Importance of Direct Patient Care in Advanced Pharmacy

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Importance of Direct Patient Care in Advanced PharmacyPractice Experiences

American College of Clinical Pharmacy

R. Chris Rathbun, Pharm.D., E. Kelly Hester, Pharm.D., Lindsay M. Arnold, Pharm.D.,

Allison M. Chung, Pharm.D., Steven P. Dunn, Pharm.D., Lisa M. Harinstein, Pharm.D.,

Molly Leber, Pharm.D., Julie A. Murphy, Pharm.D., Kristine S. Schonder, Pharm.D.,

Sheila M. Wilhelm, Pharm.D., and Kristine B. Smilie, Pharm.D.

The Accreditation Council for Pharmacy Education issued revised stan-

dards (Standards 2007) for professional programs leading to the Doctor of Pharmacy degree in July 2007. The new standards require colleges andschools of pharmacy to provide pharmacy practice experiences thatinclude direct interaction with diverse patient populations. These experi-ences are to take place in multiple practice environments (e.g., commu-nity, ambulatory care, acute care medicine, specialized practice areas) andmust include face-to-face interactions between students and patients, andstudents and health care providers. In 2009, the American College of Cli-nical Pharmacy (ACCP) identified concerns among their members thattraining for some students during the fourth year of pharmacy curriculumsare essentially observational experiences rather than encounters where stu-

dents actively participate in direct patient care activities. These ACCPmembers also stated that there is a need to identify effective mechanismsfor preceptors to balance patient care responsibilities with students’ educa-tional needs in order to fully prepare graduates for contemporary, patient-centered practice. The 2010 ACCP Educational Affairs Committee wascharged to provide recommendations to more effectively foster the integra-tion of pharmacy students into direct patient care activities duringadvanced pharmacy practice experiences (APPEs). In this commentary,the benefits to key stakeholders (pharmacy students, APPE preceptors,clerkship sites, health care institutions, academic pharmacy programs) of this approach are reviewed. Recommendations for implementation of direct patient care experiences are also provided, together with discussion

of the practical issues associated with delivery of effective APPE. Examplesof ambulatory care and acute care APPE models that successfully integratepharmacy students into the delivery of direct patient care are described.Enabling students to engage in high-quality patient care experiences andto assume responsibility for drug therapy outcomes is achievable in a vari-ety of practice settings. In our opinion, such an approach is mandatory if contemporary pharmacy education is to be successful in producing askilled workforce capable of affecting drug therapy outcomes.Key Words: pharmacy students, experiential education, direct patientcare.(Pharmacotherapy 2012;32(4):e88 – e97)

A C C P C O M M E N T A R Y



The Accreditation Council for Pharmacy Edu-cation (ACPE) issued revised standards (Stan-dards 2007) for professional programs leading tothe Doctor of Pharmacy degree in July 2007.1

The new standards require colleges and schoolsof pharmacy to provide pharmacy practice expe-

riences that include direct interaction withdiverse patient populations. These experiencesoccur in multiple practice environments (e.g.,community, ambulatory care, acute care medi-cine, specialized training areas) and mustinclude face-to-face interaction between studentsand patients, and students and health care pro-viders. The American College of Clinical Phar-macy (ACCP) has published guidance on theinterpretation of the ACPE standards for phar-macy practice experiences, indicating that intro-ductory pharmacy practice experiences (IPPEs)

should consist of at least 300 hours of struc-tured experiential activities to meet the ACPErequirement for no less than 5% of the curricu-lum, and advanced pharmacy practice experi-ences (APPEs) should comprise a minimum of 36 weeks to meet the requirement for at least25% of a standard 4-year academic curriculum,including a minimum of 24 weeks of directpatient care experiences.2

Written comments submitted as a part of ACCP’s 2009 member survey requesting identifi-cation of important issues in clinical practice,

education, and research, expressed concern thatthe experiential education of some students dur-ing the fourth year of the pharmacy curriculumwere, in effect, observational experiences withlimited involvement in direct patient care. ACCPmembers also suggested the need to identifyeffective mechanisms for preceptors to balancestudents’ patient care responsibilities with educa-

tional activities (e.g., assigned reading, topic dis-cussions, and so forth) in order to fully preparegraduates for contemporary patient-centeredpractice. In some instances, students’ experien-tial education is perceived to be a burden byhealth care institutions and preceptors because

preceptor time is diverted to teaching activitiesand clinical service productivity diminishes. Thiscan lead to reduced institutional commitment toexperiential education because students are notperceived to contribute positively to the practiceactivities of the pharmacy department or clinicalsite.

