PharmD curriculum transformation

The UCSF School of Pharmacy’s top-ranked doctor of pharmacy (PharmD) curriculum is in the initial stages of its most significant transformation in two decades. Named the UCSF Bridges Pharmacy Curriculum Project, the effort is led by Vice Dean Sharon L. Youmans, PharmD, MPH, and is currently targeted to launch fully with students entering the program in 2017.

[Update: The UCSF Bridges Pharmacy Curriculum Project is now known as the UCSF PharmD Curriculum Transformation Project: 2018 and beyond.]

To better understand the forces behind this transformation and the changes likely to take place, Editorial Manager David Jacobson asked Youmans to share her thoughts.

Jacobson: What is behind this curriculum transformation?

Youmans: Basically, it’s the shortage of health care providers and the surge in chronic diseases among an increasingly aging population, coupled with amazing new opportunities for pharmacists to expand their scope of practice and lead in new ways through advanced training.

We have a real shortage of primary health care providers. The situation practically begs for expanded practice roles for pharmacists to meet the health care needs of patients beyond what most pharmacists are licensed to provide today. And recent legislation is giving pharmacists the chance to practice to the full extent of their expertise.

Also, as one consequence of the Affordable Care Act, new health care models must focus on outcomes. As pharmacists, we’re all about therapeutic outcomes—the safe, effective, precise use of medications in individual patients—and minimizing or avoiding drug interactions. And I’m not talking about just a single medication to treat a single health problem. We’re experts in managing multiple medications for multiple diseases over time. Our outcomes expertise could be leveraged more widely for the patient.

Don’t forget—as our population ages, the incidence of chronic diseases goes up. So the demand for pharmacists with expanded roles to manage chronic diseases—and the multiple medications required to treat them—will surely only increase.

To this, add the sophisticated new medications on the horizon—some prescribed based on precise genetic patient information—and new ways of delivering medications into the body. Think about the fact that right here in the School we’re creating smart drug delivery devices that can be implanted behind the eye to slowly and evenly release drugs to treat eye diseases. This kind of delivery is a world away from an eye drop or a capsule the patient swallows. And this is only one example.

Jacobson: What you’re describing is something akin to a primary care pharmacist?

Youmans: Yes, that’s exactly it. The opportunities for pharmacists with wider patient care roles have never been greater. Actually, the need for this kind of pharmacist has never been greater.

Jacobson: Based on this, how will pharmacists be practicing in the future?

Youmans: Philosophically, it’s been about teamwork for a long time. But practically speaking, that’s been more difficult to achieve. The marketplace is now demanding that we start working in tight, mutually respectful teams, focused on one thing—the best possible health outcome for the patient. Moving forward, this is the only way to succeed—team-based care centered on the outcome of the patient.

No single health professional—physician, pharmacist, nurse, dentist, physical therapist—can know it all these days. The patient needs a team of providers that shares the responsibility of providing basic care while applying their unique expertise, evaluating the latest data and developments in their fields, and all for the benefit of that patient. Being part of a world class academic health sciences institution like UCSF provides the opportunity to bring together the professions in ways that other schools cannot.

Jacobson: In addition to being able to work in true teams, what else will the pharmacist of tomorrow be doing?

Youmans: Our profession has always been one of transformation. If you look back to the 1800s, treatment products were sold by druggists with little or no scientific training. With education, pharmacists then worked to ensure drug quality and purity through compounding and filling prescriptions and dispensing. In the mid-1960s, a revolution that started here at UCSF led to the pharmacist transforming into a clinical expert in the best use of drugs. With robots now beginning to dispense and track medications, the role of dispensing is decreasing. But all pharmacists will certainly remain medication experts—that’s our unique niche. What we’re seeing now is the clinically equipped pharmacist stepping in to deliver primary care-related services.

Jacobson: Do I see a parallel here with Sheryl Sandberg’s book, Lean In?

Youmans: Ha! Maybe so. She discusses women assuming leadership roles in government and industry. I’m talking about pharmacists who are trained in new ways, stepping into new roles in health care and leading change.

Jacobson: What kind of curriculum do you need to prepare pharmacy students to step in successfully? How do you teach this?

Youmans: We need to shape the curriculum so our students graduate as explorers who relish the unknown, who look and think beyond the traditional territory of pharmacy practice, and who seek to be leaders and life-long learners.

