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The Pharmacy Paradigm Shift: Thoughts 3 Years Later - #THELAB

Updated: Feb 17

Pharmacy has been undergoing a paradigm shift, and it is changing for the better — Here’s why


Throughout my time as a student pharmacist and transitioning into a PGY1 Pharmacy Resident, I felt like there was always a “white elephant” in the room. You’d hear small chat, but it never seemed like it was openly discussed. Less community-setting opportunities as big corporations consolidate services, low-ball hourly rate offers, and lowering of pharmacy school candidate standards.


I wrote an article for the Nevada Society of Health-System Pharmacists (NVSHP) in 2020 to share my thoughts on the profession at the time. I have copy and pasted the article below: CLICK HERE FOR FULL PDF

The pharmacy profession has continued to receive a negative outlook from the opening of new schools, job saturation, and automation. It is no secret, especially to new graduates, that positions within community pharmacies are declining due to mail order and online pharmacies. These services require fewer pharmacists, who can also work remotely for multiple locations. The U.S. Bureau of Labor Statistics’ projects that there will be little to no change in the amount of pharmacist jobs from 2018 to 2028.

The projection is “little to no change”, but this statement heavily depreciates the pharmacy profession undergoing a dramatic shift toward pharmacists outside of the community setting, such as institutional or ambulatory care practices.

The American Society of Health-System Pharmacists provided insight after releasing their 2020 Phase I results on how the profession is adapting towards this change, “Over the last five years, PGY1 residency positions have grown by 27% and PGY2 positions by 56%. Specifically, PGY2 programs in ambulatory care residencies grew by 85%, infectious disease residencies by 66%, and critical care residencies by 34%. Expansive growth also occurred in emergency medicine residencies, which grew by 141%, and in pain management and palliative care residencies, which increased by 145%”. These statistics show the increasing demand for advanced training post-graduation to fulfill the role pharmacists have taken as a part of the multidisciplinary team. Furthermore, the growth in residency positions does not include the surge of opportunities through fellowships and industry for pharmacists. It appears that the pharmacy profession’s new norm will eventually require post-graduate training.

Despite the ominous projections, there is plenty of hope for the future of pharmacy. We are experiencing an unprecedented change within our profession that requires time to unfold. As residency programs and fellowships continue to grow, so should our investment in the upcoming generation of pharmacists through education and mentorship. Schools need to provide student pharmacists with the resources to explore different pharmacy specialties outside of the community setting.

There will always be a need for community pharmacists; it may just look different than what we’re used to seeing in the near future. It would be a disservice to student pharmacists to not consider the expansive field of pharmacy. Additionally, there should be an emphasis on organizational involvement, as this may provide further exposure to various practices and professional development opportunities outside of the didactic classroom.


How much you can grow as an individual over three years…

It has been three years since I wrote that article. Much has changed since then, especially with the COVID-19 pandemic. As I continued onward with my training in emergency medicine, the thought of where our profession stood became an afterthought. High acuity patients, volume. I simply developed tunnel-vision on patient-care, and forgot about the other aspects of pharmacy that were important to me.

In my opinion, the pharmacy paradigm shift seems to have a more optimistic outlook. Let’s revisit some numbers and what has happened since I wrote this article.

U.S. Bureau of Labor Statistics and their projections for pharmacists

  • 2020: The U.S. Bureau of Labor Statistics’ projects that there will be little to no change in the amount of pharmacist jobs from 2018 to 2028.

  • 2023: The U.S Bureau of Labor Statistics’ projects a 2% increase in job opportunities (slower than average for all occupations). Additionally, they report an estimated employment change of 7,700 from 2021–2031.

Since I last looked at these statistics, a 2% increase in job opportunities sounds pretty abysmal. Better than “little to no change”. The number lacks some context: the need for pharmacists in the community setting as indicated by the COVID19 response, the growing number of jobs outside of retail pharmacy, and the declining student enrollment across all pharmacy schools.

My assumption is that the small % change in job opportunities implies that we’re still in that transition phase of finding less community jobs, while more inpatient, ambulatory, and/or industry/fellowship positions are being developed.