The ACCP Board of Regents recognized thatthese observations are not necessarily associatedwith most doctor of pharmacy programs. How-ever, given that these issues were familiar to cur-rent and past ACCP board members, they were

viewed as credible by the organization’s leader-ship. Therefore, the 2010 ACCP EducationalAffairs Committee was charged to provide rec-ommendations to better integrate students intothe delivery of direct patient care, including del-egating to students responsibility for drug ther-apy outcomes. In this commentary, the benefitsof this approach will be reviewed. Examples of the integration of students into direct patientcare practice are also provided, together with adiscussion of practical issues associated withdelivery of effective APPEs.

Benefits of Student Involvement in DirectPatient Care

Student Benefits

We believe that the benefits of increasing stu-dent involvement in direct patient care duringAPPEs are undeniable. Doctor of pharmacy stu-dents who actively participate in patient careactivities can be expected to gain increased pro-ficiency in managing drug therapy problemsthrough the longitudinal exposure to diversepractice environments that occurs during theexperiential component of the professionaldegree program. Practical, real world experiencesare necessary for students to refine thinking andproblem-solving abilities, build confidence,deepen their understanding of clinical diseaseand pharmacotherapy, and mature profession-ally. It is expected that integrating students intothe preceptor’s workflow will foster greaterknowledge retention and satisfaction with theirclinical experience — students are also morelikely to actively engage in their own learning

From the American College of Clinical Pharmacy,Lenexa, Kansas, (all authors).

This document was prepared by the 2010 EducationalAffairs Committee: R. Chris Rathbun, Pharm.D., AQ-ID, AA-HIVE (Chair); E. Kelly Hester, Pharm.D., (Vice-Chair); Lind-say M. Arnold, Pharm.D.; Allison M. Chung, Pharm.D.,AE-C; Steven P. Dunn, Pharm.D.; Lisa M. Harinstein, Pharm.D.; Molly Leber, Pharm.D.; Julie A. Murphy, Pharm.D.;Kristine S. Schonder, Pharm.D.; Sheila M. Wilhelm, Pharm.D.; and Kristine B. Smilie (student member). Approved bythe American College of Clinical Pharmacy Board of Regentson October 15, 2010.

For reprints, visit http://www.accp.com. For question orcomments, contact R. Chris Rathbun, Pharm.D., College of Pharmacy, OU Health Sciences Center, 1110 N. Stonewall,Rm 206, Oklahoma City, OK 73117; e-mail: [email protected].

PROMOTING DIRECT PATIENT CARE IN APPE Rathbun et al e89



and recognize the value of their contributions topatient care. Delegation of responsibility fordirect patient care induces students to take own-ership of patient-specific drug therapy outcomes.They learn to be more accountable by having toprovide and justify a rationale for their drug

therapy recommendations, enabling preceptorsto affirm correct therapeutic approaches whilealso facilitating recognition of students’ miscon-ceptions or knowledge deficits. Using thisapproach, students can improve problem-solvingskills and receive formative feedback to advancetheir professional development.

APPEs should also help prepare students forpostgraduate residency training. For example,interactions with other health care professionalsin the direct patient care setting can helpincrease the student’s understanding of the

health care process and the individual contribu-tions of each health care professional to thedelivery of patient care.3 In our experience, thediversity of patient care settings and degree of involvement in patient-specific pharmacothera-peutic management have a profound impact onstudents’ future career directions. In addition,direct patient care activities help build studentconfidence and instill a desire to render pharma-ceutical care — outcomes that clearly benefit bothpatients and the pharmacy profession.

