By Timothy Muckle, PhD, Board of Pharmacy Specialties (BPS), and Samuel Johnson, PharmD, BCPS
Often, when considering expansion opportunities, credentialing bodies are confronted with the question, "Should we create a new certification in this area?" Perhaps it is an especially pertinent question for specialty certifying bodies, as the proliferation of subspecialties poses distinct business opportunities.
On the one hand, creating an additional certification could translate into new revenue streams and professional engagement. On the other, it can also mean a commitment of additional, yet finite, resources to support the program and challenges in scaling existing policies and procedures to a new set of circumstances. Ideally, given the resources — both human and financial — required to build, launch and maintain a certification program, the momentous decision to develop a certification should not be taken lightly. At the very least, it should not rely on the opinions of a limited set of policymakers sitting in an ivory tower or board room, but rather on a comprehensive evaluation of the market forces and environmental scan of the professional landscape, including, and not in any order:
- Potential numbers for engagement
- Benefits that the presence of certification would offer to all relevant stakeholders (e.g., the public, patients, employers, practitioners and the certifying body)
- Risks inherent to the absence of a certification in a particular specialized practice or area of focus — from the perspective of stakeholders and the broader marketplace
The Board of Pharmacy Specialties (BPS), which is recognized as the certifying body for pharmacist specialists by the pharmacy profession, historically used a standard petition process to determine the feasibility of identifying new practice specialties and establishing emerging board certifications. External stakeholders advocating for a new specialty certification would assemble a written petition substantiating the rationale for the specialty recognition, consisting of these six criteria:
- Pertinent patient or public safety issues that would be addressed by specialty certification; rationale describing how the area of specialization fulfills the public's health and welfare, which may not otherwise be fulfilled
- Willingness and ability of stakeholders to employ the services of a practitioner in the specialty area (e.g., trends in the types and numbers of positions available or in demand)
- The number of practitioners/time spent in the practice of the specialty
- The specialized tasks, skills and knowledge of pharmaceutical sciences required for the proposed specialty (i.e., results of a role delineation study)
- Postgraduate training programs and experience required to acquire the specialized knowledge and skills
- Routes for knowledge transmission in the specialty, including journals, periodicals, bibliographies or other literature, demonstrating the proposed specialty's value
In recent years, BPS has received several requests to consider a new specialty certification for pharmacists providing pain management (PM) services. There has been much debate on this topic and pressure from external stakeholders to create the specialty certification in pain management pharmacy. However, rather than yielding to said demands, BPS decided to be deliberate and incorporate an evidence-based approach to decision-making.
BPS also contemplated a formal role delineation study (RDS) to help ascertain and validate the PM pharmacists' body of specialized knowledge. As completion of an RDS has typically fed into the petitioning procedure, BPS harbored concerns that the pharmacy profession could interpret an RDS's conduct as a signal that a new specialty certification was an imminent and foregone conclusion.
Consequently, BPS’s discussion pivoted to a perceived middle ground. Conducting a pain management practice analysis involving a combination of qualitative methodologies offered a reasonable answer to the question, "Is a new certification justifiable in this specialty?" BPS then sought to ascertain whether distillation of a distinct body of knowledge for pain management practice was practical and attainable. This piece intends to elucidate the background — and drivers — for BPS's journey through this novel approach, using a formal qualitative practice analysis to develop a conceptual framework for subsequent validation using quantitative methods (i.e., RDS). It should be noted here that while the terms RDS, practice analysis and job analysis are used interchangeably in the credentialing industry, for pharmacists the term practice analysis was deemed more suitable as an intervening step because of the nuance in messaging to the pharmacy profession.
The pain practice analysis consisted of the following components and associated findings:
Overview of Existing Postgraduate Training Programs
- Like other health professions, the pharmacy profession recognizes postgraduate residency training programs for doctor of pharmacy (i.e., PharmD) graduates who intend to develop clinical skills and specialize in practice. The American Society of Health-System Pharmacists accredits Postgraduate Year 2 specialty residencies in pain management and palliative care. In 2019, 25 accredited programs were producing roughly 30 graduates annually.
- In addition to residencies, we identified other pharmacist credentials (e.g., certifications, certificate training programs, fellowships and continuing education) focused on pain management.
National and State Regulations for Pain Management and Opioid Stewardship
- We noted significant legislative activity involving pain management or opioid stewardship (i.e., 435 new laws in the U.S. in 2019 alone). These generally fell into five broad categories: prescriber requirements, pharmacist requirements, pharmacy requirements, payer requirements and pharmaceutical manufacturer requirements.
Review of Primary Literature for Published Outcomes Associated With Specialized Pain Management Practices
- We conducted a search for primary literature focused on the role(s) of pharmacists in pain management and palliative care, pain management strategies (including the use of opioids and other palliative therapies for cancer and non-malignant pain), as well as clinical practice guidelines.
Structured Interviews With Key Informants (i.e., Vetted Subject Matter Experts in Pain Management)
- These interviews provided detailed insights and perspectives into pharmacist practice and roles in pain management. We met with roughly a dozen content experts and recorded their responses to pre-determined interview questions. We then transcribed the interview recordings to conduct a theme analysis (i.e., qualitative analysis) of each response. Once complete, we evaluated all responses to elucidate common themes from all informants.
Pain Management Position Descriptions
- We reached out to one of the pharmacist specialty societies to request job descriptions for pharmacists in pain management and palliative care. Like our theme analysis of key informant interview responses, we distilled common elements from the pooled job descriptions to describe pharmacist roles in pain management.
Pain Management Certifications or Credentials in Other Professions
- We focused on established credentials for other health professionals, including physicians, nurses, nurse anesthetists and physician assistants. The majority of these were certifications concentrating on pain management applications in different practices (e.g., emergency medicine, physical medicine and rehabilitation, psychiatry and neurology, and family medicine); however, we also found one certification in patient pain education.
Pain Management Content in Existing BPS Certification Examinations
- Because pain management content overlaps with some of our established specialty certifications, we analyzed our item banks' examination content to assess how pain management concepts are currently covered.
Overall, this alternative approach to developing consensus for a new specialty certification was useful for fostering comprehensive discussions about pharmacists' opportunities to specialize in pain management practice. While this process required additional staff time and effort investments, the perceived return on these investments was excellent based on feedback from key informants and BPS board members. At the time of writing, BPS convened a formal RDS in PM, which is underway and anticipated to conclude in late 2021.