1993–1998: Koda-Kimble

Mary Anne Koda-Kimble, 2005

In 1993, Mary Anne Koda-Kimble was named acting chair of the Division during Herfindal's leave of absence. She was appointed to the chairship in 1994 when he left the School and Donald Kishi served as vice chair for pharmaceutical services. Clifton Louie, a pharmacist and the hospital administrator to whom Pharmaceutical Services reported, became director of pharmaceutical services for UCSF Medical Center and a vice chair in the division. The goal of this arrangement was to maintain the close ties with the medical center that Herfindal had established and to ensure that the strategic directions of the division were aligned with those of the medical center. The shift from fee-for-service to managed care was driven by the unremitting escalation in the cost of health care without an apparent link to necessity or quality.

Clifton Louie, 1994

Donald (Don) Kishi, 1994

Consolidation and integration of health care delivery systems, preferred providers and independent practice associations, point of service plans, gatekeepers, capitated payments, co-payments, best-practice guidelines, and carved-out services were just some of the strategies used to achieve savings in health care costs.

Pharmacists were not immune to these changes. As payers encouraged medical groups to shift their care from the more expensive hospital environment to ambulatory settings, those in hospital practice were affected by institutional mergers, staff downsizing independent of patient load, declining clinical revenue, and the increased use of computerized and robotic equipment. Shortened hospital stays meant that more patients received care in intermediate-level facilities or at home.

Community pharmacists were also affected by pressures to cut health care costs. Carved-out pharmacy benefits decreased reimbursements for prescription dispensing. Diverse formularies, reimbursement schemes, and dispensing policies increased complexity of the dispensing process. To become more efficient, large chain drugstores merged, mail order pharmacies expanded, and automated equipment and technologies were exploited to improve the efficiency and accuracy of the dispensing process. Many independent community pharmacies, unable to compete in this environment, closed their doors. California was at the forefront of the managed care revolution and was thought to be the bellwether for the nation’s health care delivery future.

This unstable situation was making it increasingly difficult for the faculty to establish and maintain clerkship training sites delivering what we now call Advanced Pharmacy Practice Experiences or APPEs. Adjunct practitioner faculty members, finding themselves expected to do more with fewer resources, were finding it challenging to accommodate students in their practices.

Since the 1960s, the School had been integrally involved in managing and delivering pharmaceutical services within UCSF Medical Center. The advent of managed care threated this relationship, because resources that traditionally had supported professional education declined precipitously, as did the patient census, clinical staff, and clinical revenue.

Cochrane Center branch established

Lisa Bero, 2001

The San Francisco Cochrane Center, led by Lisa Bero, was established in the department 1994. The Cochrane Collaboration, an international organization, promotes high-quality research and evidenced-based decisions about health care in order to influence the World Health Organization use of research evidence in its policy decisions. Bero was director of the San Francisco branch of the U.S. Cochrane Center. She left the department in 2014 to take a faculty position in Australia.

Uncertainty with opportunities prompts curriculum review

As they observed the struggles of their clinician-teachers navigating an uncertain environment, UCSF pharmacy students began to worry aloud about how changes in health care delivery would affect their education and professional opportunities. Students directly experienced the pace of change as their assigned clerkships evaporated within days to weeks of their scheduled rotations. They also saw a turnover in faculty as clinicians began to leave what was once a stable, secure academic world for other employment opportunities.

In the context of this dynamic environment, the School embarked on an intensive curricular review in 1995 to ensure that students graduated with the skills they needed to practice for a professional lifetime. This review took into account sweeping changes in health care delivery, the pace and nature of scientific discovery, and the escalating rate of technological advances. With the advent of managed care and other aggressive reforms in the nation’s health care economy, the faculty recognized that radically new roles for pharmacists were essential. This meant changing both the curriculum content and the teaching methodology.

As part of this process, the faculty surveyed alumni to determine how recent sea changes in the health care environment had affected their practice patterns and perceptions of the profession. Relative to a previous survey, fewer graduates were practicing in hospitals (46% vs. 62%) and community pharmacies. Twice as many (42% vs. 20%) were employed in ambulatory clinics, health maintenance organizations, home infusion pharmacies, and other practice settings. Most (83%) were involved in direct patient care as part of their practice; 60% initiated or modified drug therapy per the expanded scope of practice laws in California; and 50% had a specialized practice. A majority of respondents (74%) said that the recent changes in health care delivery had altered their responsibilities to a moderate or great extent. The survey results indicated that although managed care had created a stressful working environment, our graduates were finding new opportunities to use their clinical expertise.