Benefits to Experiential Sites and Health CareInstitutions

The inclusion of students in direct patientcare activities can yield significant benefits toindividual practice sites and health care institu-tions.3 According to the American Society of Health-System Pharmacists (ASHP) 2006National Hospital Pharmacy Survey, the mostcommonly cited barriers to providing medicationinformation to patients was lack of pharmacisttime and inadequate pharmacy staffing.4 DuringAPPEs, students can extend clinical services topatient care areas that are either underserved orthat don’t have existing services. For example,inclusion of students in inpatient medical teams,or assigning them to work collaboratively withspecific physicians, enables the provision of additional pharmacotherapy evaluation andmonitoring. In ambulatory care settings, phar-macy students working with other health careprofessionals can see patients who would nototherwise undergo a clinical pharmacist’s assess-ment of their pharmacotherapy. Pharmacist-managed programs or quality assurance initia-

tives such as medication reconciliation, anticoag-ulation monitoring, or antimicrobial stewardshipcan be expanded when students are involved. Within existing patient care services, additionalactivities such as conducting medication histo-ries, referring cases to clinical pharmacy special-

ists, answering drug information questions, andperforming discharge counseling can be accom-plished by students. More complex patient careservices may still be reserved for the preceptor,with students assigned to critically analyze andcritique the preceptor’s actions. Students are par-ticularly well-suited to conduct medication rec-onciliation, structured counseling services (e.g.,warfarin, insulin, disease-state management),and therapeutic drug monitoring (TDM) in theearly stages of their clinical education. In com-munity pharmacy settings, students can further

the provision of pharmaceutical care by providingadditional health and medication information,conducting health screenings, or developing newservices such as medication therapy managementor immunization delivery. Expanding services inthis manner can facilitate identification of moredrug-related problems and lead to interventionsthat help optimize medication therapy. InvolvingAPPE students in these patient care activitiesdevelops the skills and confidence needed toassume direct patient care responsibilities whilealso working with preceptors to resolve more

complex drug therapy problems (e.g., manage-ment of drug – drug interactions). When students are integrated into direct

patient care activities, they learn to addressdrug-related problems more efficiently. In addi-tion, when the preceptor establishes these activi-ties (i.e., to identify and resolve drug-relatedproblems) as a routine expectation, studentsaccomplish higher-level interventions. Conse-quently, preceptors are more likely to experiencegreater satisfaction as student interventions posi-tively affect patient care.

A number of tangible benefits to health careinstitutions can be realized by involving studentsin patient care activities.4 Although many clini-cal pharmacists who provide direct patient careat academic medical centers are funded byhealth care institutions, relationships withschools of pharmacy may lead to additionalfunding to support other activities. Collaborationbetween health care institutions and academicpharmacy programs provides a mechanism tocommunicate institutional expectations for theessential knowledge and skills that studentsmust possess upon graduation. Increasing the

e90 PHARMACOTHERAPY Volume 32, Number 4, 2012



role of students in direct patient care can alsoenhance the institution’s clinical pharmacy ser-vices by freeing preceptors to participate inexpanded patient care activities or to focus onother activities that directly benefit the phar-macy department and institution (e.g., staff

development, formulary or pharmacy and thera-peutics committee activities, etc.). Health careinstitutions that take an active role in educatingstudents may also benefit from the enhancedstaff retention and recognition associated withserving as an experiential site. Preceptors areoften awarded faculty appointments withaffiliated academic pharmacy programs. In addi-tion to preceptor training and development,continuing education, tuition waivers, travelsupport, and library resources may be providedby the school of pharmacy. State and national

professional societies also offer awards to excel-lent preceptors. Finally, education of studentsby health care institutions can aid in person-nel recruitment by attracting students to post-graduate residency training and/or staff positions.

