Time to Dump the Dumping Ground

In the latest edition of Pharmacy Grit, there was an opinion piece trying to make the case for Surgery to be recognised by the Board of Pharmacy Specialties. There was something about this article that really irked me. I wasn’t sure why it annoyed me so much, but I knew it had something to do with this closing section…

Not a dumping ground for just any pharmacist
Surgical wards have traditionally been grouped as ‘miscellaneous’ wards that can be covered by a pharmacist of any skill level. But will you ever ask an ENT surgeon to remove your appendix? How about a urologist to fix your broken elbow? Most hospital pharmacy departments still expect any ward pharmacist to be able to provide pharmacy services to any surgical ward….

… The Board of Pharmacy Specialties (BPS) from the United States offers credentialing qualifications for a dozen specialty practices, each of which acknowledge qualified pharmacists who are able to practice pharmacy at advanced practice levels. None of these 12 qualifications cover any surgical specialty.

Are the options really that dichotomous? You either are a specialty or a “dumping ground” for “a pharmacist of any skill level”? This concerns me.

I think part of the problem is that whenever the conversation of specialisation comes up, its almost inevitable that two concepts get conflated; credentialing and mastery.

Recognition as a specialty by the BPS is a method of credentialing; a way to provide public confidence that those individuals bearing that credential meet a minimum standard of skills and knowledge relevant to that area. Credentialing is very important within healthcare…provided there is a public interest case for it.

Looking at the BPS credentials, there seem to be three broad categories of specialties. Others may categorise them differently, but generally speaking there are:

  • those that align with general principles of pharmacy practice that could be applied in many different clinical contexts – e.g. geriatrics, paediatrics, pharmacotherapy, nutrition support, ambulatory care
  • those that address clinical concerns that are most prevalent in society, have a high impact on public health and in which pharmacotherapy is a primary treatment modality – e.g. cardiology, psychiatric, infectious diseases
  • those that require very specific skills/knowledge that are carry a high risk to the public – e.g. oncology, compound sterile preparations, critical care, nuclear pharmacy, solid organ transplant

For sure, I think there is a case to be made that other specialties belong on this list. Women’s health is one that comes to mind. Drugs in pregnancy and lactation both applies across different contexts and requires specific skills that carry high risk. Pain is another one that I immediately think of. But I’m not convinced surgery belongs on this list of credentialed specialties.

That’s not to say that surgery should be considered a ‘dumping ground’ for ‘a pharmacist of any skill level’. Nor am I saying that if someone finds they have an interest in surgery and want to carve out a niche for themselves in that area that they should be discouraged from doing so. I think they should be encouraged to pursue their interest enthusiastically and lead from the front. This is where the mastery bit comes in.

I don’t subscribe to the idea that you achieve mastery by obtaining a credential. If that were the case, I could claim to be a master at geriatric pharmacy, because I passed the Geriatric Pharmacy specialty exam in 2013. (I can tell you right now, that would be a false claim). Obtaining credentials is an important part of your journey toward mastery, for sure. They can help provide direction as you work to master your craft, and highlight blind spots. Credentials can give you validation that you do know what you’re talking about, and help keep imposter syndrome at bay. But very few credentials can be relied upon to signify true mastery, because most of them are by definition describing what is considered the standard, not excellent. That is, after all, the whole point.

I subscribe to the philosophy that mastery is a continued pursuit of learning and achievement; both of your craft and of your self. This isn’t about getting to a defined destination. It isn’t about choosing an area to specialise in and progressively working toward it (although it can be). It’s about continually striving to practise to your full scope, regardless of context. If you do this, your scope will increase and evolve over time, as you yourself grow as an individual.

So let me get real specific, using surgery as an example because that’s what the article was about. I’m going to be extreme in my examples to make a point. Please don’t take this as me suggesting that all pharmacists fall neatly under these categories (I’m not).

Consider three early career pharmacists, each starting out on a three month rotation covering a surgical ward. One wants to become an oncology pharmacist, one wants to become a surgical pharmacist, and the other is happy to be employed and go with the flow.

