Widespread concerns abound over too many for-profit pharmacy schools, too few pharmacy school faculty members and a shortage in and fluctuating demand for pharmacists throughout the profession and attendant communities.
In response, federal agencies, medical and pharmacy schools and professional trade associations are releasing data on student field experience; faculty and student enrollment; building pharmacy schools on public and private medical campuses while shutting down others; changing the model, format and requirements of study; and creating programs and incentives for students to consider teaching or professorships in the field.
As an example, in 2004, the Joint Commission of Pharmacy Practitioners, or JCPP, approved its initiative “Future Vision of Pharmacy Practice” and embarked on it to involve all professional trade organizations.
The JCPP includes the Academy of Managed Care Pharmacy; American College of Apothecaries; American College of Clinical Pharmacy; American Pharmacists Association; American Society of Consultant Pharmacists; American Society of Health-System Pharmacists; National Community Pharmacists Association; American Association of Colleges of Pharmacy; Accreditation Council for Pharmacy Education; National Association of Boards of Pharmacy; and National Council of State Pharmacy Association Executives.
The groups agreed on the future standards of pharmacy practice, concentrating on the year 2015. They collaborated to establish new criteria on pharmacy practice, payment, professionalism, regulatory policy, education, communications, leadership, workforce planning and research.
They established that the number of pharmacists needed will depend on the ability of practitioners to transition from performing tasks to overseeing the actions of others and to create and executive a practice model encompassing patient care and professional compensation.
Work by Agencies, Schools, Trade Associations
Efforts by a variety of entities to change the field of pharmacy are chronicled in a Nov. 23, 2010 joint discussion paper released by the American Pharmacists Association and the ASHP and titled “Concerns about the Accelerating Expansion of Pharmacy Education: Time for Reconsideration.”
The Pharmacy Manpower Project, Inc. found that the profession, between the years 2001 and 2020, could reduce the number of pharmacists involved in order fulfillment by 27 percent through technological systems and the use of support staff.
The American Association of Colleges of Pharmacy, or AACP, has begun to promote academic instruction to college students in clinical and pharmaceutical sciences and improve faculty training. The AACP implemented the Academic Leadership Fellows program to nurture and grow faculty members and leaders and held a summit in 2005 to improve experiential education or rotations for pharmacy students.
The AACP, the American Pharmacists Association, or APhA, and the American Society of Health-System Pharmacists, or ASHP, included instructional programs at professional meetings.
APhA released a book titled “Getting Started as a Pharmacy Faculty Member” to instruct readers about the academic positions available, how pharmacy schools function, the process of securing a position and success in academia.
The Institute of Medicine, or IOM, and the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, published research, finding health care quality is linked to sound interdisciplinary education among the health professions.
However, Erick Geyer, a licensed pharmacist and pharmacy manager who has worked for Walmart since March 2007 in Ohio and obtained his doctorate in pharmacy from the University of Toledo in 2009, finds that not all efforts to motivate pharmacy students to consider a future in faculty are effective or ethical.
From firsthand experience in the workplace and in professionally developing students and graduates in pharmacy schools in Kentucky, Michigan and Ohio, Geyer points to a misguided trend in the field to expedite the learning process for pharmacy students by creating accelerated programs or schools and having them enroll.
“I think that accelerated schools may be a half-step down,” he said. “The students are literally there to get in and get out with a pharmacy degree because there are some schools that do it for three years. Some of the schools put so much stress and anxiety on the students that they don’t even get a chance to learn.”
In his own work professionally developing and working with pharmacy students and graduates, Geyer says he is discovering that “the higher the tuition is, the worse the school is in general.”
Geyer explains that the for-profit pharmacy schools, as compared with the nonprofit public and privacy pharmacy schools, generate large student bodies and profits because they lower the standards for candidates to be admitted and enroll.
