Dr. Kral was kind enough to post a quest blog regarding the credentialing process for “pain and palliative care pharmacists”; her insight of which I hope will summon opinions from our medical, nursing, and perhaps other provider partners. This is particularly relevant today since our pharmacy and medical colleagues could perhaps benefit from a refresher on the importance of an interdisciplinary team approach to medicine and essential collaboration for better patient outcomes. Consider a recent public statement by Dr. Sterling to pharmacists, “Don’t Call Us We’ll Call you”. Really? We should be calling each other about all sorts of therapeutic dilemmas for the greater good, although I do believe that in this case the AMA has some valid points. But, I don’t think that Dr. Sterling would be distraught if a pharmacist contacted him about the risk of widened QTc interval and possible resultant Torsades de pointes followed by sudden death, if a new RX was presented for methadone in a patient on amiodarone or azithromycin. We all need to recognize that well trained MD’s clearly are experts in diagnostics, but well trained pharmacists are clearly experts in therapeutics. Hence, Dr. Kral’s quest for your input follows. Dr. J. Fudin
Dr. Lee Kral is an adjunct assistant professor at The University of Iowa College of Medicine. She is a Board Certified Pharmacotherapy Specialist (BCPS) and a Certified Pain Educator (CPE). A comprehensive biosketch appears beneath this blog post.
Dr. Kral writes…
Dear pain and palliative care colleagues,
Our group of pain and palliative care pharmacists has been discussing a credentialing dilemma. We would appreciate feedback on this so we aren’t working in isolation (or an alternate universe). Let me explain.
All pharmacists must take a basic national licensure exam (called NABPLEX) in addition to state licensure exams to obtain a license upon graduation from an accredited college of pharmacy. Many graduates with entry level degrees (previously BS Pharm, now Pharm D) go on to practice in the community/retail setting or general hospital practice. This would be similar to a General Practitioner in medicine. Much like the medical field, those who wish to have a clinical practice go on to complete a residency. Our general practice residencies are similar to a medical internship year with a broad scope of clinical experiences. If a pharmacist completes a general practice residency (PGY1) he/she can then go on to a specialized residency such as pain and palliative care (PGY-2). This would be similar to a fellowship in medicine.
The Board of Pharmaceutical Specialties (BPS) is our post-graduate credentialing body. They administer the board certification exams that are the mirror of general board examinations in medicine (internal medicine, anesthesia, physical med/rehab). There are a number of principle areas for examination in pharmacy (including general pharmacotherapy, ambulatory care, pediatrics, nuclear medicine, etc.) The BPS boards are optional in pharmacy, and are pursued by those who wish to pursue academia and/or high level clinical practice. However, we currently do not have a defined system in place for board certification in pain and/or palliative care congruent with that of the medical profession.
When I speak to multidisciplinary pain groups around the country, I get questions from physicians like “We would like to hire a pharmacist for our group. How do I know who to hire and what credentials should I look for?” At this point I can suggest considering someone that has completed a specialized Pain and Palliative Care (P&PC) residency, earned general board certification, and/or earned a certified pain educator (CPE). Would it mean anything to our readers if we could offer a board certification in P&PC?
We don’t really want to explore something completely new that nobody recognizes. Nursing has their own systems and paths for various certification exams and various credentials, which can get confusing. Several of our staff nurses have an ASPMN pain certification, but I don’t know what that means.
So the questions are these:
Would it make sense to emulate the medical model of subspecialty exams?
It would seem that we have fallen into a similar model historically (see above).
Is Pain and Palliative Care an important enough practice area to be considered one of the core board exams for a pharmacist (like pediatrics)? Or should it be considered a subspecialty, as it is in medicine because it crosses all practice areas?
Are 10 or 20 years of pain management/palliative care experience adequate?
If you were hiring a pharmacist to work in your pain center, what would you consider benchmarks for a candidate?
