.

[Editor's Commentary: Preceptors, particularly those like Dr. Thompson in academic health science centers and teaching hospitals, are feeling the pressure to do more with less. Teach more students, train more residents, and see more patients with fewer resources. I'm afraid there is no immediate solution to this problem. On the one hand, pharmacists, particularly those with advanced training and skills, are needed more than ever. On the other hand, the free flow of money into healthcare systems is being increasingly scrutinized. Budgets are trimmed, cut, and slashed to meet immediate financial woes. And yet, inefficiency abounds, not only in patient care but also in the traditional methods we've used for decades to train pharmacists. Pooling limited resources and creating more efficient training models will certainly help. These problems aren't unique to pharmacy - clinical training in medicine and nursing have faced these same problems. Perhaps there are lessons we can learn from our clinical brethren? S.H.]

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