Substantial progress has occurred in psychiatric pharmacy education since Fred Elmadjain, in his role as a pharmacist/psychopharmacologist at NIMH, advocated for colleges of pharmacy to get interested in mental health during the 1960s and when Glen Stimmel created his own psychiatric pharmacy rotation at UCSF in 1971.1 Psychiatric pharmacy has grown as a specialty to include 758 board certified psychiatric pharmacists and nearly 40 psychiatric pharmacy residency programs. Yet, much is left to be accomplished. We do not have the necessary critical mass of psychiatric pharmacists to transform pharmacotherapy care for mentally ill individuals, and we must graduate primary care pharmacists who are competent to address mentally ill patients' basic direct pharmacy care needs. In his 2007 survey, Cates et al. estimated that over 75% of pharmacy schools have at least one faculty member identified as being a psychiatric pharmacist.2 However, fewer than one-half of these faculty met the criteria to be called a psychiatric pharmacy specialist. Although all reporting schools had curricular content addressing treatment of psychiatric disorders, significant variance existed in the contact hours for teaching, with some critical and common disorders such as post-traumatic stress disorder only being taught in 57% of reporting pharmacy schools. Time spent in case based problem solving of psychiatric disorders was scant as compared with traditional lectures.

Nationally, higher education is in a state of transformation from an era of students being passive recipients of knowledge toward student directed, problem oriented learning. Classrooms are being flipped, and students are working in teams to solve problems.3 Health professions educational institutions are grappling with how to best incorporate interprofessional education into their curricula. The World Health Organization defines interprofessional education as “When students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.”4 It is believed that when students and trainees from different professions learn and train together that they are more likely to work as interprofessional teams once they enter practice. Mental health has a history of being interprofessional, but if psychiatric pharmacists are going to be accepted into advanced practice roles, it is important that health professionals work with psychiatric pharmacists and student pharmacists in these roles when they are students and trainees. Therefore, we need psychiatric pharmacists involved in the education of all future physicians, nurses, and other mental health professionals, and we need all student pharmacists training with students from these other professions.

When addressing the question, “What is our vision for psychiatric pharmacy education and training in a transformed educational environment of 2023?”, we should not just speak in terms of the core knowledge that student pharmacists should possess, but rather in regard to the behavioral competencies that pharmacy graduates must have in order to provide patient care and solve medication related problems for patients with mental disorders. In a transformed healthcare environment, “the entry level pharmacy practice core will be the ability to screen, assess and manage patients' core chronic disease.”5 If new graduate pharmacists are expected to perform these services, then student pharmacists must demonstrate their ability to perform these functions as a requirement for graduation. While entry level pharmacists should be able to perform medication therapy management (MTM) for patients, the provision of collaborative, comprehensive drug therapy management services in complicated patients requires the demonstration of advanced qualifications. For example, a new PharmD graduate should be able to provide MTM to a newly diagnosed patient with major depressive disorder (MDD). This would include using brief rating scales to evaluate improvement in depressive symptoms, monitor for potential adverse reactions, perform evidence based interventions such as motivational interviewing to enhance adherence, recommend dosage adjustments if needed, and assure an effective course of treatment for the MDD. Providing comprehensive medication management, in a collaborative team based environment, for patients with complicated mental disorders, often with co-occurring chronic general medical disorders, requires a pharmacist with added qualifications, and this is most effectively achieved through completion of a psychiatric pharmacy residency and with demonstrated knowledge competency through the board certification process.

What should psychiatric pharmacy residency program directors expect of new pharmacy graduates? It is critical that new graduate pharmacists have the ‘practice ready' skills necessary to maximize their development of clinical skills during their PGY 1 and PGY 2 residency years. This means that not only must they possess the necessary knowledge about disease states and their pharmacotherapy, they must be able to demonstrate they are competent to perform the entry level pharmacy practice core as defined above. This requires that pharmacy schools change their focus from what student pharmacists know to what student pharmacists can do. We must evaluate our student pharmacists on their ability to utilize their knowledge to solve patient care problems, and not just their knowledge of the basic and clinical sciences based upon performance on pen and paper examinations. This requires high quality practice sites for student pharmacists' clinical rotations where pharmacists are performing direct patient care services. Student pharmacists must perform these services under supervision, and they must demonstrate competency in the basic practice core as a requirement for graduation.

It is highly likely that we will continue to live in a dynamic and changing health care environment for a number of years. This will require pharmacists who are adaptable and willing to change as health care systems continue to evolve. We must instill resiliency skills and adaptability in our student pharmacists, and prepare them to lead change in healthcare and not be a passive bystander to the change process. Pharmacy graduates also need to be advocates – not only to promote and advance the pharmacy profession, but to advocate for quality healthcare, to advocate for patients, and to improve public health.

In order to effectively function, lead, and advocate within healthcare systems, pharmacists must have excellent communication skills. Not only must they be able to communicate with patients, families, and other health professionals on a one-to-one basis, they must be able to communicate in both small and large groups. They must be able to communicate with patients and the public in understandable lay language. They must have proficient written communication skills – not only with regard to business letters, evaluations of the pharmacotherapy literature, and patient health record documentation of care, they must also be competent in communicating with patients, other health providers, and the public utilizing the various forms of social media that are available now and in the future.

An increased emphasis on patient adherence is necessary to improve pharmacotherapy outcomes, particularly in patients with chronic disease states. This requires that pharmacists be competent in providing those interventions, such as motivational interviewing, that have been demonstrated to produce a behavioral change in people. Before graduation, all student pharmacists must be able to demonstrate competency in performing motivational interviewing or another evidence based intervention that will improve patient adherence to pharmacotherapy and other treatments such as life style management.

Blindly promoting adherence is not a positive intervention. If a patient is receiving a suboptimal dose of a medication or is receiving the incorrect medication regimen, then promoting adherence will be an inappropriate and non-effective action. Graduating student pharmacists must be able to evaluate patients' clinical status, identify potential problems, and make recommendations for changes to improve clinical outcomes. Inherent to this entire care process is that pharmacists must assume the accountability for patients' pharmacotherapy outcomes.

Many new pharmacy graduates can now competently perform the entry level core skills defined above. However, one challenge that troubles me as well as many academic pharmacists and pharmacist employers with whom I interact is the perceived variance in competency that exists among graduating pharmacists. This variance exists among the graduates of the 109 pharmacy schools with full accreditation status from the Accreditation Council for Pharmacy Education (ACPE). In addition, excessive variance exists in the competency among the graduates from any particular pharmacy school. By the National Association of Boards of Pharmacy's (NABP) own admission, their role is not to advance the competencies required for pharmacy practice. If this is not NABP's role, then other entities must assume this role. ACPE in its role as the accreditor of all pharmacy programs in the United States could address this. If ACPE modified its accreditation approach from focusing on the process by which pharmacy schools educate student pharmacists to assuring that pharmacy schools produce graduates that meet the minimum competencies needed to practice in an ever changing healthcare environment, this might decrease the variance in competency among new pharmacy graduates. The American Association of Colleges (AACP) could be an instrumental organization in advocating that we advance the minimum behavioral practice competencies required of all U.S. pharmacy school graduates. Similarly, all pharmacy professional organizations who advocate for advancing the pharmacist's role in patient care should be mandating that pharmacy schools enhance the behavioral competencies of their graduates. In reality, this is an essential obligation of the entire pharmacy profession – to advocate for and demand that we increase the minimum behavioral competencies and decrease the variance in competence among the graduates from our nation's pharmacy schools.

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