Marilyn Stebbins, PharmD, is a professor in the Department of Clinical Pharmacy at the University of California, San Francisco, School of Pharmacy. She is currently researching, among other things, some of the novel roles that pharmacists are now playing as part of team-based health care; one of her studies appeared recently in the journal Research in Social and Administrative Pharmacy. We spoke with her to help sort out the many questions consumers may have about pharmacists—including all the different settings (aside from the drugstore) in which they work.
Where do pharmacists work, aside from retail drug stores?
Pharmacists work in many different places. They can work in hospitals, ensuring that the right drug is given to the right patient at the right time. Some drugs require intensive monitoring in the hospital, where the pharmacist would work as part of the team treating the patient. Pharmacists are also part of what are called antibiotic stewardship programs at hospitals, which help ensure that patients receive the most appropriate antibiotic to help prevent antibiotic resistance. Other pharmacists work in home health-care settings or in infusion centers, such as those where people receive chemotherapy.
There are also pharmacists working in closed-door—that is, non-retail—pharmacies that supply nursing homes with medications, for example, or supply nuclear medicine to radiology practices or compounding pharmacies. Some pharmacists work in compounding pharmacies, where the pharmacist prepares a customized drug as per a physician’s prescription.
Pharmacists can work side-by-side with other practitioners in primary care clinics or in specialty clinics for people who take certain medications, such as blood thinners, or have chronic diseases that are medication-intensive, such as diabetes or hepatitis C. Most health care facilities (including hospitals, health systems, clinics, and nursing homes)have a director of pharmacy as part of the managerial staff; this pharmacist would oversee pharmacy services as well as the whole regulatory process.
And, of course, pharmacists may work in community pharmacies—either large chain pharmacies such as Walgreens, CVS, or Rite Aid, or independently owned community pharmacies—dispensing medications and providing medication therapy management services. The same is true at mail-order pharmacies. In short, wherever there are drugs, there are pharmacists.
Who Are the Other People at the Pharmacy?
Not everyone working at your local pharmacy is a pharmacist; often they're joined by a pharmacy clerk, a pharmacy technician, or both. Here's a quick definition of each.
How are pharmacists educated?
Since 2000, the minimum standard has been a six-year program: two undergraduate years plus four years of doctoral training and professional education. And many of the PharmD programs are four-year programs that are done after a four-year bachelor’s degree. At UCSF, 95 percent of the students we accept have at least a four-year undergraduate degree. The Bachelor’s degree can be in anything. At UCSF, we have business and music majors, for example, and we love that because we love a well-rounded person. But, as with medical schools, you have to fulfill certain coursework prerequisites to be admitted to the PharmD program. Most people do have a science major, because the requirements are very science-based, such as biology, inorganic and organic chemistry, molecular biology, and biochemistry.
How are pharmacists licensed or credentialed?
Pharmacists are licensed by their individual state board of pharmacy. Every state has a licensing exam requirement. There is also a national licensing exam that a pharmacist must take, but the state requires you to take another exam specific to that state’s laws and regulations.
Credentialing is something very different. Pharmacists may be credentialed through their institution to perform specific expanded practice that’s allowed in that state. This expanded practice is typically covered by something called the “collaborative practice agreement” within that institution. As a result, the pharmacist is practicing at a higher level. Under these sorts of agreements, pharmacists can prescribe medication, order lab tests, and co-manage patients. When you work under a collaborative agreement, it’s an agreement where you work with a physician or a group of physicians. When I worked for the Veterans Administration, for example, I was credentialed and could write prescriptions and order lab tests for my patients I co-managed with physicians; I also worked for a medical group under a collaborative practice agreement and was able to perform these functions to help optimize patients' medications. Not every state allows a collaborative practice agreement.
There is also board certification for pharmacists that is similar to that for physicians. So a pharmacist could be board certified in a given specialty through a national board. You could be board certified in infectious diseases, ambulatory care, or oncology, for example. And certification may allow you to become credentialed within your institution more easily.
What are pharmacists trained to do, and what are some things not within their repertoire?
Pharmacists are medication experts. They are skilled in anything related to medication: therapeutics, dosing, contraindications, adverse effects, and drug interactions. Pharmacists are skilled in optimizing drug therapy and can work with prescribers when they find errors, omissions, or duplicate drug therapy. They are also required to know over-the-counter (OTC) medications. And they are trained to evaluate conditions that an OTC medication can treat.
Pharmacists are not licensed to diagnose. But they are licensed to treat common OTC conditions: coughs, colds, skin rashes, and allergies, for example. In the world of team-based care, a pharmacist would say to the patient, “If this omeprazole doesn’t work for your heartburn, you really need to contact your physician.” Or, “If you have to use this medication for more than 14 number of days, that’s when you should contact your physician.” In a collaborative practice agreement, a patient who has already been diagnosed may be referred to the pharmacist, who could prescribe medication and develop the therapeutic plan in collaboration with the physician.
In some states, including California, Washington, Oregon, North Carolina, Minnesota, and New Mexico, pharmacists have an expanded scope of practice as providers even outside of collaborative practice agreements. For example, in California and some other states, pharmacies can provide immunizations and sometimes oversee travel medicine programs. In California, pharmacists can also furnish smoking-cessation aids and oral contraceptives, and can order lab tests.
Do pharmacists know about dietary supplements in addition to drugs?
Pharmacists get training in dietary supplements, and there are pharmacists who may specialize in them. Pharmacists’ extensive training in drug interactions also includes identifying potential interactions between drugs and supplements.
What are some recent trends in retail pharmacy?
With more people having access to health insurance with the Affordable Care Act, and baby boomers reaching Medicare age with more chronic conditions and medications, plus a shortage of primary-care providers, we have a perfect storm: more people in need and fewer physicians to care for them. In the community, pharmacists are on every corner. With expanded scopes of practice, we can help decrease the burden of access for patients. So the trend in retail pharmacy is to take on more in terms of clinical care of patients. This can include the immunizations, travel medicine, hormonal contraception, smoking cessation, and lab tests mentioned above, which pharmacists in California can now furnish or order.
Some pharmacists in California, called “Advanced Practice Pharmacists,” have an advanced certification that allows them to work collaboratively with a community physician under a collaborative practice agreement. Under this agreement they might do such things as perform patient assessments, make referrals to other health care providers, and prescribe or change drug therapy. This can be especially valuable in rural areas.
A problem with this is that the payments to the pharmacists for these expanded scopes of practice have not followed. We can’t, in the traditional sense, bill for clinical services beyond the actual prescription—unlike nurse practitioners, for example. Every state has its own rules. In the state of Washington, for example, insurers or Medicaid will and do pay pharmacists for advanced practice services. But overall, pharmacists are not recognized nationally as providers in terms of payment. There are two bills in Congress that would give provider status to pharmacists in any county that has a rural designation, which is a large proportion of counties in the U.S. This would allow pharmacists to bill much like physicians or nurse practitioners.
Also see Buying Drugs Online: What to Know.
Published April 05, 2018