Benefits to Academic Pharmacy Programs

Several benefits of greater student involvementin direct patient care may accrue to academicpharmacy programs. First, direct patient care

provides the real-world opportunities that arenecessary to achieve the ability outcomesrequired to provide pharmaceutical care. Givenample time, direct patient care experiences willallow the student to progress such that his/herperformance of patient care activities steadilyimproves. This improvement requires increas-ingly less direct supervision by the preceptor.Eventually, the successful student is able tocomplete even complex tasks independently.Second, the professional confidence of graduatesis strengthened when experiential activities aredesigned to consistently challenge students toattain higher levels of performance. Conse-quently, as students recognize the impact ontheir individual personal and professionalgrowth, they derive increased comfort in con-fronting the challenges of clinical practice. Ulti-mately, the academic pharmacy program canpoint to its skilled and confident graduates whoare prepared to enter the next phase of careerdevelopment. This creates a favorable reputationfor the academic institution that can promotecompetitive applicant pools and productive rela-tionships with pharmacist employers. Students

who experience satisfaction with their clinicaleducation and training are also more likely tohave a positive view of their academic experi-ence and thus serve as active alumni involved inthe clinical training and mentoring of futurestudents.

Faculty and Affiliate Preceptor Benefits

Faculty and institution-based, affiliate precep-tors benefit from experiences that incorporatestudents into direct patient care in a number of ways. Students are most helpful in assisting pre-ceptors with patient care activities when theyfunction with greater autonomy. This autonomy(and the competence that facilitates it) resultsfrom deliberately delegating to students directpatient care responsibilities that enable repeated

application of their growing knowledge andskills. High-performing students can help dividethe patient care workload with the preceptor,contributing to greater efficiency while extend-ing care to a greater patient base than the pre-ceptor can address alone. In addition, theincreased visibility and accessibility of clinicalpharmacy services has the potential to result ingreater demand among other health profession-als and patients for clinical pharmacists’ services.The value of expanding clinical pharmacy ser-vices by integrating students into patient care

has been quantitatively and qualitatively demon-strated through documented patient care inter-ventions.5, 6

Barriers to Student Involvement in DirectPatient Care

A number of practical barriers to cultivatingproductive patient care experiences for studentsduring APPEs exist. These usually focus onissues pertaining to (i) student readiness foradvanced clinical experiences, (ii) competingpriorities of preceptors and health care institu-tions to meet other responsibilities not related tostudent education, and (iii) logistical issuesrelated to individual practice sites. A brief dis-cussion of how these issues impact the deliveryof high-quality APPEs is followed by recommen-dations on how to mitigate their effects on expe-riential education.

Adapting to patient care delivery in diversepractice settings can be challenging for studentsdue to their limited exposure to many practicesettings prior to entering APPEs and the need toapply problem-solving skills to the treatment of




more complex patients. Patient case scenariosused in the didactic setting may in someinstances be relatively straightforward and resultin a “one best answer” approach. This can dis-courage the retrieval and assimilation of clini-cally-relevant information, minimize the

application of problem-solving skills, and leadstudents to a false sense of the complexity thatoften surrounds clinical decision-making in thereal-world setting. Depending on the profes-sional program’s curriculum, insufficient timemay be devoted to some specialized practiceareas (e.g., intensive care, oncology), and stu-dents may have had limited practice in applyingthe practical aspects of routine pharmacotherapy(e.g., dosing, pharmacology, pharmacokinetics)to these specialized practices. Students may alsoexperience varying degrees of receptivity to their

drug therapy recommendations by health careprofessionals. In our experience, this is oftendue to some practitioners’ uncertainty regardingthe extent of a pharmacy student’s pharmaco-therapeutic knowledge base and his/her abilityto effectively participate in direct patient care.

