On rounds with student pharmacists and residents from the University of North Carolina’s family medicine residency program, Peter Koval, PharmD, CPP, BCPS, saw a patient he’d known since he started at Moses Cone Memorial Hospital in Greensboro, NC. The 84-year-old woman had been hospitalized with cellulitis.
As Koval explained to the patient how to take her antibiotics, she told him, “I wouldn’t even be alive today if I hadn’t quit smoking.” She hadn’t forgotten that it was Koval who had helped her kick the habit 16 years earlier during his first month as a faculty member in the residency program.
Koval hasn’t forgotten either. “A physician grabbed me by the shirt collar and said, ‘You need to come with me. I need you to help this lady quit.’ I was literally dragged into the room. She was having severe lung issues, and over the course of the next several weeks, she was able to quit smoking,” he told Pharmacy Today.
Koval with Clinical Pharmacist Practitioner–sponsoring physician William Hensel, MD (right)
Long-term patient–provider relationships like this one are at the heart of ambulatory care pharmacy, the outpatient-based specialty Koval has helped establish at Moses Cone.
Koval chaired the first Board of Pharmacy Specialties (BPS) Specialty Council on Ambulatory Care in 2011, which counts among its duties the writing of the board certification exam. The first exam was administered last October.
While ambulatory care is BPS’s newest specialty, Koval has practiced in this area for most of his career as a teaching pharmacist. In addition to teaching and precepting students and residents across the allied health professions, Koval treats patients with complicated chronic conditions, with a special focus on tobacco cessation, in the family medicine clinic, the hospital, and the nursing home.
Since his initial exposure to outpatient family medicine during his first year of pharmacy school, Koval knew he wanted to practice in that setting. Some 15 years later, the exam he helped write may become the distinguishing credential for future pharmacists who hope to practice in a variety of outpatient settings.
“Ambulatory care is [Department of Veterans Affairs] pharmacists. It’s pharmacists working in clinics like mine. And there’s no reason that people practicing at the corner drugstore couldn’t be very well suited to take this exam,” Koval said. “I think the am-care exam reflects what might be the majority of pharmacists practicing in the country. This exam is for the most common type of practice setting—which isn’t to say that there’s just one.”
Koval with recently board-certified ambulatory care pharmacist Dawn Pettus, PharmD, BCACP (right)
Board certified in pharmacotherapy, Koval and the other founding council members cannot sit for the ambulatory care exam until 2 years after leaving the specialty council, which, for Koval, is still several years away.
But Koval has plenty to keep him busy in the meantime.
A typical week might find him in a different place every day. He’s in the classroom with pharmacy, medical, and psychology students some days. Others, he’s in the clinic with patients referred for tobacco cessation or complicated chronic conditions, such as diabetes and chronic obstructive pulmonary disorder. Still other days, there are rounds with students and residents at the hospital and rounds at the nursing home.
Both as an educator and a health care provider, Koval’s style is to motivate and empower students and patients alike to achieve their goals.
Sometimes that means teaching students to teach themselves. Each month a different student is appointed to teach the other students about the latest pharmacy news. A whiteboard in Koval’s office teems with headlines that the appointed student posts about product approvals and other drug therapy news.
Koval engages in a group case discussion session with (from left) Jesse Mack, PharmD candidate; Kristina Sucic, PharmD resident; and Kate Smith, PharmD candidate.
Other times, Koval is empowering patients to be in the driver’s seat of their own treatment. “In ambulatory, chronic care, motivating patients to take ownership of their own health is a significant portion of everything we do. In patient-centered medicine, the patient decides what their goals of care are. We have goals we’d like the patient to meet, but if the patient’s not bought into those goals, we won’t get there.”
Not getting there happens more often than not when tobacco cessation is the focus of your practice. The success rate 6 months after intervention is typically 20%, Koval says.
“In ambulatory care, you won’t be able to save everyone from themselves,” he says.
In an environment where it’s all too easy to focus on failure, Koval’s primary focus is progress. “I’m always looking for progress. Even if you don’t quit, can you cut down, can we try again?”
What Koval does is more diverse than the norm in pharmacy and the rest of health care. “Not that many people spend time in all these environments —nursing home, hospital, and clinic. You either work in the hospital or you don’t. Some people’s work bridges that gap, and I’d like to think I’m one of them,” Koval says.
This unique job description led the American College of Clinical Pharmacy (ACCP) to identify Koval as a subject matter expert in ambulatory care—an early step in establishing a specialty—which ultimately led to his appointment as council chair.
Before there are board-certified specialists in an area, subject matter experts are used in every step of the process of establishing a specialty and writing the exam. Part of a subject matter expert’s role is to help determine what’s unique about the proposed specialty.
While pharmacotherapy requires an expertise in inpatient drug therapies, such as injectable drugs and acute care, ambulatory care requires proficiency in patient advocacy and practice management.
Koval reviews a patient care quality issue with Steven Newton, MD, family medicine resident.
