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I would like to respond to the article written by Lachlan Rose: the FAQs concerning MMRs.
As an accredited pharmacist since 1997, member of the National Advisory Group and Director of Australian Association of Consultant Pharmacists (AACP), I have heard this argument that recent graduates have all the competencies to conduct medication reviews the minute they leave University.
Competency encompasses skills, knowledge and attitudes.
To suggest that undergraduates achieve this, as Lachlan states, in a five hour period over six weeks, confirms the very reasons why there is a mandatory requirement for 2 years experience, before sitting for accreditation to conduct medication management reviews.

The National Advisory Group (NAG) advises the National Director and Board of Directors of AACP.
The NAG consists of a number of academic pharmacists and experienced accredited pharmacists. This requirement has been considered at various stages by the NAG and the recommendation is strongly supported.
Initially the requirement was two year post-registration.
It was reduced in recent years due to pressure to increase the number of accredited pharmacists with the introduction of remuneration of DMMRs.
There are those on NAG who strongly argue for a 5 year experience requirement.

SHPA is also an approved accrediting body, recognised by the Commonwealth Government for RMMRs and DMMRs. Their accreditation process requirements pharmacists to sit for the US Certification in Geriatric Pharmacy. To be eligible to sit for this exam, pharmacists must have at lest 2 years experience.

Look to other professions - they all require experience as a necessary prerequisite for higher qualifications.
You cannot become a QC straight out of University, no matter how well trained and knowledgeable you are.
The medical model also acknowledges this.
Medical practitioners cannot gain specialty status within eight years of graduation, no matter how brilliant they are, or what degree of mentoring and experience they have.
It is about gaining practical experience on real-life patients, who do not comply with the text books.
To establish credibility with the medical profession and sustainability of the service, we must have the respect of GPs.
Unfortunately we all make value judgements based on people's age, amongst other parameters.

One of the main reasons for the two year experience requirement is attainment of clinical judgement. Clinical judgement can only be gained through experience; it cannot be taught. I would also disagree that all the pharmacists at the age of 23 years would have effective communication skills.
Some people never develop these skills.

Lachlan states that the review process is a combination of "data collection (including pathology) and collation, patient interviews, fact finding, referencing, identification of problems and determination of solutions".
This indicates his lack of understanding regarding the depth and breadth of medication reviews.
What about communication and discussion with the prescriber and/or nursing staff?
What about prioritisation of problems and determining the relevance to the individual patient.
One of the main criticisms from GPs about medication reviews is their relevance to the individual patient.
Stating drug interactions and potential adverse drug reactions (ADRs) without relevance to the individual patient is useless to GPs. GPs need to hear something they don't already know or can look up on their computers.
Having a sound knowledge of disease state management is crucial to quality outcomes from medication reviews.
Accredited pharmacists must be able to apply advanced clinical knowledge especially in the area of geriatric pharmacotherapeutics.
They must be able to make sound recommendations to medication management plans based on changes in patient status.

The implied statement that pharmacists lose their clinical skills taught at undergraduate level by practising in community pharmacy is of huge concern.
Does community pharmacy cause such 'dumbing-down' in such a short period?
I don't believe so, but it is concerning that others do.
To say that pharmacists lose their skills in the workforce is an appalling reflection on community pharmacy in Australia.
Do recent graduates not feel empowered to use their knowledge?
Do they feel pressured to do 400 scripts a day without appropriate clinical consideration and counselling?
If so, this demonstrates an immaturity and lack of certain skills, at the heart of this debate.

It should also be recognised that the pass mark at Universities is around 45%.
If you only get 45% when you are dealing with real patients, there will be a lot of poor outcomes.
The black and white of textbooks and case studies is changed to shades of grey in many cases in the real world.
Graduates need some time in the real world before they have the experience and skills to discuss doctor issues related to patient drug management.

In summary, the issues are clear.

Accredited pharmacists require:

- experience with drug usage patterns (what drugs and drug combinations are commonly used, what are the reasons they fail and what are the alternatives
- experience with adverse drug reactions (what did the patient experience, how was it managed and how did the patient respond
- experience with drug interactions (why do patients given drugs with minor rug interactions suffer untoward effects; and the reverse, when is it rationale to use combinations of drugs with well documented clinically significant interactions
- experience interacting with patient concerns about their medications (what to do when a patient is uncertain that they want to take a particular medication, how to avoid undermining the patient's confidence in their doctor
- experience with interacting with doctors (identifying drug related problems - ADRs, drug interactions, compliance and administration issues, QUESTIONABLE therapeutic decisions).

I think what is confused by many is what Schools of Pharmacy are required to do, that is, produce base grade pharmacists, not accredited consultant pharmacists.
In their pre-registration year, many of the graduates will gain little experience with interacting with doctors of their preceptors believe that is the role of the pharmacist.
Most will gain no experience with dealing with nursing home and hostel patients and nursing staff. Reading medication charts and medical records are not common activities of community pharmacists.

In my previous position as a clinical pharmacist in hospitals, I have had many undergraduates for their clinical placements.
I have had the best and brightest as placements.
I have not experienced one undergraduate who has the competencies to be an accredited pharmacist. Sure, they may pass the current accreditation case studies.
But that is only one criteria for accreditation.
Experience gives some indication of clinical judgement and communication skills.
I have also had many pre-registration pharmacists attend my stage 1 accreditation workshops.
They are usually the first with the answers to clinical questions, but perform poorly in the role-playing of case studies, and have little confidence in identifying significant drug-related problems.
As pharmacists, we cannot change the patient's drug regimen.
We therefore need to communicate our concerns to the prescriber in a non-aggressive manner to achieve the quality outcomes we should expect from medication reviews.

The acceptance and sustainability of remuneration for RMMRs and DMMRs is dependent on quality outcomes and positive feedback from prescribers and patients.
Working in community pharmacy or hospital pharmacy, seeing the myriad of disease states and their management is the ideal training for pharmacists.
If they then choose to further develop their skills and knowledge to conduct medication reviews, that is great.
We need more accredited pharmacists.
The decision of AACP to have a requirement of two year experience is not a "seemingly empirical two year delay"; it is based on sound academic and professional rationale.

Debbie Rigby