Facilitating Direct Patient Care Roles DuringAPPEs

Learning Experiences Prior to APPEs

Effective use of IPPEs, simulations, and class-room-based case scenarios that foster integrationof treatment concepts and a progressive develop-ment of pharmacotherapeutic knowledge andskills can help prepare students for increasinglycomplicated issues that arise in real-world prac-tice. Sequencing these activities in a manner thatfacilitates stepwise, integrative application of drug therapy concepts can allow students tobuild confidence and develop foundational skillsbefore being faced with managing complexpatients. This limits the student’s tendency to

become overwhelmed when transitioning to AP-PEs. In addition, teaching and reinforcing asystematic approach to patient and pharmaco-therapeutic assessment is necessary to developproblem-solving and critical thinking skillsacross the broad spectrum of experiential rota-tions. Such practical preparation prior to APPEscan positively influence student performanceand, in turn, the perceptions of other health careproviders of pharmacy students’ ability to con-tribute to positive patient outcomes.

Preceptor Roles and Expectations

Academic program and practice site leadersshould work with preceptors to promote viablestudent practice roles and establish clear perfor-mance expectations for APPE students. Faculty

and institution-based affiliate preceptors serve asvital contributors to experiential learning. How-ever, they may encounter difficulty integratingstudents into their respective practices. The roleof the pharmacist in patient care delivery maybe ill-defined in some practice settings. Forexample, when preceptors are not consistentlypresent at a practice site throughout the year, itmay be more challenging for students to “stepinto” direct patient care roles at the site. Col-lege-based faculty preceptors often supervise stu-dents for more than 50% of an academic year,requiring the faculty to balance other academicresponsibilities (e.g., didactic teaching, commit-tee service, scholarship) with the time theydevote to teaching students in experiential set-tings. Preceptors who are partially funded byboth a clinical site and a college of pharmacymay also struggle to effectively balance the needsof the practice site and the academic program.For institution-based affiliate faculty, practicesite workloads may not be adjusted to allow thetime needed to model clinical pharmacy practiceand effectively supervise and educate students atan advanced level. Affiliate faculty may also be

unfamiliar with students’ previous didactic andexperiential learning prior to entering an APPE.Hence, they may have expectations for studentperformance that vary widely from those of full-time faculty or the students themselves.

Balancing Preceptor Roles and Responsibilities

In order for students to have rewarding andproductive training experiences, it is critical thatclinical practice roles be sufficiently developedand maintained so the clinical pharmacist’s

impact on patient care is clearly evident. It isalso vital that the institution demonstrate a com-mitment to experiential education by ensuringthat preceptor workloads are apportioned appro-priately and that institutional priorities do notdetract from the experiential learning. Similarly,the academic program must ensure that facultyworkload is appropriately balanced so that stu-dent learning is not compromised by other fac-ulty responsibilities. Faculty developing newpractice sites should be allowed sufficient time




to establish direct patient care roles within thepractice environment before they are assignedstudents to precept. Continual communicationbetween academic experiential program directorsand practice site preceptors can harmonizeexpectations for student performance and pro-

mote more consistent student assessment.

Guiding Students’ Direct Patient CareInvolvement

Supervisory requirements for students canvary greatly among practice settings. In acutecare settings where patient management is moremedically complex, immediate drug therapydecisions are often required. It can be difficultfor preceptors in this environment to strike abalance between being involved enough to

ensure effective delivery of patient care and notbeing a hindrance to student involvement,because the medical team seeks the preceptor’sinput in making real-time decisions, leaving lit-tle or no opportunity for the student to partici-pate in the decision-making process. In addition,academic pharmacy programs may require that alarger number of students be assigned to facultymembers than the practice site can adequatelysupport, resulting in competition for one-on-onecontact with the preceptor. This can impact thequality of student experiences, particularly at

ambulatory care sites where space is limited andpatient volume may be relatively low. With themovement to electronic medical records (EMR)among many health care institutions, studentaccess to patient medical information may berestricted by licensing agreements, thereby limit-ing their involvement in direct patient care. It isour impression that this restriction may be morecommon at practice sites where patient careroles for pharmacy students are not recognizedor valued. Of course, EMR access for studentscan also be contingent upon contractual com-

mitments between a college of pharmacy and ahealth care institution.