A new curriculum emerges

The overarching goal of the faculty was to keep the newly designed curriculum flexible and contemporary and to incorporate new teaching methods that emphasized student participation. To identify the competencies, the faculty reviewed the literature, performed market surveys, and listened to the feedback of graduates. Integrating ethics throughout the curriculum and emphasizing the mastery of information technology, the goal was to encourage students to engage in lifelong learning and entrepreneurial endeavors. Faculty aimed to do this by stimulating innovation among students, encouraging them to work in teams, placing a strong emphasis on communication skills, and exposing students to the principles of research design by academic focus on problem-solving throughout the curriculum.

Three elective pathways introduced

Clinical pharmacy remained an integral component of the new curriculum, although the PharmD program was no longer centered exclusively on patient care. To broaden the curriculum, the program offered three elective pathways, each comprising one-third of the curriculum: Pharmaceutical Care, Pharmaceutical Health Policy, and Pharmaceutical Sciences. The faculty encouraged students to pursue postgraduate experiences beyond the clinical residency, such as research or industry fellowships, and dual degrees.

In 1996, the year the division gained departmental status, Dean George Kenyon asked for an early accreditation visit by the American Council on Pharmaceutical Education (ACPE). He requested this early evaluation because the radically new curriculum was not necessarily aligned with current standards. The ACPE evaluation team supported the curricular study process and urged the School to pursue reform and its implementation with celerity.

George Kenyon, right, with Lorie Rice and Robert (Bob) Day, 1993

The faculty began to develop and deliver new courses in 1996, which included expansion of clerkship opportunities outside the hospital and community pharmacy settings. Students practiced in free clinics, managed care organizations, industry, and government agencies, for example. The first students matriculated into a fully developed pathway curriculum in 1998.

Over this period, department faculty members began to re-engineer their work to better reflect the skills needed in the new environment and to enhance their research capabilities. The decline in strategic support from the UCSF-Stanford merged entity in 1997 stimulated the department to develop new partnerships and expand support through research. For example, new contracts were established with medical practices in Sacramento and Palo Alto and with chain store pharmacies. There was a severe pharmacist shortage nationally as chain store pharmacies began to expand and extend their hours. In response, new schools of pharmacy began to emerge, primarily in private colleges or as freestanding for-profit schools. This led to heated competition for clerkship sites and increasing pressure for UCSF to pay for experiences. The School’s position was that the program was sending well-prepared students who would add value to the institutions providing clerkships.

The School’s 2002 Self Study noted:

The department of clinical pharmacy has achieved a greater balance in the practice of the faculty among contemporary practice models in a variety of settings (e.g. hospital pharmacy, community pharmacy, managed care). This has been accomplished through new partnerships with the private sector, faculty development, and focused faculty recruitment. As a result we see greater diversity in career choices among our students who previously gravitated toward hospital practice.

Scholarship

The department focus on research sharpened with the appointment of B. Joseph Guglielmo to the new position of vice chair of scholarship. Guglielmo initiated an Annual Research Seminar.

1997–1999: A UCSF-Stanford merger is short-lived

Michael Bishop, 2011

Haile Debas, 2004

In November 1997, the UCSF Medical Center entered into a merger agreement with Stanford Medical Center—including Packard Children’s Hospital—in an effort to strengthen and increase the cost efficiency of tertiary care services offered in Northern California and to sustain the academic missions of both institutions. All clinicians were asked to rethink their practices in the context of the new environment, to measure the value added by their services, and to find ways to contain or reduce costs. Chancellor Joseph Martin, who initiated the merger, departed for Harvard in 1997. Chancellor Haile Debas oversaw its implementation until Chancellor J. Michael Bishop became chancellor in 1998.

The new merged entity had no loyalty to the historic relationship between UCSF Medical Center and the School, nor did it support the department’s contribution to patient care. Consequently, strategic support for the department’s contribution to patient care was rapidly and severely slashed by one-third ($1.2 million to approximately $800,000). A de-merger was initiated in 1999 when huge deficits were incurred by the merged entity and differences in institutional cultures could not be resolved.

Faculty hires during this period include

Sharon L. Youmans

Cathi Dennehy

Lee Cantrell

Patrick Finley

Lisa Kroon

James Lightwood

Katherine Yang

Candy Tsourounis

Leslie Wilson

Mitra Assemi

Next: 1998–2000: Winter (interim chair)

Image credits: © majedphoto for Mary Anne Koda-Kimble; David Powers for Lisa Bero; Elisabeth Fall for Mitra Assemi and Cathi Dennehy; Susan Merrell for Lisa Kroon; Kaz Tsuruta for Lee Cantrell and Patrick Finley; Frank Farm for Katherine Yang

All trademarks are trademarks of their respective owners.