If some type of board certification exam is developed for pain/palliative care, what does it mean in today’s healthcare system? As with any credible professional board exam, there is significant time and financial commitment involved in developing the exam (and studying for it).
Does a subspecialty certification mean anything to those who would hire us (healthcare systems, hospices, private practice pain clinics)? Or will any warm body do?
Are we wasting our time and money or is it money well spent?
Dr. Kral received her BS and Pharm.D. degrees from the University of Iowa College of Pharmacy and completed a pharmacy practice residency at the University of Iowa Hospitals and Clinics (UIHC). She is a board certified pharmacotherapy specialist (BCPS) and a Certified Pain Educator (CPE). She is on the faculty at the University of Iowa Center for Pain Medicine and holds adjunct professor status at the University of Iowa Carver College of Medicine. She serves as a preceptor for pharmacy residents, anesthesia residents and pain fellows. She provides clinical pharmacy expertise for the acute pain service, runs a pharmacist-based pain medication management service, leads house-wide pain education and serves on the hospital Pain Management Task Force.
Rivey MP, Allington DR, Reinivaara-Hall T, Mathis JB, Miller DC, McKernan JL. Development of a pharmacy practice residency with a focus in pain management in a small hospital. Poster (refereed) presented to ASHP Midyear Clinical Meeting, New Orleans, LA, December 9, 2003.
2003?
Dear Dr. Kral,
I feel very honored for this opportunity to express my opinions to someone who has so much experience and dedication to the field of specialty I eventually hope to pursue following a PGY-2. My name is Abhishek Shrivastava, PharmD Candidate of 2014, who just days ago completed my 6 week rotation in pain management with Dr. Fudin.
From my perspective, I’d like to address various pros and cons. From my understanding (apologizing beforehand if I am incorrect!), if this proposal is passed, a pharmacist would have to complete a PGY-1 then sit for an exam to become board certified in a general practice area and only then could qualify for board certification in pain management. Alternatively, I imagine one could skip a PGY-2 if they obtained significant experience in a pain practice setting.
Certainly the benefit of this proposal is that whoever chooses to embark on this journey would be well exposed to and educated in specialty of pain management. If I was a patient I would feel a lot more confident if my pain was managed by someone who had experience with pain and had board certification to verify credentials. But this process does present with some downfalls.
One major issue is the long journey to become specialized in pain management, or any sub-specialty. From a student’s perspective, it can be quite intimidating to achieve such a goal as a young graduate pharmacist and in some ways seems out of reach. Additionally, there are financial stressors to consider in an already compromised economy assuming the average student coming from a middle income family with debt already at the six figure mark. In my opinion, I think this might shy people away from becoming board certified in any sub-specialty area, but most particularly pain management since there are so few specialists in this area to begin with. And finally, there is the prospect of the never ending renewal for board certification which I suspect comes with a hefty price both timewise and financially.
The bigger issue I feel is education at the basic level during the first 6-8 years of schooling added to another 2 years of residency experience for validation that should in large part should have occurred when one reached the doctoral level in the art and science of pharmacy. Perhaps a more reasonable approach to obtaining specialty practice is to require that students select a track towards community, industry, institution, and/or clinical while still in college; that would allow development towards a specialty field upon graduation rather than jumping through so many hoops subsequent to licensure.
What’s worse is that the at my college of pharmacy, the topic of pain was very briefly covered for maybe about one week or so for my entire didactic stay! As you know this is preposterous because a pain management specialist could teach a class on methadone alone for a full year! And then we wonder why people come out with with a PharmD (or MD for that matter) and still know very little about pain. Pain is probably the most common thing we see in the medical world as it is intertwined throughout all specialty areas. The time I spent with Dr. Fudin, I saw many different types of patients present to the clinic with pain that had various disease states. I am not here to single out pharmacy school because this may also be true for medical school and other healthcare fields including dentistry, podiatry, nursing, etc.
