About becoming a clinical pharmacist

In this post we'll discuss some of the basic questions about clinical pharmacists including the steps in becoming a pharmacist, resident, and clinical pharmacist and what competencies a clinical pharmacist should have.  I'll also mention some statistics to give objectivity to the process.

Becoming a pharmacist

As of 2014, there are 133 pharmacy schools in the United States.  Every one of the schools offers the Doctor of Pharmacy (PharmD) degree which has presently superseded the Bachelor of Pharmacy degree.  So, though there are current pharmacists working with a Bachelor degree, you must now earn a PharmD degree to practice pharmacy in the United States (a degree in pharmaceutical science or a related discipline will not prepare or allow someone to practice pharmacy).

Program structure differs among schools.  The minimum requirement is two years of undergraduate study (which doesn't necessarily have to result in a degree) followed by four academic professional years.  Though this means a minimum of 6 years of study, most students enter a pharmacy program after three or more years of undergraduate study so will end up taking 7 or 8 years total.  Some pharmacy schools offer a single program that includes both the undergraduate and professional years.  These are referred to as "0-6" programs and are currently in the minority (only 9 out of 133 schools).

After obtaining a degree, a graduate must pass a board examination to obtain a license to practice pharmacy.  Licensure requirements differ by state but generally include a national examination (NAPLEX), a law exam for each state (MPJE), and sometimes a compounding exam (where various drug products are prepared in a lab from raw ingredients).  At this point, licensees should be competent to fulfill the traditional pharmacists' role of preparing and dispensing medication and counseling patients.  More advanced roles and direct patient care may require post-graduate training.

Becoming a pharmacy resident

In 2012-2013, there were about 13,500 PharmD degrees awarded in the United States.  At this point, following graduation and licensure, pharmacists can begin to work in community pharmacies where about 62% of pharmacists are employed (ie. chain stores like Walgreens, CVS/pharmacy, and independent stores).  Others work elsewhere such as hospitals, managed care, public health, pharmaceutical industry, or academia.

Depending on the responsibilities required in different positions, pharmacists may need to first complete 1 or 2 years of residency (or have equivalent experience).  Obtaining a residency position has many similarities to the model for physician residencies - including an application process, on-site interview, a "Match", and post-match scramble.  Residency programs generally apply to be accredited by the American Society of Health-System Pharmacists (ASHP) which sets the standards for program requirements.

Attaining a pharmacy residency is becoming increasingly competitive.  The number of candidates seeking residencies has increased continually in recent years, outpacing the growth in the number of positions. Following the 2014 ASHP Match, 2,640 positions were filled by 4,142 applicants (leaving 36% unmatched) for PGY1 programs and 446 positions were filled by 657 applicants (leaving 32% unmatched) for PGY2 programs.   

What differentiates a clinical pharmacist?

Upon graduating, new pharmacists are not fully competent as clinical pharmacists.  They may be able to perform basic clinical activities such as patient counselling, targeted drug monitoring, or providing drug information but are not able to provide more complex clinical services.  Just because a pharmacist may perform some clinical activities, this does not automatically qualify them as a clinical pharmacist (the same way that all physicians who perform heart auscultation are not automatically cardiologists, even though they may perform competently).  The American College of Clinical Pharmacy's (ACCP) white paper on clinical pharmacists' competencies states that:

"Clinical pharmacists have a broad scope and depth of pharmacotherapy knowledge and clinical skills.  Knowledge is obtained and clinical skills are developed through formal education and training programs, including doctor of pharmacy degree and postgraduate residency programs, lifelong learning, and continuing professional development.  Clinical pharmacist competence is achieved when one possess the knowledge, skills, and attributes to provide direct care to patients and to ensure rational medication use."

Clinical pharmacists fill a variety of important positions in the inpatient (including a diverse number of subspecialties), outpatient, and community pharmacy settings (performing Medication Therapy Management (MTM)).  They generally spend a majority of their time providing pharmacotherapy as an important part of a medical team or without other health care providers but their position always engages them in patient care.  One barrier in becoming a fully competent clinical pharmacist is the requirement that some pharmacist positions have in filling medication orders (so generally, clinical pharmacists do not verify orders or handle medication).

Specialty certification

After meeting certain experience requirements, pharmacists may be eligible to obtain specialty certification in a variety of fields.  Some areas of certification include:

• Board Certified Pharmacotherapy Specialist (BCPS)
• Board Certified Ambulatory Care Pharmacist (BCACP)
• Board Certified Nuclear Pharmacist (BCNP)
• Board Certified Nutrition Support Pharmacist (BCNSP)
• Board Certified Oncology Pharmacist (BCOP)
• Board Certified Psychiatric Pharmacist (BCPP)
• Board Certification in Critical Care Pharmacy - first exam in Fall 2015
• Board Certification in Pediatric Pharmacy - first exam in Fall 2015
• Added Qualifications can also be obtained in Cardiology and Infectious Diseases
• Certified Geriatric Pharmacist

The BCPS is the most common certification but was only held by 13,961 total pharmacists in 2013.  At this point, specialty certification does not generally have practical meaning as it is not often related to privileges, pay, autonomy, or insurance compensation.

Take home points:

• Pharmacy residencies are becoming increasingly popular and candidates far outnumber available positions.
• Clinical pharmacists take a path similar to physicians - requiring 4 academic years of professional education, at least 1 (and often preferably 2) years of postgraduate training, and have an optional board certification process.
• Clinical pharmacists have a broad scope and depth of knowledge and clinical skills and are involved in direct patient care.

References:
1.  AACP: Academic Pharmacy's Vital Statistics.  Available at: http://www.aacp.org/about/pages/vitalstats.aspx  Accessed August, 2014.
2.  AACP: Admissions.  Available at: http://www.aacp.org/resources/student/pharmacyforyou/admissions/Pages/default.aspx  Accessed August, 2014.
3.  ASHP: Match Statistics.  Available at: https://www.natmatch.com/ashprmp/stats/2014applstats.html  Accessed August, 2014.
4.  Burke JM, Miller WA, Spencer AP, et al.  ACCP White Paper: Clinical pharmacist competencies.  Pharmacotherapy 2008;28(6):806-815.

photo by aussiegall