Rethinking Experiential Education (or Does Anyone Want a Pharmacy Student

The scene is a busy emergency room in any city in America. In addition to the countless patients waiting to be seen, there is a large complement of medical and nursing staff members. Doctors, interns, residents, etc. It is sometimes difficult to differentiate between the experienced physician and the interns and residents who are still in training. If your arm needs suturing, you may in fact be cared for by a house staff member. The reality is that the interns and residents are there providing direct care to patients. That is how they learn to be doctors. Now, go upstairs. Here the medical team is making rounds. Again, you will find attending physicians, interns, and residents reviewing the care of their patients. Every now and then, the team includes a pharmacy faculty member with fourth-professional year (P4) students enrolled in advanced pharmacy practice experiences (APPEs). Unfortunately, on many rotations, the pharmacy students only observe patient care activities, and depending on the demands of their preceptor, they may or may not do anything more than observe. Since the pharmacy faculty preceptor may only be on service 6 months out of the year, the medical team unfortunately does not rely on them on a consistent basis. The result is that many times, the physicians are unsure of what the pharmacy students are supposed to do, and how to incorporate them into patient care. Although there are many excellent models in hospitals today where this does not occur, there is a great deal of ambiguity and uncertainty in the role of the students on rotations in many sites. What is wrong with these pictures? Are our APPE rotations simply observational, or do the students actually provide direct patient care? Are they pharmacy students or student pharmacists? Pharmacy students observe. Student pharmacists would provide care. So I ask: do our students make a difference in the health outcomes of their patients on a consistent basis? If not, how could we change this so that they do make a difference? ASHP Executive Vice President Henri Manasse is calling for a quantative analysis of the capacity of hospitals and health systems to offer P4 APPEs. I think this is only part of the story. As a former director of pharmacy, I do not believe the only problem is the number of rotations. To understand the issue, we also need to look at the quality of care that can be provided by student pharmacists. We need to examine what they actually do when they are on rotation. There are many pharmacy directors who state that they can not have their staff precept our students because the staff is already overextended and they do not see the addition of pharmacy students as a means of improving patient care. I contend that we are making a huge mistake because we have not required students, on a daily basis, to demonstrate their value to the site. Similar to medical students, interns, and residents, student pharmacists need to provide patient care. They need to be monitoring drug therapy outcomes and documenting the care they provide. At the end of each APPE, all students should be expected to document the value they brought to the site. Sites, quite simply, must see the value of our students – and they must need our students. If they did, sites would compete for our students! Now wouldn't that be a change? Now I know that many people will say that the reason students do not need to show their value to the site is because of state laws that prevent students from dispensing medications. However, I submit that there are many things that students could actively do that would help improve patient care. Many years ago, the schools in California convened a meeting of pharmacy directors. We asked the directors why they did not want to take our students on rotations. The immediate response was that they just could not spare their staff's time to precept pharmacy students. So we asked them to list duties that (within state laws) the student pharmacists could do for the hospital. The list was wonderful; everything from monitoring adverse drug reactions to drug use evaluations and patient education activities. Most importantly, the discussion started to raise the level of expectation of students on APPEs. It is time that pharmacy as a profession asks what students do on APPEs and make a list of the opportunities for students to contribute to improving the quality of care. There are many wonderful opportunities, and it is time we seize them. For example, starting in 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in their National Patient Safety Goals, began requiring that medication reconciliation (MedRec) be provided for every patient. MedRec requires that hospitals “accurately and completely reconcile medications across the continuum of care.” It includes obtaining a complete list of patient medications from the time of admission, through transfers, and discharge from the hospital. This includes taking a medication history and ensuring that medications and doses are appropriate, and if problems are found, that the physician is contacted and revisions are made as needed. In a recent editorial in Pharmacy Today, Bruce Canaday observed that the profession of pharmacy does not currently own this process, but we should. I agree with Canaday, but I am also sensitive to the resource issues he raised. However, there is a tremendous untapped resource in our schools and colleges of pharmacy. This seems like the perfect role for our student pharmacists. If pharmacy directors knew that their student pharmacists would perform MedRec, and be there every day, 12 months a year, to perform that service, I believe they would welcome assistance from pharmacy students. Everyone would benefit. The hospital would meet JCAHO requirements; the students would be working with patients and demonstrating their value to the site. The patients, nurses and physicians would see what the pharmacy profession is all about. The colleges and schools of pharmacy would have excellent APPE sites for their students (more APPE sites and quality APPE sites). This is only one example of what student pharmacists could do to show value to a practice site. There are many other untapped opportunities for students to improve patient care. It will take collaboration between colleges and schools of pharmacy and hospitals and health systems to rethink what pharmacy students do on rotations and assess the quality of their contributions to patient care. I believe if we carefully consider changing the way we look at what students contribute to patient care, the issue of the number of rotations would be minimized. Pharmacy education would be helping to improve the quality of patient care that is provided and we would be advancing the profession of pharmacy. Isn't that part of our mission? I believe it is time that we engage in this dialog.