Student – Preceptor Interactions

It is incumbent upon preceptors to maintain alearning environment that enables students todevelop professional abilities and confidencewhile still meeting the practical needs of patientsand health care practitioners. In instances wherepreceptors must intercede because students areunable to provide timely drug therapy recom-mendations to practitioners, preceptors should

subsequently review with students the thoughtprocesses used to formulate such suggestions,thereby preparing them to formulate their ownrecommendations in the future. Ongoing reviewof students’ patient-specific assessments anddrug therapy plans can also provide the precep-

tor with opportunities to facilitate student pre-paredness to provide meaningful contributionsin direct patient care settings. Academic phar-macy programs must ensure that there are anappropriate number of student learners at eachexperiential site to avoid compromising individ-ual student learning. Impediments that limit stu-dent access to patient medical records (e.g.,hard-copy or electronic charts, progress notes,and laboratory and test results) should also beidentified and addressed through coordinatedefforts between the academic program and the

practice site.

Ambulatory Care and Acute Care APPE Models

Summary of Published Literature in AmbulatoryCare

A limited number of studies have been pub-lished describing the involvement of APPE stu-dents in patient care in community andambulatory care practice settings.7 – 12 In general,these reports demonstrate that students are capa-

ble of expanding the scope of services (e.g., healthscreenings, medication therapy management)delivered to patients and can increase the numberof patients served. Improvement in hemoglobinA1C levels was noted in one study of diabeticpatients receiving care from pharmacy students.10

Improved accuracy of medication records wasnoted in another report where pharmacy studentsparticipated in medication reconciliation.12 Medi-cation therapy management services involvingAPPE students in the community pharmacy set-ting have been reported to result in reimburse-ment for those services.9 Overall, pharmacystudents have consistently cited more engagementin their experiential rotations when they areinvolved in direct patient care activities. Theseexperiences also result in identification of a largernumber of medication problems and improvedpreceptor satisfaction with the higher levels of student performance.8

Example: HIV Primary Care Clinics

An example of clinical pharmacy services pro-vided to two federally-funded HIV outpatient




clinics exists at Auburn University and the Uni-versity of Oklahoma Health Sciences Center,where students play a central role in the deliveryof care to patients with HIV infection.13, 14

Through collaboration with the schools of phar-macy at each of these universities, students are

integrated into direct patient care services andassume the clinical pharmacist’s role, under thesupervision of a preceptor. Direct patient careactivities carried out by the pharmacy studentsinclude patient health education and medicationtherapy counseling on new prescriptions, medi-cation reconciliation and histories, and adher-ence assessments. Clinical pharmacy services canbe extended in this setting by pairing pharmacystudents with other health care practitionerswhere medication therapy review for drug-related problems, recommendations for optimi-

zation of therapy, and drug informationresponses are provided. In addition, studentsprovide antiretroviral resistance evaluations,review of abnormal laboratory tests, and answersto drug information inquiries.

For patients referred for medication therapymanagement services for hypertension, dyslipi-demia, smoking cessation, and diabetes, studentsperform a medical chart review to formulate apharmaceutical care plan in advance of seeingthe patient. Students routinely interviewpatients, perform physical assessment, and edu-

cate patients regarding their individual therapeu-tic plans and medications. Immediate feedbackis provided by the preceptor regarding the stu-dent’s therapeutic plan in advance of the patientencounter. Once students have developed aresponse to a consult and have reviewed thiswith the preceptor, they report their clinicalimpressions and recommendations to the healthcare provider. Following each patient visit, stu-dents document their patient care activities inthe medical record. As a result, students gainexperience in clinical decision-making anddevelop confidence through the development of drug therapy plans and consultative interactionswith other health care practitioners. The benefitsof this APPE model include the students’ exten-sive interaction with health care providers andpatients, involvement in delivery of direct patientcare, and the opportunity to assume well-definedclinical pharmacist direct patient care roles.