Some exceptions, he says, exist such as Ohio Northern University, which is over a century old and is ranked among the top ten schools in the country and second in the Midwest; Purdue University, 60 percent of whose deans actually graduated from the school; his own alma mater, the University of Toledo, with its high admission requirements, and the University of Cincinnati with its challenging academic workload and high NAPLEX passing rates.
One could compare the nonprofit Ohio Northern to, for example, the for-profit Lake Erie College of Osteopathic Medicine, which offers an accelerated program, a traditional academic one and a long-distance, online one on three different campuses. The college’s title, Geyer points out, does not even contain the word “pharmacy” to indicate that it provides pharmacy instruction.
Additionally, he says that for every for-profit school he critiques, Geyer can identify one to two good students who hailed from it. Conversely, for every exemplary non-profit public or non-profit private school he praises, Geyer says he remembers one or two bad students from it.
“I don’t think there is 100 percent direct correlation,” he said. “It’s more of a bell curve with the way the schools fall with the for-profit schools being on the lower end of it or shifting it left, which, unfortunately, means that the standard of quality is being lowered.”
As part of the overall professional trend, the University of Toledo has, too, had to lower its grade point average to admit students who would not have been accepted in the year Geyer entered — 2003.
“They would not have even come close to making it,” he said. “When I say not come close, I mean not just half a point of GPA — not a point 1 or 2 but the difference between a 3.3 and a 3.7 and never mind some questionable character issues.”
Decreases In Pharmacy School Faculty
Among the biggest issues facing pharmacy colleges and schools is the decline in pharmacy school faculty. Across the nation, a severe shortage in faculty exists in schools of pharmacy.
Moving from one pharmacy school to another factors heavily in faculty position openings. The new schools may be luring faculty members away from traditional learning sites for higher salaries and opportunities to create new programs.
For the 2008 to 2009 academic year, researchers found the main reasons for vacancies: another position at another school of pharmacy (20.1 percent); the development of a healthcare private practice (15.4 percent); or retirement (12.6 percent). The same data applied to the 2002 to 2003 academic year.
For the 2008 to 2009 academic year, about 396 vacant or lost faculty positions were reported from survey responses from 1,010 schools. This represents a decline from 425 for the 2007 to 2008 academic year.
The majority of faculty positions in the 2008 to 2009 academic year were in clinical science/pharmacy practice (53.5 percent), pharmaceutical sciences (31.3 percent), social and administrative science (8.1 percent), administrative positions (4.88 percent), and research/non-instructional (2.3 percent.)
Again, for the 2008 to 2009 academic year, about half of the positions stayed vacant as there were not sufficient candidates fit for these titles (48.1 percent), an uptick from the 2007 to 2008 academic year (47.4 percent).
The lowered standards and high tuition translate into the compromising of faculty quality, he explains. And some school rankings are contingent upon how many individuals are in faculty and residency positions, which Geyer does not believe is a solid indicator of the quality of a pharmacy school.
With available candidates not best suited to fill gaps in faculty, it appears as if the new schools will not be able to locate the best instructors without drawing from conventional schools, researchers said. Moreover, the shrinking of the faculty pool will proceed, lowering the effectiveness of schools to meet the learning needs of students.
One of the means of tracking the caliber of on-campus faculty alumni is to examine their progress at five-, ten- and 15-year marks, he says. Doing so would reflect well on the level at which instructors began and how much they’ve improved overtime, Geyer concludes.
“The newer schools don’t have as many trained faculty because, the way they are pushing residencies, you are getting people graduating with residencies and going into teaching without any real-world experience,” he said, citing some California schools’ policies on residencies as an example.
“No matter what they say, one to two years of residency is not equal to three to five years of real-world experience.”
Increases In Schools, Enrollment, Graduations, Pharmacists
To address the shortage of pharmacists, pharmacy schools and professional trade associations came forward with solutions. The respondents were primarily non-profit private schools and, increasingly, for-profit schools. Solutions included new schools, more campuses and larger classes at older schools.
The fast pace compelled researchers to wonder if the schools could locate and place well-trained instructors to teach the resulting influx of students.
