Abstract
Purpose.
The results of a national survey to evaluate on-call practices and responsibilities of pharmacy residents nationwide, as well as opinions related to duty-hour changes, are reported.
Methods.
A 39-question survey was distributed to 1292 residency program directors (RPDs) listed in the American Society of Health-System Pharmacists (ASHP) online residency directory, which includes programs in all stages of the accreditation process. The survey opened on November 7, 2011, and closed on November 28, 2011. The survey collected demographic information and answers to questions about the residency’s on-call component (if applicable) and barriers to the creation of an on-call component. Respondents were also asked to indicate their support of or opposition to the adoption of the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour rules and identify the areas of greatest concern.
Results.
Of the 1292 RPDs listed in the ASHP online residency directory to whom the survey was sent, 521 surveys were completed, yielding a response rate of 40%. Of these, 471 identified their residency program as including or excluding an on-call component. Of the 138 programs with on-call services, 102 programs (74%) indicated the inclusion of an overnight experience. Programs that did not utilize an on-call component indicated barriers such as a perceived lack of demand (39%) and duty-hour limitations (21%). Common on-call activities included drug information consults and therapeutic drug monitoring. There was not a clear consensus from RPDs regarding the adoption of the 2011 ACGME duty-hour standards.
Conclusion.
Among usable responses to a survey of pharmacy residency programs, 29% indicated that their program included an on-call component. On-call programs varied greatly in activities, location, hours, and requirements.
On-call programs have been in existence in pharmacy training for nearly 40 years.1 In the current context of residency growth, duty-hour limitations, and the continuing expansion of pharmacy services in the inpatient setting with the Pharmacy Practice Model Initiative (PPMI),2 the integration of an on-call component into a pharmacy residency program is at an interesting crossroads. In 2012, before the publication of the study described here, the American Society of Health-System Pharmacists (ASHP) published pharmacy-specific guidelines for duty-hour requirements, modeled after the guidelines recently released by the Accreditation Council for Graduate Medical Education (ACGME).3 These changes could affect not only the current structure of some on-call programs but also the implementation of new programs and the expansion of clinical services by residents.4
To date, no comprehensive published data have quantified the number of pharmacy residency programs nationwide with an on-call component, and descriptions of the breadth of on-call services provided by pharmacists or pharmacy residents are limited. A small survey published in 2011 revealed that only 16 of 72 postgraduate year 1 (PGY1) pharmacy residency programs that responded to the survey had a residency that included an on-call component.5 The most notable descriptions of services provided by on-call residents came from the University of Illinois—Chicago and the University of Kentucky (UK).1,4,6,7
The purposes of the current study were to quantify the number of residency programs with an on-call component, describe common on-call activities and responsibilities of pharmacy residents nationwide, and evaluate residency program directors’ (RPDs) opinions and concerns related to potential changes in duty hours. It was timed to assist the ASHP Commission on Credentialing in its deliberations about duty-hour regulations.
Methods
Study design.
A 39-question survey was developed jointly by UK and the ASHP Accreditation Services Division and Commission on Credentialing. The survey was approved by the UK institutional review board after pilot testing for question clarity and understanding. The survey was distributed to 1292 RPDs listed in the ASHP online residency directory, which includes programs in all stages of the accreditation process. The survey opened on November 7, 2011, and closed on November 28, 2011, with two reminder e-mails sent in the interim. The survey content consisted of demographic information and questions pertaining to aspects of the on-call component (if applicable) and barriers to the creation of an on-call component. Respondents were also asked to indicate their support of or opposition to the adoption of the 2011 ACGME duty-hour rules and identify which specific areas were of greatest concern to programs. (Note: This survey was completed before the announcement of ASHP’s pharmacy-specific standards.)
Objectives.
The primary objective of this survey was to investigate the percentage of pharmacy residency programs with an on-call component. Secondary objectives were to identify the common activities of on-call residents, describe the typical structure of on-call programs, and identify barriers to implementation. The general opinions of RPDs regarding moonlighting and the 2011 iteration of ACGME duty-hour rules were also sought.
Study population.
The study population consisted of RPDs across the United States and Puerto Rico who were listed in the ASHP online residency directory at the time of the investigation (n = 1292). The survey was e-mailed to a representative of each program within an institution who would then have the opportunity to complete the survey personally or forward it to the appropriate delegate within the program for completion. All programs and directors that met our inclusion criteria were invited to participate. Participation was voluntary, and no compensation was offered.
Data collection and analysis.