Overall, I think what is proposed has its attributes and pitfalls. The positive side is that the pharmacist who completes the suggested process of sub-specialty will be very well-informed on how to provide pain management and will be “board certified” to reassure his/her education is appropriate for treating various challenging patients. However the other side of this is that it may dissuade pharmacists from pursuing a specialty area because of the daunting journey. Respectfully speaking, after completing a 6 week rotation in pain management, I feel I know how to treat pain better than many licensed clinicians, but at the very least I have seen more than most. Perhaps though I haven’t been at it long enough to know what I don’t know. In any case, after completion of my rotation, I do believe that I can indeed one day become a pharmacist who specializes in pain management regardless of the road to achieve that goal. I believe that the focus for any specialty should not be on the long journey, but instead, on fixing/correcting the foundation of pharmacy education/curriculum such that inadequacies are addressed up front. If this was done, we would likely see more highly qualified pharmacist graduates and perhaps clinicians that are even more driven to see clinical pharmacy develop over the next generation.
Dear Abhishek,
EXCELLENT questions! Exactly what we are looking for.. I think I can address some of your concerns
The current pre-requisites for board certification are either an accredited residency (PGY-1) OR have at least 3 years of clinical experience, 50% of that experience in your area of specialty (e.g. am care if you’re sitting for the am care board). The structure for subspecialties (if BPS goes that way) is not established yet, but could imagine something similar. Would a PGY-2 in pain and palliative care (P&PC) be a requirement? I don’t know. If it was required, that means current practitioners (like me and Dr. Fudin) would need to complete not only a PGY-2 but ALSO the boards. I would think that it would be set up as either PGY-2 OR experience for those practitioners who have been practicing for many years already.
Now, that doesn’t mean that a PGY-2 P&PC residency is not important. An employer may say that they “prefer” either the P&PC PGY- 2 OR board certification. It just depends on the employer. This is why I would love to have feedback from potential employers/physicians.
You are correct. HUGE time and effort involved for what gain? That is one of the big questions….I was hired right before I took the BCPS (so “board eligible” but now, sometimes you have to have it to be considered for a position….) And I had to earn my BS Pharm and THEN go back and do another 2 years of post-bacheloreate training to earn my PharmD. AND a PGY1 – and that was almost 20 years ago. Nothing worthwhile is easy my friend. So after you complete your PGY2, you and I have spent the same amount of time in training! Mine happened in the classroom and yours will happen in the field.
Board renewal is something that I think every discipline employs, and, yes, it is a significant time and financial commitment, but this is equivalent to the provider’s professional commitment and dedication to be credible, relevant and respected. I suspect experts like Dr. Fudin would never need to take a board exam to get hired – his expertise speaks for itself. But for the rest of us, we need to prove that we are credible.
You have hit upon a concern across professions in that, just like your college of pharmacy and mine, very few colleges of pharmacy, medicine, nursing, etc. spend an adequate amount of time on pain management. Typically 1-3 hours total of pain management education. You’re right, a methadone elective could be a semester class! So many nuances. And yet, we as providers, have demonstrated that we are quite ignorant with regard to pain management, to the detrimetn of our patients. There are continuing efforts to address this (e.g. the Pharmacy Pain Summit and the NIH Centers for Excellence in Pain Education, which is multidisciplinary). How many cardiovascular lectures did you have? (does every patient have CAD or HTN? no) How many infectious disease lectures? (does every patient have an infectious disease? no). How about pain and palliative care? (does every patient have pain at some time? YES, does every patient eventually die? YES) Hmmm…begs the question of curriculum revision…
A “triaging” system early in pharmacy training would be ideal, except many students don’t know what they want to do until the last year of clinical rotations…Sometimes I miss the old way, where the folks with the Bachelor’s degree could hop right into community practice and those who wish to do clinical practice could stay on for a post-bacheloreate degree….That is now water under the bridge. Have to look forward.
Thank you for adding your very important young person’s voice to our discussion. It is vital – you are our future and your thoughts and opinions matter very much.