Researchers speculate that quality may be compromised because of the shortage of faculty members, a lack of practitioners and mentoring sites during the beginning and advanced stages of pharmacy curriculum.
Additionally, while there is a push in the field to educate health professionals in an interdisciplinary setting, pharmacy schools not affiliated with the other health profession schools may find it difficult to instruct their students accordingly.
“A lot of schools, which is a common problem among the Millennial generation, are capitalizing on the fact that everyone loves an education so much that they’re willing to go well over $100,000, $200,000 or even $300,000 in debt to get a pharmacy degree as if it were some Willa the Wonka golden ticket,” Geyer said.
“If you are already [a registered pharmacist] and you’ve been in the field, you feel that the only element holding you back in the field is a PharmD. That’s what they are going to do to try to advance themselves. Does that make them better practitioners — that they have been in the field for 20 years? I doubt it.
“This causes a lot of issues because, when they graduate, they are willing to work for a lot less money and they try to do whatever they can to meet unfathomable numbers just to get a paycheck and be a slave to the Man.”
Most pharmacy students and graduates are envisioning work prospects in which they generate six figures on average, Geyer says. When asked, he replies that solutions to this are difficult.
“They are willing to justify any cost to get there,” he said. “They say, ‘If it costs me $500,000, I’ll make that in five years, forgetting taxes and interest compiled on top of that.’ Everybody will look at this as their own special snowflake, thinking, ‘Oh, I can make this work’ or ‘That won’t affect me.’ That’s a big issue.”
Medical schools tend to carry out policy in the same manner, Geyer says. He explains that he knows students in medical practice residency graduating with $700,000 in student loans. Some may make this figure in the future in the medical specialty professions.
Additionally, schools such as the University of Toledo recruit and retain middle managers to level positions because they need them to handle sponsorships of such athletic teams as the Detroit Tigers or the Detroit Cavaliers — mostly societal issues rather than that only and directly pertaining to the field of pharmacy, he adds.
Reports anticipate that, between 2001 and 2016, there will be a 100 percent increase in the number of pharmacy school graduates in 21 states throughout the country with no letup and in the face of a lower demand for pharmacists.
Key research identifies the year 1987 as representing the start of the proliferation of pharmacy schools. In 1987, there were 72 pharmacy schools in the nation, which was consistent for several years as well as that of student enrollment figures.
By 1995, these numbers increased with more expanded pharmacy school programs, new schools and satellite initiatives at non-pharmacy institutions. This was accompanied by similar growth patterns in the number of new schools in the allied health or ancillary health professions in the same time period. In 1998, a shortage in pharmacists was first identified.
In July 2010, about 115 colleges and pharmacy schools existed, offering accredited full or candidate status professional degree programs, as well as five schools with pre-candidate status. In December 2009, pharmacy students attended 120 colleges and pharmacy schools.
Then, 20 more schools were considering or establishing new programs. The new schools were created in anticipation of a 25 percent growth in pharmacist employment between the years 2010 and 2020 by the Bureau of Labor Statistics.
In 2012, the Accreditation Council for Pharmacy Education, or ACPE, reported that 129 pharmacy schools offered full, candidate or pre-candidate status programs. From 2007 to 2012, the growth of accredited pharmacy schools went from 87 to 129, representing a nearly 50 percent increase and the majority of it taking place at private facilities.
The boost in pharmacy schools resulted in an increase in pharmacy student enrollment of 42,000 to 58,915. From 2005 to 2008, the ACPE reported an expected 36.5 percent increase in student enrollment. Eighty-four percent of the enrollment growth was attributed to the expansion of pre-existing schools.
In the 2008 to 2009 academic year, about 10,998 students received first professional pharmacy degrees.
