With the increasing complexity of disease state management and rapidly growing ageing population seeking care in various healthcare settings, there is an urgent need for pharmacists in the workforce with advanced training in geriatrics. According to one epidemiological study, 67% of Medicare beneficiaries over the age of 65 years had multimorbidity (two or more chronic conditions).1 Multimorbidity is associated with increased risk of death, functional impairment and adverse drug events. The benefits of pharmacists as part of the geriatrics team managing older adults with multimorbidity have been reported in the literature.2 Pharmacist-led interventions have been shown to significantly improve therapeutic, safety, adherence and hospital admission outcomes in geriatric patients.
The American College of Clinical Pharmacy (ACCP), a strong proponent for post-graduate training, envisions that direct patient care will be “the standard of pharmacy practice in all patient care settings”.3 In contrast to the traditional dispensing role, pharmacists are increasingly involved in direct patient care and are expected to be able to evaluate, interpret and recommend drug therapy as part of the healthcare team to influence patient outcomes.3 While recognition and opportunities for pharmacists in geriatrics has increased in recent years, the role of consultant pharmacists providing direct patient care to older adults has been well established for over 40 years.
Although 93% of older adults live within five miles of a community pharmacy in the USA, pharmacy schools have been slow to incorporate geriatric-specific competencies as required into didactic and experiential curricula.4 Furthermore, it is well known that there are not enough geriatricians to care for older adults and continued efforts are in place to increase all healthcare professionals’ geriatrics competencies. There is evidence of the push by national organisations and interprofessional coalitions towards required baseline competency in geriatrics for entry-level pharmacists and other health professions.5 The Partnership for Health in Aging recommends six universal competency domains in geriatrics for all entry-level practitioners6 and this has been endorsed by over 30 health professional organisations, including most of the major pharmacy organisations in the USA. While these baseline competencies are important to establish foundational knowledge and skills to work with older adults, this is a starting point only; meeting them does not mean a pharmacist will be proficient at managing this unique patient population.
The Geriatric Pharmacy Curriculum Guide7 details competencies for students graduating from pharmacy school, and the newest edition offers a toolkit with suggestions for learning opportunities across the spectrum of professional development. The Lamy Center on Drug Therapy and Aging at the University of Maryland School of Pharmacy has used this as a tool for its Geriatrics and Palliative Care Pathway teaching, as well as for its postgraduate training programmes.
Landscape of postgraduate training in geriatrics
Although no mandate currently exists for pharmacy graduates to pursue postgraduate training, major pharmacy organisations envision that, by 2020, residency training will be an expectation before entering clinical practice.3 The primary motivational factor for students to pursue advanced training is to gain additional knowledge, experience and specialist training.8 For pharmacy students interested in seeking out advanced clinical training in geriatrics, the primary pathway is through residency training.9 Graduates are required to complete a PGY-1 programme and then may pursue a specialised PGY-2 Geriatrics Residency Programme. Whereas PGY-1 programmes commonly offer several residency positions each year, PGY-2 programmes typically only offer one position per year. Specialty residencies in geriatrics around the country are limited but the number of programmes is now growing. At the time of writing, there were 17 accredited PGY-2 geriatric residency programmes in the USA, with four new programmes seeking accreditation status.10 Some accredited PGY-1 programmes offer strong experiences or an “emphasis” on geriatrics, but this is an unofficial designation and primarily used to advertise the programme to potential candidates. Other non-accredited geriatrics specialty residency programmes exist: based on an internal report of geriatrics residency programmes in the USA by the American Society of Consultant Pharmacy’s Pharmacy Educators and Research Council (ASCP PERC), there are currently three non-accredited specialty geriatric residency programmes and four PGY-1 programmes with an “emphasis” on geriatrics.
For candidates interested in academia or other researchfocused positions, fellowship training or graduate level programmes are the preferred route for postgraduate training.10 These are highly individualised and usually offer a graduate level degree during the programme. Candidates interested in both clinical practice and research are expected to have prior experience in the therapeutic area or residency training before completing a fellowship or graduate training. A number of schools of pharmacy in the USA offer graduatelevel clinical research degrees and fellowships.8 Candidates interested specifically in geriatrics will find many unique opportunities with graduate programmes but options are limited for geriatrics-focused fellowship programmes, with only one US programme available at the time of writing.
Schools and colleges of pharmacy have a multifaceted role with relation to the success of postgraduate training. In addition to funding residency and fellowship programmes, they have a unique opportunity to expose and influence students to pursue advanced training.7,11 Colleges and schools of pharmacy also receive the benefits of increased numbers of pharmacists in the workforce with advanced training because it increases the pool of qualified candidates for faculty positions. Residency and fellowship trained faculty and alumni serve as model practitioners, advocate for funding of new programmes and serve administratively or as preceptors for postgraduate training programmes.12 Pharmacy graduates benefit from postgraduate training with increased active participation in pharmacy organisations, engagement in professional lifelong learning activities, and career advancement opportunities.13,14
It is paramount that continued efforts are placed on training the pharmacist workforce to meet the needs of older adults and their care support system both during pharmacy school as well as after graduation. The number of opportunities is not matching the demand, so it falls upon all of us to create innovative programmes to address this gap in knowledge, skills and attitudes not only of pharmacists but also of the entire interprofessional healthcare team.