The wannabe oncology pharmacist sees the rotation through. They see to their daily tasks, medication reconciliation, organise discharge medicines and respond to queries from the ward. They do a perfectly adequate job. After enduring a few more rotations in other areas they eventually get their position to train to be an oncology pharmacist.

The wannabe surgical pharmacist is a superstar. They seek out opportunities to learn as much about surgery as they can during the rotation. They read up about every detail of every case. They ask questions of the nurses. They ask to be involved in pre-admission clinic. They talk to the patients about their experiences to develop their empathy and understanding. They do an amazing job. After enduring a few more rotations in other areas they are eventually able to get back to surgery and build a practice in that area.

The happy go lucky pharmacist embraces the opportunity. They follow their curiosity. They learn new things by reading up on cases, asking questions of the nurses, and being generally inquisitive. They talk with patients about their experiences and as they do, their empathy and understanding grows. They hear about the pre-admission clinic and ask to see what it’s about. They move to their next rotation where they learn more new things. They bring with them the things they learned from their surgery rotation, and develop those skills and areas of knowledge even further. They continue to learn and grow in whatever context they are in, and so too does their scope of practice.

I believe that achieving higher standards of quality pharmacy practice in surgery (or any area) relies upon attitude more than recognition as a credentialed specialty. In fact, I think that the use of the term ‘specialty’ can get in the way of driving the quality agenda. Because the way that ‘specialty’ is used often carries with it an implication that specialists are by default advanced. Whether it’s intended or not, this infers that generalists are less advanced, which undervalues their role. How do we expect to get the most out of the workforce if they don’t feel valued? This sort of conversation reinforces a dumping ground mentality, it doesn’t remove it.

I think we need to change the conversation from specialty to mastery. Start talking about attitude, not outcome. Start setting the expectation that pharmacists will employ a growth mindset, practice to their full scope and pursue personal mastery. Recognise that personal mastery begins with mastering the craft of pharmacy practice. If our primary purpose is to deliver quality care, you work to deliver that care because you’re a professional. It doesn’t matter what the context is or if you’re going to get a certificate at the end of it. Credentials are a part of the journey toward mastery, not the destination.

If you’re lucky enough to know what you want to be when you ‘grow up’, then I’m happy for you. Pursue it with gusto. We need you. But make sure you’re not so focused on your destination that you miss the learning and growth opportunities along the way, whether they fit within your ideal path or not. Make sure you have the skills to survive if an obstacle gets in the way, or circumstances change and disrupt things. And if you do get to where you wanted to be, don’t stop.

But if you don’t know where you are headed, that’s ok. Don’t use that as an excuse to under perform though. Don’t give credit to the idea that your value is determined by the position you hold, because that’s bullshit. Whether you’re an early career pharmacist, a part-timer or someone who simply enjoys variety…your value is in your contribution, not your job title. That is within your control.

No area of pharmacy practice is a ‘dumping ground’. Not the surgical ward, not the dispensary, not medicines information, not manufacturing, not aged care, not community pharmacy…you get the idea. If you want to specialise, specialise. If you want to get one credential or many, go do it. No one career path is superior, nor any setting of practice. All are essential to achieving quality use of medicines. Let’s embrace our diversity, pursue mastery and get rid of the ‘dumping ground’ completely.


Same data, different view

I thought about sharing this post on our Traversity blog, but I’m not quite sure it’s appropropriate. I’m still learning how to navigate this whole business communications thing, and I have a feeling I need to err on the side of conservative a bit more than I would like. So I shall share it here instead.

I’ve been taking my start up obsession deeper lately and have been re-watching Silicon Valley. The final episode of season one is particularly hilarious (albeit crude) scene, even when watching the second time around.

I will try and remain professional so won’t go into the details of what they’re talking about (you can watch it here if you don’t get offended easily), but the crux of it is that they’re a small team looking at a tech problem that heaps of smart people have tried to address before, all of whom have reached a similar outcome. Their team made what appeared to be a major breakthrough recently which they thought would put them at an advantage, only to be matched by a much larger competitor. They find themselves in the position where they need to do something better, or fold.