Survey responses were submitted anonymously, and results were compiled and analyzed in aggregate. Survey data were collected using Qualtrics (Qualtrics Labs, Provo, UT). Raw survey data were released only to the researchers within ASHP and UK for further analysis before presentation in any official form. Surveys did not have to be completed in their entirety to be included in data analysis. If a particular question was not answered and an answer could not be deduced, that survey response (or lack of response) was excluded for that particular data point. To be included in any questions related to the analysis of the on-call group versus the not on-call group, respondents had to answer the basic question defining inclusion or exclusion of an on-call component in their residency program. For the purpose of this survey, on-call was defined as any program component that each specific residency defined as on-call.
Statistical analysis.
Descriptive statistics were used to describe the demographic data and information related to on-call programs. Nominal demographic and institution-specific data were analyzed using chi-square analysis. Continuous between-group variances were evaluated with analysis of variance. The a priori level of significance was 0.05.
Results
Of the 1292 RPDs listed in the ASHP online residency directory to whom the survey was sent, 521 surveys were completed, yielding a response rate of 40%. Of the 521 RPDs who completed the survey, 471 (90% of the completed surveys) identified their residency program as including or excluding an on-call component.
Respondent demographics.
A total of 138 respondents (29%) indicated the inclusion of an on-call component in their residency program. The majority of respondents worked in teaching institutions, and most programs were ASHP accredited (Table 1). Programs with an on-call component tended to be in larger hospitals (81% reported a daily census of ≥300), compared with only 55% of the programs without an on-call component. Among the characteristics investigated, those that were significantly more common in on-call programs were the provision of 24-hour clinical services and an association with the local ACGME affiliate. On-call programs had existed significantly longer than programs without an on-call component.
Table 1.
Characteristics of Pharmacy Residency Programs With and Without On-Call Componentsa
| Characteristic | Fraction (%) Programs With Characteristic |
p | |
|---|---|---|---|
| With On Call |
Without On Call |
||
| Teaching institution | 93/111 (84) | 205/266 (77) | 0.17b |
| Daily census (no. pts) | 0.17c | ||
| <200 | 11/108 (10) | 71/264 (27) | |
| 200–299 | 10/108 (9) | 47/264 (18) | |
| 300–499 | 45/108 (42) | 86/264 (33) | |
| >499 | 42/108 (39) | 60/264 (23) | |
| 24-hr clinical services | 129/138 (93) | 275/333 (83) | 0.002b |
| Program accreditation status | 0.30c | ||
| Accredited | 113/133 (85) | 271/329 (82) | |
| Candidate | 12/133 (9) | 30/329 (9) | |
| Conditional | 0 | 2/329 (1) | |
| Precandidate | 8/133 (6) | 21/329 (6) | |
| Preliminary | 0 | 5/329 (2) | |
| Program age (yr) | 0.01c | ||
| 0–2 | 13/138 (9) | 56/333 (17) | |
| 3–5 | 14/138 (10) | 54/333 (16) | |
| 6–10 | 21/138 (15) | 61/333 (18) | |
| >10 | 90/138 (65) | 162/333 (49) | |
| Local affiliation with ACGME programs | 106/133 (80) | 229/327 (70) | 0.04b |
| Avg. time worked by resident (hr/wk) | 0.26c | ||
| 1–50 | 26/137 (19) | 143/332 (43) | |
| 51–60 | 70/137 (51) | 127/332 (38) | |
| 61–70 | 30/137 (22) | 50/332 (15) | |
| 71–80 | 11/137 (8) | 12/332 (4) | |
| No. residents at site | 0.26c | ||
| 1–3 | 44/136 (32) | 174/324 (54) | |
| 4–6 | 22/136 (16) | 66/324 (20) | |
| 7–13 | 44/136 (32) | 60/324 (19) | |
| >13 | 26/136 (19) | 24/324 (7) | |
Includes only the 471 respondents who indicated that their program did (n = 138) or did not (n = 333) include an on-call component. Not all respondents provided answers to all questions. ACGME = Accreditation Council for Graduate Medical Education.
Chi-square analysis.
Analysis of variance.
On-call programs.
Of the 138 programs with on-call services, 102 programs (74%) indicated the inclusion of an overnight experience. Eighty (58%) of the 138 on-call programs had pharmacists who were not residents participating in the on-call component; 62 of these programs (78%) included an overnight component. However, pharmacists other than residents had inhouse (not necessarily overnight) on-call responsibilities in only 13% of on-call programs; 33% and 37% of these programs assigned such responsibilities to PGY1 and postgraduate year 2 (PGY2) residents, respectively (Table 2). Overall, the majority of programs were designed so that the pharmacist or resident was off-site but may be expected to return to the site if required. Very few respondents (1.5%) indicated that they were considering creating an on-call program within the next two years.
