The pharmacist's professional identity: Preventing, identifying, and managing medication therapy problems as the medication specialist

Pharmacy has long struggled to embrace a unified professional identity despite many leaders calling for such. With societal and scientific evolutions, the functions of the pharmacist have changed over time, often assuming multiple identity discourses. Pharmacy has also been seen as a very heterogeneous profession with product‐ and patient‐focused practitioners, contributing to the lack of a unifying identity. This commentary argues that to advocate for and promote our profession we must confront the brutal facts and realize the true state of pharmacy practice. The fact is that all areas of pharmacy practice, both product‐ and patient‐focused, have always shared a central theme which is and has been the pharmacist's professional identity: the prevention, identification, and management of medication therapy problems and their root causes as the medication specialist. Fully embracing this professional identity will help the profession assume a clear and unique role on the healthcare team in optimizing patient care and allow for meaningful practice‐based research, grounded in theory, which will improve the education of currently practicing and future pharmacists. A firm professional identity will also allow for a seamless continuation between pharmacist education and practice across a lifetime, strengthening the pharmacy profession as a whole.

The profession of pharmacy has seen many changes and advances over the past 100 years to meet societal needs. Many of these advances have sought to shift practice from product to more patient-centered care. However, given the heterogeneous nature and diversities of pharmacy practice, with pharmacist responsibilities becoming increasingly specialized and differentiated, some suggest these advances have contributed to the lack of a unified vision for the profession at large. 8 This has raised questions as to the professional identity of the pharmacist. 9 A recent discourse analysis of pharmacist identity revealed five identities that have emerged over time including "apothecary," "dispenser," "merchandiser," "expert advisor," and "healthcare provider." Kellar and colleagues note that these individual discourses "piled up" rather than progressively or clearly shifting over time. 10 This "pile up" of professional identities has resulted in a weak professional identity, 11 despite the many calls to action by pharmacy leaders. [12][13][14][15][16][17] A recent attempt by the Joint Commission of Pharmacy Practitioners (JCPP) to resolve this lack of professional identity and create a unified vision resulted in the publication of a Vision for Pharmacists' Practice including five responsibilities of the pharmacist, four of which focus specifically on safe and effective medication use, 18 and the publication of the Pharmacists' Patient Care Process (PPCP). 19 However, the PPCP does little to distinguish the pharmacist's professional identity from that of other health care professionals in its outline of five core elements or functions of the patient care process. [20][21][22] Thus, pharmacy remains in a state of limbo trying to find its place among health professions.
How can pharmacy's lack of professional identity be resolved? Kellar and colleagues have stated that pharmacist professional identity constructs are neither simple nor self-evident. 10 While pharmacists are predominantly associated with the product-focused "dispenser" discourse by those outside the profession, the patient-focused "healthcare provider" discourse is noted to be the predominant identity within the profession today. This self-identification as healthcare providers is rooted in a clinically focused pharmacy curriculum which has been fueled by the transition to an all PharmD degree and legitimized through patient care activities that "mimic those of physicians." 10 Perhaps part of the issue of pharmacist lack of professional identity is that we have not collectively sought or defined a unique pharmacy identity, but rather an identity in the shadow of medicine. It is time to confront the brutal facts 23 and no longer deny the true state of pharmacy practice 13 in order to form a professional identity unique to pharmacy. 24 This paper argues that defining the pharmacist's professional identity is simpler and more self-evident than we have made it to be. There is a common thread running through the five identity discourses of pharmacy since 1937 which spans the myriad of practice settings, bridging product-and patient-focused practice, and is unique to the pharmacy profession: medication therapy problems (MTPs).