In their moment of despair and feeling downtrodden, they turn to rude insults and banter to lighten the mood. And they go deep with the insults…using a whiteboard to map out a whole schematic with equations and everything (which are apparently mathematically sound).

As Richard, the Founder and lead developer sits absorbing the conversation around him he has a mental breakthrough. A breakthrough enabled through the structural analogy. Everyone’s been approaching the issue from the same angle – unidirectionally. What if they approached it from the middle-out – bidirectionally – instead?

This results in a mega breakthrough which catapults their technology ahead of their dominant competitor and everyone else, and they’re back in the game, at least for a few more episodes.

As inappropriate as this analogy may be, I use it because it relates to my own experience recently with my understanding of integrated care.

Integrated care is one of the major concepts that underpins health policy initiatives of many nations trying to deal with the growing demand for health services relating to an ageing population and increased prevalence of chronic conditions. When my PhD supervisor suggested that I look into the concept of integrated care I did so more out of compliance than desire. I begrudgingly worked my way through the literature, a lot of which was very wordy and confusing. It felt to me like the kind of concept that was built for policy, not practice. The interventions reported in the literature looked great on paper, but how could you possibly deliver them at scale across an entire country? It’d be like running tests based on a Rolls Royce but using Toyota Corollas for the roll out…it wouldn’t exactly provide the same user experience.

If you approach integrated care only from the top down (i.e. through policy and infrastructure etc), it doesn’t go very far. There’ll be the practices that get paid for the pilot, then a few other early adopter/innovators, but there’ll probably come a point where a local maximum is reached and it’s hard to get broad scale adoption. This is great for the pockets where the innovation happens, sure. But there’s a risk it will end up broadening the divide between the exemplary care providers (who were probably pretty good at quality improvement anyway) and those who are satisfied with sticking to the status quo. Not exactly equitable healthcare.

If you approach integrated care only from the bottom up (i.e. through practice based initiatives), it doesn’t go very far either. Say there’s a group of motivated care providers who can see a way of delivering care differently and they get themselves a grant to run a practice improvement project. This sort of practice based research is really valuable, and chances are it will produce a positive outcome for the patients that they serve. But how do you get that innovation to spread beyond that particular practice? How do they continue to deliver that standard of service once the funding runs out, as it so often does? Implementing innovation without the support needed to deliver it (remunerations, infrastructure, policy etc) runs the risk of ending up with a bunch of highly skilled but burnt out care providers, who may one day grow tired of martyring themselves and disengage completely.

For integrated care to work, it has to come from both directions. This message is throughout the integrated care literature, it’s nothing new. It just took Silicon Valley scene for me to see the practical implications of it.

Australian governments and decision makers are doing a lot of work to develop the policy framework and remuneration models to support the development of new ways of working required to deliver more integrated care. That’s great, we need this. But we also need more. We need a way of moving the concept of integrated care beyond policy speak, and into something that is meaningful to those who will have to do the work to make it happen.

I’m not talking about accreditation standards and other mechanisms of fear and control. You can’t just create a policy with accompanying standard, it won’t work. You can’t just ‘do’ integrated care.

Integrated care not only requires individuals to engage in new ways of working, it requires people to work together in new ways. This isn’t just hard work, it’s bloody hard work. I’m not just talking about clinicians here by the way. Administrative staff, practice managers, technologists…there are many types of people who are integral to delivering these types of complex interventions.

We need to create an environment that fosters connection between the policy and decision-makers and those who are doing the work to make change a reality. An environment built upon mutual respect. One that motivates individuals to participate in integrated care initiatives by providing them with greater fulfilment in their work. Supports them by providing what they need to get the work done. Encourages them to develop their professional autonomy, mastery and purpose.

That’s what Traversity is here for, to provide a venue for this to happen. It’s up to all of us to take action and make good things happen, so we might as well get started. Please join us.