For Koval, the opportunity for long-term relationships with patients throughout the lifespan sets ambulatory care apart from other specialties.
“What might draw one to am care is the contact over time, throughout the continuum of the patient’s lifespan. It’s the entire spectrum of age and diseases. It’s not just grandma, but the whole family,” Koval explained. “That’s part of the value: I know the whole family. You hear people say, ‘I’ve always gone to this pharmacist, and this pharmacist has always been my family’s pharmacist.’ That’s the ambulatory care potential.”
That’s not the only potential for ambulatory care.
Ambulatory care stands to be the second most common BPS specialty by its third or fourth year in existence, Koval says. While pharmacotherapy exams are now taken by 3,500 pharmacists per year, it took the specialty 6 years to certify its first 1,000. Ambulatory care will likely surpass that number this year after the results of the October 6 examination become available.
In all, 661 pharmacists sat for the first am-care exam last year; 518 passed. This year, 672 people registered for this exam.
This is a crucial time for such a specialty, Koval notes, as payers are pressuring health systems to keep patients out of the hospital.
“Hospital pharmacists are the safety net to save the patient, but the role of pharmacists in trying to keep patients out of the hospitals is becoming ever more valuable,” Koval says. He believes board certification in ambulatory care will show health systems that a pharmacist has the skills to keep patients out of hospitals.
The Triad Healthcare Network is already putting the value of this certification to work. Its recently hired accountable care organization pharmacist Dawn Pettus, PharmD, BCACP, was the only pharmacist in the region who passed the am-care exam last year.
“Now she’s the right person for the job and had the credentials with or without the exam,” Koval said. “There may be people at that same level who are not board certified, but if I can get a board-certified one, I want them.”
Before a practice area becomes a specialty, practitioners of that discipline may request that the Board of Pharmacy Specialties (BPS) research its validity as a specialty, or BPS may recognize the discipline’s potential to be a specialty and initiate the research.
“[Postgraduate year 2] training programs are specialized residencies, so that’s one place we find emerging specialties,” said William Ellis, BSPharm, MS, Executive Director of BPS.
Next, BPS conducts a role delineation study. This brings together subject matter experts who attempt to define the job description of a potential specialist in the area, the domains in which the specialist must be proficient, and the time a specialist spends working in each of these domains.
Ambulatory care’s practice domains include direct patient care; practice management; public health; retrieval, generation, interpretation, and dissemination of knowledge; and patient advocacy.
If the role delineation study finds that practitioners in this area indeed possess a unique body of specialized knowledge distinct from the knowledge of other specialists, BPS will call for petitions.
“We require outside groups to petition for a specialty,” Ellis told Pharmacy Today. “We won’t ever say that something should be a specialty. You must petition us.”
A successful petition must be signed by a minimum of 25 people practicing in the proposed area and demonstrate the following:
Once a petition is approved by the BPS Board of Directors, six subject matter experts and three pharmacists from outside the area form the first specialty council. The council undertakes the process of writing the exam. After the first exam is administered, future councils include six members certified in that specialty.
“Certification organizations such as BPS [Board of Pharmacy Specialties] rely on the use of psychometrics to help ensure that all BPS exams are both valid and reliable,” said William Ellis, BSPharm, Executive Director of BPS.
Psychometrics is the science behind valid test creation. A psychometrically valid exam is a reliable, valid, and objective measure of someone’s knowledge in the area. Questions are written and a passing point is set so that all who possess the expertise will pass, and no one without the expertise would pass.
“This standardizes our practice, so that people know what they’re getting when they hire a board-certified specialist,” said Peter Koval, PharmD, CPP, BCPS, and founding chair of BPS’s Specialty Council on Ambulatory Care.
On a psychometrically valid exam, all answer choices must be feasible options to eliminate the possibility of a lucky guess.
“If three answers are numbers, and one is a color, you don’t have to be an expert to figure out that one doesn’t belong, which weakens the rigor of the assessment,” Ellis said. “We try to eliminate the possibility for application of standardized test–taking strategies.
Subject matter experts write the first version of an exam. Board-certified specialists in the area write all subsequent versions. “The most important step that helps ensure psychometric validity is that we use subject matter experts in the field at all steps of exam development,” Ellis said.
BPS solicits questions from outside experts, and then brings in additional experts to ensure the questions are based on the most current treatment guidelines and that they represent issues seen in clinical practice. “So most of our exam questions will go through three to six revisions before they are put in our item bank of possible questions,” Ellis told Pharmacy Today.
After 500 people have sat for an exam, it’s eligible for accreditation by the National Commission for Certifying Agencies. With the exception of the ambulatory care exam, all BPS certification exams are NCCA accredited. The ambulatory care exam, which was administered for the first time in October 2011, will begin the accreditation process after it is administered this October.
“I view the fact that BPS certifications are NCCA accredited as a mark of achievement because we have attained a level of excellence in our processes as determined by a group of our peers in the testing industry,” Ellis said.
The tests are challenging, Ellis said, “but they are fair exams to test the level of knowledge that a specialist has to have.”