In the course of establishing these practicesites, several barriers were overcome to facilitatestudent participation in direct patient care. Stu-dent access to medical records was initially lim-ited by health care institutional policies and

procedures, requiring coordination with thedepartment of pharmacy at the institution. Inaddition, implementation of an EMR platformprovided no means for students to view medicalrecords because of site license requirements,requiring purchase of site licenses for students

by the college of pharmacy to enable students togain access to the EMR.

Summary of Published Literature/Abstracts inAcute Care

A number of studies of APPEs in acute caresettings have described the positive impact onpatient care that can be realized when studentsare delegated direct patient care responsibilities.These studies report student involvement with avariety of activities including medication history

taking and reconciliation, medication counsel-ing, therapeutic drug monitoring, adverse eventreporting, and intravenous to oral therapeuticconversions.15 – 19 In these reports, student inter-ventions accounted for 13 – 29% of total phar-macy department interventions, with about half of the student interventions classified as being of moderate to high significance.6,20, 21 Addition-ally, 92 – 97% acceptance of student interventionswas reported.20, 21 In order for students toassume these direct patient care responsibilities,time must be devoted early in the APPE to ade-

quate training and assessment of student abili-ties. One study described involving currentpharmacy residents or other APPE students atthe practice site in the training of incoming stu-dents to expand the length of this initial trainingperiod beyond the extent that a preceptor alonemay be able to offer.19 Student activities alsoresulted in substantial financial benefit to theinstitution. Based on 63 4-week experientialrotations, a total cost benefit of $354,752 wasrealized during one year of student rotations.6 Inaddition to the institutional benefits, studentsreported gaining confidence as well as acquiringa sense of responsibility for the patients thatthey recognized as being reliant on them forprovision of quality care.17

Practical Example: Henry Ford Hospital APPE

The APPE training program utilized by HenryFord Hospital provides an exemplary model of integrating students into the institution’s phar-macy services. Henry Ford Hospital participatesin the Wayne State University longitudinaladvanced pharmacy practice (LAPP) program




that allows students to spend the majority or allof their seven 6-week APPE rotations within oneinstitution.22 After completion of a 6-week gen-eral hospital practice experience, students areassigned to a variety of rotations, including coreinpatient practice experiences (infectious dis-

ease, internal medicine, nephrology, cardiology),as well as elective, ambulatory care, and commu-nity rotations in 6-week blocks.

Within the core areas of care, rotations aredesigned so that a clinical pharmacy specialistpreceptor, or a co-funded faculty preceptor, isresponsible for a floor of patients that encom-passes two patient care teams. The preceptorhas two trainees (one or two fourth year LAPPstudents or a pharmacy resident) most of theyear, one to cover each of the two teams on thefloor. Since the preceptor does not round with

the team, the student or resident is relied uponto serve as the pharmacy department’s represen-tative on each team. Students are responsiblefor fully evaluating patients covered by theteam, rounding daily, providing appropriatetherapeutic recommendations, answering druginformation questions, and providing all otherservices a clinical pharmacist would beexpected to render for that medical service. Stu-dents carry cell phones and are the individualscalled if there is a question or problem associ-ated with a medication order for a patient cov-

ered by their team. They are required toprovide comprehensive care for their patients,including anticoagulation and pharmacokineticdosing services. Students meet regularly withthe preceptor to discuss the patients for whomthey have responsibility. They possess stateinternship licenses and are fully trained as stu-dent members of the pharmacy department.Because of this, they are included in the dele-gated authority agreements that have beenapproved by the institution’s pharmacy andtherapeutics committees and do not require aco-signature from a preceptor for the servicesthey provide. Students are also ACLS-certifiedand attend medical emergency codes with oneof the institution’s pharmacists. Students docu-ment their interventions in an electronic track-ing system that allows annual assessment of interventions made as a department as well asassessment of the impact of student interven-tions on individual patient care teams. Duringthe months that a student is not assigned toone of these teams, a pharmacy specialist isresponsible for providing care to patientsassigned to that team.