First, students must be able to navigate what they don’t know. This has to be automatic. We have to teach them to think through problems: “This is what I know. What other information do I need? Where do I get it? What other lab tests should I order and be looking at? Is there someone else I need to consult? What is the underlying science?” In order to succeed—to lead in the new workplace—a high command of key areas of science, from biomedical to systems science, and coupled with critical thinking, is essential. I can’t emphasize this enough.

Second, they need to be confident in thinking of what is possible, not just knowing what is. We teach this by exposing students to concepts on the edge of scientific discovery. What better place for this than UCSF, where frontiers in science are being pushed back every day? We don’t regularly showcase this exciting science for our students now, because they don’t have to know it to graduate. In the new curriculum, students will come to expect us to share the science on that edge of discovery. We want the science to come alive in the teaching environment for our students.

And third, our pharmacy students must learn in teams with medical, nursing, dental, and physical therapy students, if we expect them to practice in teams, move forward in teams, after they graduate. We have an opportunity here at UCSF to welcome all health professionals to the playing field. But let’s think bigger. I see PhD science students and health professions students working together—experiencing how science translates to care and vice versa. What a fantastic model of team learning all the way around.

Jacobson: I understand you’re also advocating for an increase in hands-on learning. Why is it important for students to be more involved in practice situations, rather than in lecture or classroom settings?

Youmans: A senior faculty member once told me that our curriculum was originally set up with the notion that everything you needed to teach a pharmacist, you could teach in a classroom. But that’s not the case these days. There’s so much information today, no one person can know or memorize everything. So we have to decide the basics our students need to know and give them the skillset to think through a question or problem where they don’t have an immediate by-the-book answer.

What we teach students in the first year—or even in the third year—might be out of date by the time they graduate. New drugs, new diagnostics, new tests are coming on the scene all the time. We have to prepare students to adapt to change and to evaluate information and make clinical judgments.

It comes down to critical thinking and experience. The continual hands-on application of critical thinking makes this habit of mind stick.

Jacobson: Students in the first three years of the PharmD program are now in lectures, seminars, and workshops for much of the week. How exactly will those didactic course hours be reduced to make room for more hands-on learning?

Youmans: There will be hard decisions—what to cut and what to keep. We need to better integrate courses so we can reinforce topics and concepts, and to provide more time for students to dive deeper into the most common medical problems and their management.

Here’s a practical example. Instead of reviewing the pharmacotherapy of 15 or 16 infectious diseases, perhaps we can focus on six or seven of the most common ones. In other words, it’s better to learn the critical thinking process and approach toward the pharmacotherapy of infectious diseases. Once this process is clearly articulated, it can be used toward the management of less common infections.

Part of this transformation is also asking if we have the correct prerequisites. Our students are entering pharmacy school with tremendous educations. Perhaps over time we need to consider a stronger baseline of knowledge shared by all incoming students. We’re even thinking about enabling students to complete their PharmD requirements in fewer calendar years.

Jacobson: The current curriculum includes 300 credit hours of Introductory Pharmacy Practice Experiences (IPPEs) during the first three years. The Pharmacy Bridges Curriculum Project website [now retired] notes that the new curriculum will “build authentic interprofessional education and practice opportunities into the foundation of our curriculum.” What’s the difference? Aren’t the current experiences authentic?

Youmans: In the new curriculum, introductory experiences will be there in ways that we’ve never seen before. A goal is to provide interdisciplinary experiences for students where they’re actually giving back to the health care system, adding value as a corollary to what we do in the real world. A lot of these experiences will synchronize with the concept in the School of Medicine’s new curriculum of what are called “clinical microsystems,” in which medical students work on projects to improve care at different hospitals.

We’ll also have more intentionally planned interprofessional activities, starting in year one. I feel strongly that’s one of the ways we’re going to distinguish ourselves. We’re a pharmacy school associated with three other health professional schools (UCSF Schools of Medicine, Dentistry, and Nursing) plus the Program in Physical Therapy. We’ll be able to do things that other pharmacy schools can’t do, work together like no other university—and we need to capitalize on this.

Jacobson: The UCSF School of Medicine has been undertaking its own curricular transformation under the “Bridges” rubric since mid-2012 and will implement it next year. The School of Pharmacy’s Bridges curriculum site [now retired] notes: “We are building on the foundations laid by our partners in the School of Medicine.” What do you see as a prime example of that?

Youmans: One of the strands of medicine’s developing curriculum is called the Habit of Mind of Inquiry, which means always being in the habit of thinking about how you’re going to answer a question, always being in the habit of thinking critically. We want the student to think, “Okay, we’ve got this problem. I’m looking through this lens—this is my expertise. Who else should I seek out to help me solve this problem?”