2019 ASHP Midyear Regional Meeting | Las Vegas, NV

As long as ASHP Phase I Match Report continues emphasizing continued growth in new programs, I think we’re in a good place

  • 2020: “Over the last five years, PGY1 residency positions have grown by 27% and PGY2 positions by 56%. Specifically, PGY2 programs in ambulatory care residencies grew by 85%, infectious disease residencies by 66%, and critical care residencies by 34%. Expansive growth also occurred in emergency medicine residencies, which grew by 141%, and in pain management and palliative care residencies, which increased by 145%.”

  • 2022: “The Match continued its steady growth in the number of available residency positions. Since 2017, residency positions have increased by 1,196, or 26%. Specifically, PGY2 programs in palliative care/pain management grew by 107%, emergency medicine grew by 69%, and ambulatory care grew by 57%. Additionally, PGY1 community-based programs grew by 31%.”

This was taken from the 2022 ASHP Phase I Match Report (2023 ongoing; GL!). 2020 had a 27% increase in PGY1 positions (going back to 2016). For the most recent report in 2022, there was a reported 26% increase in PGY1 residency positions (going back to 2017). Additionally, emergency medicine reported a 141% growth for 2020, compared to the 69% for 2022. This declining trend of new residency programs continues with ambulatory care and palliative care/pain management.

What does this mean to me? The percentage decrease in new residency programs is probably more indicative of the effort to explore opportunities for student pharmacists. This would result in less impressive “percentages”, but likely the smaller difference is attributed to the ratio of new to overall programs.

Since writing this article, there have been a few important announcements/reports that you may find… interesting.

Pharmacy College Admission Test (PCAT) will no longer be required for entrance into pharmacy school. You can have your personal opinions on this, but personally, I don’t understand why we are reducing the standards when we should be improving them.

The National Association of Boards of Pharmacy recently released the overall scores for the North American Pharmacist Licensure Examination (NAPLEX)

Several things to point out:

  • First, click here and see where your school lands. You can’t be a pharmacist if you don’t pass the baseline competency exam. Period. We had a 78% pass rate nationally for all test takers. You wouldn’t use an antibiotic lower than 80% effective per your antibiogram, right? 🦠

  • During the 2003–2004 academic year, there were 89 pharmacy schools. Today, there are 142 schools.

  • Downtrending first-time attempts, first-time pass rate, and all-time pass rate. Are these a result of the quality of pharmacy schools? How has accreditation changed over the years? What considerations are being discussed to address this?

You got a pulse? Alright, you’re in. I’ve heard many stories…

This was reported by the 2021–2022 Pharmacy College Application Service (PharmCAS) Applicant Data Report. You can see from the table that schools kept opening, while less and less people wanted to be pharmacists (as evidenced by # of applications). As enrollment continues to drop, pharmacy schools need to fill seats to stay open. This is purely my speculation. Depending on what source you’re looking at, pharmacy school admission is hovering around 90%. Yikes, we're really trying to make it statistically significant (95% CI).

What do I think looking back at the profession after three years?

The tone of the article appears shallow. I am just pointing out the numbers for you to make an informative decision about your career.

I am extremely optimistic about the future of pharmacy, but that will come with new expectations for the profession. Post-graduate training should be encouraged early in pharmacy school. We want to continue producing competent, impactful, and advanced pharmacists to maximize patient-centered care.

How do you expect to do anything outside of the community setting after pharmacy school? Do you feel confident to provide safe, patient-centered care immediately? Medical doctors train for a minimum of three years (few specialties) while others will go up to nine years, including fellowship. You’re the medication expert. Three to four years of pharmacy school doesn’t provide enough direct patient care. Pharmacists shouldn’t be “learning” their job, on the job.

We never really made “decisions” and took “ownership” with our interventions during rotations. That’s how you become an independent clinician.

Some of the things mentioned may not be what you want to hear, but I see light at the end of the tunnel.

  • From my understanding, the US Bureau of Labor Statistics may agree with the assessment of less community positions in comparison to growing non-community pharmacists.