Within the first decade of the millennium, enrollment fluctuated: 4.1 percent in the autumn of 2001; 8.4 percent in the autumn of 2002; 10.7 percent in the autumn of 2003; 5.1 percent in the autumn of 2004; 6 percent in the autumn of 2005; 4.4 percent in the autumn of 2006; 4.3 percent in the autumn of 2007; 3.9 percent in the autumn of 2008; and 3.8 percent in the autumn of 2009.
As a consequence of the proliferation of pharmacy schools and student enrollment, the number of pharmacists in the job market skyrocketed, a 2008 report titled “The Adequacy of Pharmacist Supply: 2004 to 2030” by the Health Resources and Services Administration of the Department of Health and Human Services, or HRSA-HHS, showed.
The HRSA report predicted an increase of 79,000 new pharmacists from 2004 to 2020 — from 226,000 to 305,000 pharmacists. For full-time pharmacists, the report projected a growth of 68,800 from 191,200 to 260,000.
The report also pointed to the growth in the population and subsequent rise in the consumer use of medicines and drugs as well as a mild dropoff in the number of pharmacists in 2004 with supply figures matching demand rates.
It also foresaw a graduation rate of 10,000 pharmacy students in 2008, jumping to 12,000 in 2030. By the 2008 to 2009 academic year, about 11,000 graduates joined the job market and student enrollment rose by 3.8 percent in 2009.
In May 2010, the Pharmacy Manpower Project calculated the aggregate demand index, or ADI, as 3.28, decreased from 0.09 from the month before and 0.45 from the previous year at that time. The ADI scale spans from 1 to 5 with 1 indicating a high surplus and 5 meaning a high demand.
The ADI rate for community pharmacy plunged to 2.85, which points to a surplus in community practice. The rate for institutional pharmacy is 3.8, showing a mild shortage for this category. Overall, rates have decreased in the past decade.
The Role of Geography
Some new pharmacy programs were created to meet the needs of the underserved, disadvantaged and geographically challenged, however, others were built in already oversaturated educational markets and cities, researchers said.
Geyer says that he sees the downside of non-profit as well as for-profit schools and pharmacies reaching out to these populations.
“You are seeing crazy recruitment strategies such as the University of Toledo advertising pharmacy on the west 54th or 56th blocks of Cleveland, which is the absolute middle of the ghetto,” he said.
“There were very few people who could qualify to be pharmacists but the schools and pharmacies are using them to get them into the door of the college or university as a way of the pharmacies or schools making a profit out of it. That’s a whole other issue.”
Geyer explains that such efforts represent band-aid solutions to the endemic problems in these communities and don’t begin to address them or to recognize and work with the professional and academic level limitations of the residents there.
“You are talking about one of the worst schools in the United States and they are advertising about pharmacy,” he said. “They should be advertising ancillary/allied health or vocational trade training programs to get a job or to get into a community college, if nothing else.”
Outside of Ohio, similar scenarios are playing out in other cities. For example, Walgreens and possibly other pharmacies such as CVS worked with Chicago State University to fund and develop their school of pharmacy programs and to regulate their labor market, especially in terms of costs. Overall, Chicago had two schools of pharmacy but may now contain five to seven.
Geyer says he knew of a student who attended Chicago State after not being admitted to the University of Toledo because his grades, though high, did not meet the university’s enrollment criteria.
When asked about limiting the expansion of pharmacy schools by geography as a solution to the proliferation of schools, he expressed support.
As instances of geographical changes, the Medical College of Wisconsin has sought to open a pharmacy school because of a shortage of pharmacists in the state. Meanwhile, the University of Florida College of Pharmacy has already started a four-year plan to lower its student-to-faculty ratio as part of reform because of the reduced demand for pharmacists.
“I am more in favor of that because laws vary from state to state,” Geyer said. “For example, in Ohio, they’re very strict on weight loss and dietary medications as opposed to other states like California who aren’t.
“If you train people who are from that area to work in that area, it’s a better result for everyone concerned because the pharmacists know their patients. They know the population.