Table 2.
Pharmacist Location During On-Call Hours
| Type of Pharmacista | No. (%) Programs Indicating Pharmacist Location | |||
|---|---|---|---|---|
| Remote | Inhouse on Demand |
Inhouse | Not Specified |
|
| PGY1 resident (n = 122) | 41 (34) | 39 (32) | 40 (33) | 2 (2) |
| PGY2 resident (n = 86) | 24 (28) | 27 (31) | 32 (37) | 3 (3) |
| Other (n = 80) | 31 (39) | 35 (44) | 10 (13) | 4 (5) |
PGY1 = postgraduate year 1, PGY2 = postgraduate year 2, other = pharmacist other than a resident.
Nature of on-call consultations.
To investigate the nature of the consultations received while on call, respondents were presented with a list of consultation types and asked to classify them based on the frequency of consultation (Table 3). The most common or frequent activities performed included drug information consultations, therapeutic drug monitoring, and anticoagulation monitoring. Of the available choices, the service most often identified as not provided was stroke alert response (62%).
Table 3.
Frequency of Consultations Performed by Pharmacy Residents During On-Call Duty
| Subject of Consultation |
No. (%) Programs Indicating Frequency of Consultation Type |
|||
|---|---|---|---|---|
| Common or Frequent |
Occasional | Rare | Consultation Not Provided |
|
| Drug information (n = 130) | 82 (63) | 26 (20) | 12 (9) | 10 (8) |
| Therapeutic drug monitoring (n = 131) | 82 (63) | 19 (15) | 12 (9) | 18 (14) |
| Anticoagulation monitoring (n = 128) | 47 (37) | 35 (27) | 23 (18) | 23 (18) |
| Emergency response (n = 128) | 32 (25) | 11 (9) | 20 (16) | 65 (51) |
| High-risk medication (n = 126) | 30 (24) | 28 (22) | 27 (21) | 41 (33) |
| Nonformulary approval (n = 128) | 30 (24) | 27 (21) | 22 (17) | 49 (38) |
| Staffing (n = 127) | 25 (20) | 10 (8) | 19 (15) | 73 (57) |
| Discharge counseling (n = 128) | 18 (14) | 26 (20) | 36 (28) | 48 (38) |
| Stroke alert (n = 125) | 18 (14) | 8 (6) | 22 (18) | 77 (62) |
| Medication reconciliation requests (n = 128) | 13 (10) | 16 (13) | 38 (30) | 61 (48) |
| Medication history requests (n = 126) | 12 (10) | 15 (12) | 37 (29) | 62 (49) |
| Administrative consultation (n = 125) | 12 (10) | 11 (9) | 27 (22) | 75 (60) |
Barriers to on-call components of residencies.
Respondents whose institutions did not offer on-call programs cited a perceived lack of demand as the most common barrier to implementation of an on-call component (n = 130, 39%). “Too few residents” and “question the educational value” were the second (n = 128, 38%) and third (n = 121, 36%) most cited barriers, respectively. Duty hours were cited as a barrier to on-call implementation by 21% of RPDs (n = 69). Other barriers to on-call program implementation included lack of resident supervision (n = 100, 30%) and lack of facilities (n = 17, 5%).
Concerns regarding duty hours.
We also asked RPDs to compare the 2011 ACGME duty-hour regulations with those issued in 2003. Notable updates to the regulations were the exclusion of PGY1 residents from moonlighting and allowing only 16 hours of continuous duty for PGY1 residents, with 55% (n = 245) and 17% (n = 77) of program directors noting these as concerns, respectively. Twenty percent of RPDs (n = 90) were concerned with residents having, on average, only one day in seven free of duty. There was not a clear consensus from RPDs regarding the adoption of the 2011 ACGME duty-hour standards. Based on the survey findings, 49.7% of respondents (228 of 459) recommended the adoption of the 2011 rules, and 50.3% (231 of 459) did not recommend their adoption. Twelve percent of RPDs (53 of 446) questioned the 80-hour maximum work week (averaged over four weeks). Conversely, 24% of RPDs (107 of 446) had no concerns with the 2011 ACGME duty-hour regulations.