  • There will continue to be new programs/positions opening. I’ve learned that there is so much more to explore within pharmacy itself; you just have to take the initiative and find, or even create your “place”.

  • Nationally, student pharmacist pass rates are declining. This should prompt the Accreditation Council for Pharmacy Education (ACPE) to use this opportunity to make a change for the better; shut down schools that don’t provide the education a student’s six-figure loan would expect. We’ve come to a national all-time pass rate of 78% in 2022…

  • It seems like the trend of less pharmacy school applicants will continue. Less and less new graduates. Post-graduate training opportunities will slow down. I assume that the decrease in applicants will provide graduating student pharmacists more opportunities to pursue what their passionate about within pharmacy. The current student pharmacists will likely have less competition, access to more diverse and established specialty training, in addition to more expansive opportunities.

You cannot complain about something without offering solutions. Here would be my recommendations.

  1. Shut down pharmacy schools that have a < 70% first-time pass rate for two consecutive years and tighten accreditation standards. Pharmacy schools with a conditional accreditation should have conditions revised with higher standards. Limit the amount of “conditional accreditation” offered to pharmacy schools each cycle.

  2. Improving the pharmacy education curriculum by finding student pharmacists more opportunities for direct-patient experiences. Some schools have reduced the didactic portion to allow for more exposure during rotations. We learn more from actual patient experiences, rather than pumped and dumped facts just to pass an exam.

  3. Expand opportunities for increased exposure to different specialties for first- and second-year student pharmacists. Would it be unrealistic to have students shadow a pharmacist from different specialties every couple weeks?


COVID19 restructured my thinking to reconsider "numbers" and "statistics". Dentistry and medical residency programs have a match rate hovering around 90%. What's being hidden?Here are some numbers to add for the pharmacy programs for the past three years.

That is a pretty solid trend towards increasing the applicant match rate. Let me point out that the listed match rate is based on those considered to be in the match, and excluded those who withdrew or did not return rankings. Out of the initial pool of applicants (which students pay to create an account), 15-18% withdrew or did not return any rankings. Not only are we consistently matching less than 70% of candidates each year, we have almost 1/5 of students placed in a position where they felt they couldn't even submit a ranking.

The mission is to close that gap for the 1/5 of students and those who didn't match. It is time we start taking the initiative in the quality of pharmacists, not quantity. This matters to me because companies (ahem, "Pharmacy Benefits Managers") within the pharmacy profession are in the top 20 in GLOBAL REVENUE. We can't circulate some to reinvest into the growth of the profession? Give students the resources to advance the pharmacists role in healthcare.


Don’t let the numbers downplay your potential to be whatever pharmacist you want to be.

The Pharmacy Paradigm Shift, from my point of view, is currently unraveling itself to expand the role of pharmacists. Can you really call a pharmacist, a pharmacist? It’s not a matter of chronic disease management and dispensing anymore. Pharmacists are specialists. Emergency medicine, critical care, infectious disease, ambulatory care, cardiology, internal medicine, oncology, compounding pharmacy, academia, community pharmacy, drug information, drug development, patient safety, pediatric, infusion, etc. How many patient-centered interventions would a community pharmacist make with access to electronic health records? Good luck knowing you've dispensed valacyclovir 1000 mg po tid to a visiting hemodialysis patient. We're the medication experts; give us the resources to actually become one. There is a niche within the profession for all pharmacists; you just have to find (create) it.

Thanks for taking the time to read this article, Mark Nguyen, PharmD

If you would like me to cover a specific topic and/or medication, please let me know in the comments or send a DM on all social media platforms @pharmwyze.


I do not have any relationships to report. This is for educational purposes only. This is not medical advice. As always, patient-centered care relies on your clinical judgement. Refer to institutional policies, guidelines, and standard operating manuals to abide by employer requirements. Emergency medicine pharmacist responsibilities referenced are within the context of writer’s practicing state; practice according to your state law. The content of this article are based on my views and personal experiences, and are not representative of any affiliation I am associated with.

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