“For example, I work in a predominately white area but the pharmacy staff I work with is Indian. A lot of people do not connect with the one male Indian pharmacist there. They only come around on my days or when I am there because they only want to deal with me because they only feel a bond with me and no bond in any way shape, manner or form with him.
“Now, I am not saying that’s right or wrong or that he is a bad pharmacist but he might work better in the Chicago area where there are more people of his ethnicity.”
Geyer says geography should not come between quality care and a pharmacist’s patients.
“I don’t have a problem if Chicago can support five, six or seven schools of pharmacy,” he said. “I have a problem if they’re going to North Dakota and they’re not happy with life because they want to be in Chicago and this translates down to their patients. That being said, if I am moving to Arkansas, I am taking a job in product development.”
Effects of Increases
When asked if his colleagues have seen patterns of the influx of pharmacists in the field as a result of the proliferation of schools just as he has, Geyer responds that many have.
“There are many people,” he said. “I’d say anyone who has been out at least five years as I have been knows and has seen the effects. You see it everywhere. My boss was a pharmacy owner turned into Walmart store manager or pharmacy manager turned into market director. He said that half of the young people who graduate know everything in the book but cannot interact with people.
“That is part of the PharmD focus as opposed to the real-world experience, which is again why residency does not always equate to three to five years of experience.”
The addition of more schools and programs will force these entities to raise the bar on the quality of instruction while populating classes with the best students, researchers said. Researchers ask whether this will sacrifice the quality of graduates and affect the employment needs of the field.
Geyer says he witnessed the negative effects of this expansion in the workplace and the classroom.
“The one problem I have noticed with pharmacists — and I have worked with these myself — are those who don’t know basic information such as vitamin deficiencies,” he said.
“One of them who I have worked with failed the NAPLEX at least three if not four times. He did not even know that a lack of vitamin C caused scurvy, which is a basic fact that most pharmacists are expected to know. He went to a school that is relatively new. I will not mention the name but it is a for-profit school, which presents some of the basic problems I see.”
Once they enter the workplace, he says many pharmacists emanating from the for-profit schools and their collaborators become beholden to their employers to raise their profits margins, gradually corroding the ethics and reputation of the field.
“It’s a multi-fold problem,” Geyer said. “The pharmacists are willing to do anything to get a paycheck, which is contributing to the degradation of the profession. They are wiling to do literally whatever it takes.”
He recounted an incident in a pharmacy in Cincinnati in which a person got a pharmacist out of medical practice management claims worth at least $4,000. Personnel in the pharmacy considered the manner in which the practice was handled a travesty.
“If I remember correctly, a recent graduate was doing it,” Geyer said. “He was willing to do anything to meet corporate numbers instead of caring for patients and healthcare insurance overall. It’s all about dollars and cents, at that point.”
He adds that this demonstrates employers’ lack of concern for guiding principles in the field.
“I don’t think they care what the standards are as long as they can make money in the end,” Geyer said. “As much as I am a Republican and I am actually not a fan of Ronald Reagan, this actually needs to be a top-down issue, instead, of a bottom-up issue. This calls for the expansion of the accrediting bodies and the schools and their roles.”
He holds up a pharmacy in the greater Cleveland area as an example of this lack of concern, for cutting initial starting pay for staff between $12 to $10 an hour, which Geyer states represents a 12 to 15 percent pay reduction cut.
“If the employees don’t concede, the employers have a managers’ meeting and say to them, ‘If you can’t do the work or don’t want to do the work, we’ll find someone else who will.’ They may look great cutting but few people realize that they just cut their staffing and support by 25 to 30 percent.” He adds that his figures come from an actual local pharmacy district manager he knows.
At the same time, Geyer says he supports the latest positive trends in the field of pharmacy such as the broadening of the role of the clinical pharmacist with medical practice management, more professionals working in hard-to-reach communities and taking on undesired shiftwork, changes in tasks in the medical professions and the comeback of the compounding pharmacist.