Discussion
The most common barrier institutions identified for developing an on-call program was too few residents. Yet, most RPDs from programs with and without on-call components indicated that the total number of residents in all programs at their site ranged from one to three. Smaller programs (three or fewer residents) were more likely to utilize nonresident pharmacists for on-call services or offer on-call duties over finite periods of time, such as daytime or weekend coverage. Resident-only inhouse on-call services in the current age of duty-hour standards would not be feasible in sites with one to three residents.
While the initiation of an on-call program may not be plausible in all residency settings, the types of consultations seen are certainly relevant to clinical pharmacy practice (e.g., therapeutic drug monitoring, anticoagulation, drug information). Allowing an on-call resident (or other pharmacist) to provide these functions can help institutions meet the practice model goals of ASHP’s PPMI, using pharmacists as direct patient care providers not only during traditional business hours but also into the nights and weekends in an effort to provide the same level of care to patients at any time of day.3 Furthermore, engaging in these clinical consultations may permit residents to broaden their exposure to different populations or manage medication therapy that is not often seen in standard rotations such as stroke or emergency response.
Pharmacists are necessary and valuable members of the health care team, and many pharmacy-related issues and emergency scenarios occur when there is not adequate available coverage. The reports from the PPMI suggest that pharmacists should be a part of resuscitation teams, and many institutions are using on-call residents to provide emergency responses into evening, night, and weekend hours.3,8-12 The advantage is clear in situations where high-risk and high-expense medications such as thrombolytics are being used.6,13 Having on-call programs also can facilitate a more timely response to therapeutic drug monitoring. There is a wealth of opportunities for residents to take advantage of while providing on-call services, and these experiences can lead to enhanced learning through unique situations and the opportunity to handle consultations with an expanded degree of autonomy.14
Many pharmacy residency training programs have the tools and assets with well-trained preceptors, progressive health care settings, and a graduate medical education infrastructure to add innovative components to their program, well beyond the minimum requirements set forth by ASHP. Having an on-call program affords residents an opportunity to grow as confident and independent clinicians, while also providing new challenges and learning opportunities for residents and extending clinical coverage for patients to nights, evenings, and weekends. On-call experiences also allow programs to develop opportunities beyond the minimum standards set by ASHP while taking part in activities that align with ASHP’s PPMI, including, but not limited to, involvement in medication monitoring, cost savings, and interprofessional collaboration.3 Exploring the resident’s perspective of on-call experiences and learning opportunities would be a valuable future endeavor.
Many RPDs expressed concern about the effect of the ASHP and ACGME duty-hour standards on the initiation and maintenance of an on-call program. There was essentially no agreement among survey respondents regarding ASHP’s potential adoption of the ACGME duty-hour standards. After our study was conducted, the ASHP Board of Directors approved pharmacy residency specific duty hours that will apply to PGY1 and PGY2 pharmacy residency programs.3 In this new document, moonlighting, the most commonly cited concern with the 2011 ACGME rules in our survey, is permitted. There are, however, stipulations to ensure that moonlighting does not interfere with the resident’s educational activities and must count toward the resident’s maximum of 80 hours per week. With these new guidelines, some programs may have to adjust their current structure to comply with these new standards.4 Much like research that has been done for medical and surgical residencies,15-18 assessment of the impact of the 2012 ASHP duty-hour standards on pharmacy residency training would be desirable.
While this survey provides valuable information concerning the prevalence of on-call programs as well as a global description of the activities and interventions that occur during on-call services, there are limitations to the extrapolation of these data. The response rate was less than desired, and the survey was only sent to those programs that were accredited or in some stage of the accreditation process. Further, we were unable to collect data on regional differences. There may have been some response bias by singling out RPDs who felt strongly for or against on-call programs or duty-hour changes. Not all surveys were completed in entirety; therefore, many questions had variable response rates. Most importantly, we were unable to group data that were collected from multiple residency directors within the same institution or overall program. Respondents were asked if they were part of a multiprogram site, but certain data could be inflated by reflecting the responses of RPDs of different programs at the same site. Finally, these data were intentionally collected before the ASHP duty-hour guidelines were released. This project was conducted in collaboration with ASHP to better inform its considerations about pharmacy-specific duty-hour guidelines. A description of existing program practices was important for the Commission on Credentialing to consider as it debated the potential impact of changes in ACGME regulations on pharmacy residency programs.
Conclusion
Among usable responses to a survey of pharmacy residency programs, 29% indicated that their program included an on-call component. On-call programs varied greatly in activities, location, hours, and requirements.
Acknowledgments
The assistance of Janet Teeters and Colleen Bush in questionnaire development and survey administration is acknowledged.
Footnotes
The authors have declared no potential conflicts of interest.
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