The Henry Ford Hospital LAPP allows stu-dents to gain valuable experience in becomingautonomous, independent practitioners in a set-ting where preceptors and other pharmacists areavailable to provide guidance. From the precep-tor’s standpoint, this model provides an incen-

tive to have students assigned to a patient careteam because it allows the preceptor to devotetime to other institutional responsibilities, suchas quality assurance projects, protocol and path-way development, and research projects. Fromthe pharmacy department’s viewpoint, studentshelp to expand the provision of clinical phar-macy services to teams that couldn’t otherwisereceive these services.

Final Comments

Students integrated into direct patient careenvironments can be expected to gain firsthandexperience by fulfilling the role of the clinicalpharmacist within the interprofessional healthcare team. Such experiences are essential to thedevelopment and advancement of patient careskills. Motivated students who acquire extensivedirect patient care experience have the potentialto contribute to the development of a highly-trained and competent clinical pharmacy workforce. Benefits to other key stakeholders can alsobe realized through student involvement in

direct patient care. Development and extensionof clinical pharmacy services to more patientscan be achieved at substantially lower costs tohealth care institutions. When APPE are struc-tured properly, faculty and affiliate preceptorscan devote more time to other professional obli-gations while at the same time providing respon-sible patient care experiences to students.Academic pharmacy programs can developstronger collaborative relationships with practicesites, resulting in access to diverse patient careenvironments and support for other academicpriorities.

In order to achieve these benefits, APPE sitesmust be provided with support from academicinstitutions to enhance APPE outcomes. Affiliatefaculty and new faculty should be providedaccess to preceptor development programs, suchas the ACCP Academy Teaching and LearningCertificate Program, other national professionaldevelopment programs, and precepting programsdeveloped by individual institutions. Equitableallotment of workload for preceptors that bal-ance teaching activities with other responsibili-ties is necessary. Faculty establishing new




practice sites should precept a limited numberof students initially to allow time to determinehow students can best be integrated into directpatient care activities and to maximize thoseactivities at the practice site. Academic phar-macy programs that offer training and educa-

tional sessions for affiliate and junior facultyshould communicate clearly their expectationsfor student performance and assist in identifyingmechanisms to incorporate students into directpatient care roles in diverse practice settings,leading to more well-rounded and consistentlearning experiences for students. Improvedcommunication between institution-based pre-ceptors and academic pharmacy programs canprovide affiliate faculty with the opportunity toexpress both their individual preceptor develop-mental needs and the expectations for the stu-

dents they precept. By addressing these factorsprospectively, both preceptors and students willbe better positioned to maximize the learningpotential at each practice site.

Where possible, sequencing of APPEs shouldbe coordinated in a manner that facilitates pro-gressive growth of clinical knowledge and skills,attempting to avoid assignment of students tomore complex patient care experiences beforethey are adequately prepared (e.g., assignmentto a level 1 trauma unit as a student’s firstAPPE). Preceptors should create a learning envi-

ronment that both challenges and supports stu-dents toward achieving progressively higherlevels of practice performance as they progressfrom basic to more complex patient care envi-ronments. Institutions involved in residencytraining are particularly well-positioned to pro-vide advanced clinical practice experiences withthe added mentoring and guidance of a PGY-1or PGY-2 resident. Involving pharmacy residentsas co-preceptors in APPEs can provide greaterflexibility for preceptors while at the same timecomplementing students’ learning experiences.Residents may more readily empathize with stu-dent fears or concerns and can model positiveattitudes and behaviors that bring anotherdimension to student learning.

In summary, enabling students to engage in highquality, direct patient care experiences and assumeresponsibility for drug therapy outcomes is achiev-able in most practice settings. This is an essentialfoundational step in the profession’s preparationof a skilled workforce capable of optimizing drugtherapy outcomes, and a clear commitment to thisobjective by all stakeholders is critical. While prac-tical barriers to the integration of students in the

delivery of direct patient care exist in some APPEsettings, the immediate benefits to students,patients, academic pharmacy programs and healthcare institutions, and the long-term benefits to theprofession far outweigh these barriers.

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Importance of Direct Patient Care in Advanced Pharmacy

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