“I think it’s great,” he said. “MPM is becoming a broadening field with the way that doctors are getting paid and accepting money from certain insurers such as Medicare and Medicaid because of the changes to the Affordable Care Act.
“I see that pharmacists will take over the primary care role in the near future. You have pharmacists prescribing, giving immunizations, asking all of the questions and going over the medications. If you look at what pharmacists make now versus even two years ago or even what primary care physicians made in the 1990s, that gap has closed significantly.”
Geyer says the increased income level for pharmacists is fully warranted because of the amount and quality of work they perform. He explains that he sees his patients who are on several medications 30 times a year. By contrast, a primary care physician may see them two to three times a year or possibly four if they are managing their diabetes or serving as a medical specialist.
“I know my patients better than their prescribers do,” he said. Geyer says he and other pharmacists face resistance when they make MPM claims but he is certain that his recommendations are on target because he is confident that the changes he calls for will improve his patient’s care and achieve cost savings or efficacy or both.
He adds that more medical students are entering the field of primary care and earning less income as a result. “I see pharmacy as going that way. If you see what companies are rolling out, my company Walmart has its own counseling rooms and some pharmacies,” Geyer said.
Among other pharmacies in Colorado, he recalls a Safeway in Idaho Springs, Colo. where the supermarket has an office next to a pharmacy for processing MPM claims and sitting and conferring with patients. Geyer says there is potential for a vital resource to improve access and affordability to health care.
To bring accountability, transparency and integrity to the graduation, licensing and recruitment processes for pharmacy graduates, especially in light of questionable residency practices, Geyer says the task will be difficult but suggests vigorous “multi-layered or multi-level interviews” for candidates to determine not only their clinical knowledge but also their social skills, especially for pharmacy schools screening prospective students.
“Most employers in retail pharmacy or even hospital management are not really worried about what you know clinically because they assume you know it all,” he said. “They are more worried about how you are as a person. A lot of times, that’s where they are having issues.
“They are trying to filter out weaknesses or strengths. For example, they ask a student, ‘Tell me something about yourself.’ The student can’t do it. They may say to a student, ‘Here is a case workup.’ They can work the case perfectly fine but, when it comes to interacting with people, that’s a bigger issue.
“What actually makes a quality pharmacist is someone who not only knows the clinical and medical information but can also correlate it, no matter if the pharmacist works in a hospital or in retail.”
Naming his mother, too, a pharmacist with 30 to 40 years of experience, Geyer points out that many pharmacists who have been out of school in the past 20 to 30 years may not be up to date on workplace guidelines and regulations but they “usually know their patients and can read them well.”
Additionally, Geyer recommends that pharmacy schools allow accrediting bodies such as JCPP, JCAHO and ACPE be present during the candidate interviewing sessions. This would expand the roles of the accrediting bodies and render the process more ethical.
“They sit during the interview, rate the interview and rate the student from what they see,” he said.
“In this way, everyone is being held accountable. In this way, the schools can’t just sit there and say, ‘All our students are great. They have a 3.9 GPA.’ Really, all they have is a GPA. Just because you can read from a book does not mean you can effectively communicate. I actually think that there needs to be a bachelor’s degree before the doctorate in pharmacy.”
Geyer holds himself up as an example as to why expanding the accrediting bodies in this manner is beneficial. A member of the Millennial generation, other wise known as Generation Y with birthyears starting from 1984 to 2002, as he grew older, Geyer explains he became more mature and developed more of the communications skills necessary for success in his field.
“I entered a pharmacy school when I was 19,” he said. “There is a very big difference between me at age 19 and me at 21. When I graduated, I was 23. There is a difference between me at 23 and me now almost at 30.
“I am not trying to sit here and say that I am the exception but I think me being an Eagle Scout and being a little bit more outspoken about my thoughts in a fairly respectful manner is different from people who are not. I think that would translate more than people who are not.”
Dr. Geyer and others have been very vocal about their support for a change in the regulation of the field of pharmacy. As such, he and others have signed this Change.org petition.
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