What Should Constitute an Acceptable Advanced Pharmacy Practice Experience?

The practical training of pharmacists experienced a dramatic change in the 1970s. Prior to that time, experiential training for pharmacists was under the supervision of state boards of pharmacy. In many states, licensed pharmacists had to sign off on documentation stating that pharmacists-in-training had completed a set number of hours of experiential training as interns. Too often these interns spent time engaged in activity that did not prepare them to be practice ready (eg, working the candy, cosmetics, or tobacco counter). With the advent of clinical pharmacy, schools and colleges of pharmacy became increasingly in favor of the experiential education component being focused on areas that would prepare students for the practice of pharmacy. Hence, a shift took place in which schools of pharmacy took on the primary responsibility for experiential education (though some states still require internship hours outside of the experiential program).

It is important to note for this commentary that schools’ motivation for assuming responsibility for experiential education was to assure that students were spending their time in activities that were preparing them to function as practicing pharmacists. It is reasonable to ask if we are honoring the trust placed in our schools to assure that experiential education is creating graduates who are practice-ready.

Having the opportunity to serve on the faculty at several schools of pharmacy and to review numerous other pharmacy programs as an accreditation reviewer, I have been struck by the growth of advanced pharmacy practice experiences (APPEs) wherein students are not engaged in the medication use system in any identifiable fashion. Increasingly, students are undertaking practice experiences labeled as academic or administrative that do not appear to contribute to a graduate being practice-ready. This trend suggests that it may be time for critical debate regarding what appropriately constitutes an APPE. To put it in the form of a proposition: Advanced pharmacy practice experiences should be limited to those in which the student engages in the medication use system.

I am not questioning the value of alternative experiences in a student’s overall education. Rather, I am questioning whether such experiences should be viewed as fulfilling the goal of preparing our students to be practice-ready and, therefore, viewed as acceptable APPEs. There is arguably much value to an elective course (outside of experiential requirements) or internship that provides students with an opportunities to enhance their understanding of career paths and to develop skills that would be of value in a wide variety of settings. But such experiences should not reduce the amount of practice-relevant experiential education.

It is important to define what is meant by the “medication use system.” The schematic in Figure 1 outlines the elements intended by the use of the phrase in this Viewpoint. As outlined, this is slightly more expansive than other authors have proposed, wherein the medication use system has been limited by others to prescribing through monitoring. It also recognizes that pharmacists are engaged in other elements of medication use that utilize their unique knowledge base and professional experience. In addition, factors such as regulatory affairs have an impact on pharmacy practice and medication use and are, thus, rightly considered a component of the medication use system.

Figure 1.

Schematic of a Medication Use System. Modified from: Overview of the drug development, regulation, distribution, and use system. In: Preventing Medication Errors, National Academy Press, page 68, 2006; wherein prescribing through monitoring steps appeared in original, with the exception of medication reconciliation.

We lack clearly defined boundaries for what constitutes an acceptable APPE. Some might argue that “fuzzy” boundaries are preferred to allow programmatic latitude. While this is a rational argument, not having meaningful boundaries limits criteria by which to assess acceptable APPEs. I propose that the scheme in Figure 1 define the boundaries of an acceptable APPE. Based on these criteria, experiences in the academic environment and administrative experiences in which students do not directly intersect with the medication use system do not help students become practice-ready. It is true that the “boundaries” proposed herein are based on current roles for pharmacists. As it would be detrimental to the profession to not provide latitude for experiential education in areas that represent emerging roles for pharmacists, a means to assess and approve APPEs in such emerging areas would be essential.

It could be argued that required APPEs are sufficient to prepare practice-ready pharmacists and that elective APPEs should be open to any career enhancing experience that students may find appropriate. I assert, however, that the limited number of required rotations, as well as their length and time, is inadequate to make our graduates practice-ready. Moreover, if one believes that the required APPEs are sufficient to make graduates practice-ready, the total hours should be substantially reduced to equal that number.

I find it difficult to believe anyone could make a reasonable argument for such a move. The expectation outlined in the Accreditation Council for Pharmacy Education’s (ACPE) Standards 2016 that a maximum of two elective APPE experiences may be without a patient care focus indicates that ACPE recognizes that required rotations are, in themselves, insufficient to make graduates practice-ready. Interestingly, a review of accreditation standards indicates that pharmacy is unique among health professions programs in requiring a specific number of hours of experiential education.¹

The biggest impact of restricting APPEs to experiences that involve the medication use system may be the elimination of a growing number of academic/administrative APPEs. When discussing these types of practice experiences with dean colleagues, a common question arises: Are these experiences valuable to students or to faculty members or administrators? In addition, are these experiences selected by students because they have a serious interest in an academic/administrative career or because they view them as less demanding than patient care experiences? If the latter, then is it really be in the best interest of students to offer such opportunities?

Some suggest that an academic teaching practice experience may address what is perceived as a shortfall of faculty candidates.² To date, there is no evidence that students who complete an academic practice experience enter into academic positions at a higher rate than those who do not. In addition, a strong case could be made that these opportunities are best presented within the structure of a residency, especially since such postgraduate training is generally a minimal requirement for entry into the faculty ranks. Numerous programs of this nature have been developed across the country and described in the literature.^3,4 In my opinion, the setting of postgraduate training is the most appropriate place for providing opportunities that give experience and insight into an academic position.

When I have spoken with employers and practicing pharmacists in a variety of settings, their assessment of today’s pharmacy graduates is fairly consistent: they have an extremely high level of knowledge but have not achieved the level of proficiency that makes them ready for practice. Such proficiency can only be achieved with experience over time. It makes sense then that our students, their future patients, and our profession would be better served by maximizing the time that students spend in relevant experiences within the medication use system.