And that, to me, is a perfect set-up for interprofessional education and interprofessional teaching across the schools. It’s not solely about content expertise, it’s about teaching students to be comfortable with the unknown, giving them a question to which there’s not one exact answer, and the goal is to figure out how to address the problem behind the question, not necessarily just “getting the answer.”

There’s a lot of work going into developing the cases, developing the objectives. I think that’s one place where we want to link our curriculum schedules. It’s really giving the students the room and space to think out loud, and the faculty is there to guide the conversation.

Jacobson: Introduced into the School’s curriculum in the 1990s, the three pathways—Pharmaceutical Care, Health Services and Policy Research, and Pharmaceutical Sciences—each require a related research project. Will research projects continue to be a part of the curriculum if the pathway system is changed during this transformation?

Youmans: Our first pharmacy graduate in 1874 wrote a research thesis—so it was a condition of graduation even then. Our school is part of a university system that is renowned for its research; thus, research and science will always be a theme in our curriculum. But how we go about it with our students will be different. For example, right now students begin research projects in the spring quarter of their third year, which is late. The research component could be strengthened if we allow students to start their projects earlier.

Jacobson: In response to the increased need for primary care—given that there are more insured patients under the federal Affordable Care Act—a state law (SB 493) that took effect in 2014 expanded the scope of practice for California pharmacists with advanced training, particularly in retail (community) settings. How do you see the new curriculum as better preparing students to practice under the new law’s potentially greater latitude?

Youmans: SB 493 is a tremendous opportunity for us. It opens the door for pharmacists in California—with advanced training—to provide care such as immunizations, smoking cessation counseling and nicotine replacement medications, and hormonal contraception. We already train our students to do those things now—not in a consistent and progressively more challenging way, but we will. Our goal is to ready our graduates to bridge into advanced practice training so they can practice at the top of their licenses, not only as clinicians with primary care roles, but also as critical thinkers who will be leaders in policy, research, business, industry.

Jacobson: So it seems like you see the School’s PharmD graduates going on for additional training?

Youmans: Quite right. In fact, we see the PharmD degree as the first step. We see our students entering the PharmD degree program with the understanding that this will be their base degree that bridges to the training needed for advanced pharmacy practice, or to earn an MBA, a PhD, or an MS in a specific area.

Jacobson: This is quite a shift in expectation?

Youmans: I look at it as a shift up in opportunity for our students.

Jacobson: Broadly speaking, what are the big sorts of structural changes you feel are needed? What do you want to see more of in the curriculum?

Youmans: What’s needed is less time in the classroom and more time actively learning. Less time isolated with pharmacy students and more time working in teams with diverse students from other professional schools and graduate programs. A strong science base in traditional and new domains of science with time for students to explore an area in depth is a must. Also, we want students to experience practice from day one and see the impact of their contributions—not just on the project at hand, but on systems when possible.

We also want a curriculum that’s nimble. So if we decide to make changes, to continually test new courses for example, it won’t take an act of Congress and it won’t destabilize the program. Any changes will be carefully monitored and evaluated by a curriculum committee. Think of the curriculum as a structure—strong steel framework, connected floors, moveable walls.

Jacobson: How will the School go about changing something as big and complex as the PharmD curriculum?

Youmans: We have faculty teams at work now, but the work has to be supported by a transformation of thought. We respect the curriculum we’ve had, because our students do brilliantly in the workplace, but we feel we can do even better. As a state institution, we owe it to the public to do better.

Before talking about courses, we have to decide the competencies our graduates should have and how we’ll go about measuring them. Only then can the faculty get into the conversation about how to teach to these competencies through specific courses. As we progress, the School’s curriculum design teams will collectively suggest a plan for change to the faculty, with input from alumni, students, industry, and other stakeholders. We will continually access our new curriculum and adapt based on the outcomes of our own research.

Jacobson: Final thoughts about educating the 21st century pharmacist?

Youmans: We’re at the beginning stages of construction, so stay tuned for details. As we plan, we’re intent on providing what no other pharmacy school can.

I don’t want prospective students to say, “I want to go to UCSF because it has the number-one ranked PharmD degree program.” I want them saying, “I want to command this expanded scope of pharmacy practice and lead change. I want to step into new roles, to leverage the PharmD to new roles. I want to go to UCSF because what I can learn there I can’t learn anywhere else.”

Image credits: Elisabeth Fall