| HISTORY OF PHARMACIST PROFESSIONAL IDENTITY AND MEDICATION THERAPY PROBLEMS
Although there has been an evolution of the discourses used to describe the professional identity of the pharmacist from "apothecary" to "healthcare provider," pharmacists have continually served as medication specialists. Throughout this discourse evolution, the theory behind identifying, preventing, and managing MTPs has remained central to the role, or desired role, of the pharmacist through patient recommendations and prescription order verification, even though the term "medication therapy problem" and other related terms, such as drug-related problems, drug therapy problems, and medication-related problems, did not appear in the literature until later.
As "apothecaries," pharmacists would use their collective knowledge about the therapeutic properties of natural and synthesized substances to care for patients through combining the art and science of medicines. 10 They were often known as "'on the corner doctors,' responsible for prescribing, compounding, and dispensing medications" 25 to prevent or manage MTPs and facilitate positive patient outcomes.
As the profession shifted more towards "dispensing"-where pharmacists focused on dispensing premanufactured medication products and educating customers on those products-the role of the pharmacist required more scientific understanding and clinical knowledge. 10 The types of MTPs pharmacists were responsible for identifying, preventing, and managing shifted as pharmacists were required to use their specialized knowledge to assess the appropriateness of prescription orders and to prevent and/or manage dispensing and medication administration errors. Examples of dispensing MTPs include dispensing the incorrect drug, dose, or dosage form; dispensing the wrong quantity; the inappropriate, incorrect, inadequate, or confusing labeling or directions for medication use; and the incorrect or inappropriate packaging or storage of medication prior to dispensing. 26 The introduction of the "merchandiser" discourse, however, created a more business-focused role of the pharmacist, allowing for prescription volumes and quota as major markers of success. 10 As such, the pharmacist's professional identity became much more commercialized, shifting away from patient care, identifying, preventing, and managing MTPs as the primary role of the pharmacist. Not coincidentally, this discourse is also thought to have caused the "loss of status of the profession." 10 In fact, ethical standards around the time of this discourse prevented pharmacists from discussing patients' prescription drugs with them or labeling the product with the appropriate medication name for fear of violating the physician-patient relationship. 27 To regain our professional standing, the profession has worked toward providing more clinically focused care, above and beyond medication dispensing. The "expert advisor" discourse emerged from the increasing complexity of drug information and knowledge. Pharmacists assumed consultant and drug information roles while rounding with inpatient medical teams and establishing the first hospitalbased drug information centers. 28 In the 1970s and 1980s, published reports described pharmacists identifying MTPs, making clinical recommendations related to medications to prevent or manage MTPs (eg, change dose), and providing medication-related education to physicians. These services were often provided in settings outside of community pharmacies, such as inpatient units, outpatient clinics, and skilled nursing facilities. [28][29][30][31][32] The idea of pharmacists as "healthcare providers" also began to emerge in the 1970s with a handful of pharmacists being able to alter patient medication regimens autonomously, provide patient education, and administer medications. 33 This idea flourished in the 1990s after the concept of patient-centered pharmaceutical care was introduced by Hepler and Strand. Along with the "healthcare provider" discourse came a formalized framework for MTPs broadly categorized according to medication indication, effectiveness, safety, and adherence (IESA). 34, 35 Hepler and Strand described MTPs as "patient" problems instead of inherent problems with medications themselves. 28,34,36,37 This was a key shift in thinking for the profession with drug-related problems defined as: "an undesirable patient experience that involves drug therapy and that actually or potentially interferes with a desired patient outcome" 34 "and requires professional judgment to resolve." 37 The purpose of patient-centered pharmaceutical care was to proactively contribute to positive patient outcomes by identifying, preventing, and managing patient-specific MTPs. 34,36 The concept of pharmaceutical care was also embraced by pharmacists globally. The Pharmaceutical Care Network of Europe (PCNE) defined it as "the pharmacist's contribution to the care of individuals, in order to optimize medicines use and improve health outcomes." 28,38 Much like the original framework developed by Strand and colleagues, the PCNE emphasized the importance of pharmacists identifying, preventing, and managing MTPs to improve patient outcomes. Beyond categorizing MTPs as problems with medication indication, effectiveness, or safety, the PCNE also delineated potential causes of MTPs, such as inappropriate medication prescribing (eg, inappropriate medication selection or non-optimal dosing), insufficient medication monitoring, or errors in medication dispensing, administration, or storage. 39 The MTP Categorization Framework developed by the US-based Pharmacy Quality Alliance (PQA) in 2017, describes similar causes, or "rationales," for MTPs. 35 These frameworks highlight the breadth of MTPs and MTP root causes pharmacists are uniquely equipped to address regardless of care setting, and underscore the unique knowledge and skills pharmacists contribute to the medical team in optimizing patient care.

| ESTABLISHING A UNIQUE PROFESSIONAL IDENTITY THROUGH MTP-FOCUSED PHARMACY PRACTICE, RESEARCH, THEORY, AND EDUCATION
With today's emphasis on team-based healthcare, distinct professional identities are critical. While each profession will and should have some overlap in the "attitudes, values, knowledge, beliefs, and skills" with other professions, each profession must understand and embrace their unique "attitudes, values, knowledge, beliefs, and skills" or the unique lens through which they view shared "attitudes, values, knowledge, beliefs, and skills." These unique perspectives in patient care are the foundation of a discipline in patient care and serve as a basis for an identifiable body of evidence that is developed, studied, and practiced by members and its students. 40 Practice, research, theory, and education are cornerstones of pharmacy's identifiable body of evidence to establish us as a professional discipline, grounded in our professional identity (see Figure 1).
The development of the PPCP by the JCPP in 2014 attempted to provide some definition for the profession's practice by describing the five-step process (eg, collect, assess, plan, implement, follow-up) pharmacists should follow when providing patient-centered clinical care.
However, it did not explicitly define how each step of the process would be operationalized by the pharmacist to fulfill their unique contribution to the healthcare team, which would serve to clearly differentiate pharmacy's unique professional identity from other health professions. Nevertheless, it is an excellent example of the shared healthcare professional identity. or management, and drug interactions. [54][55][56][57] These MTPs also stem from antimicrobial and insulin orders as opposed to medications for chronic conditions. [54][55][56][57] Perhaps the best evidence of MTPs unifying the pharmacy profession is the effort to reduce MTPs when transitioning patients from the hospital to home, and vice versa. 58,59 Schullo-Feulner and colleagues described the overlap and differences between inpatient and ambulatory care pharmacists, noting both frequently identify the need for additional drug therapy and patient education due to lack of understanding; however, inpatient pharmacists more frequently identify medication order inaccuracies whereas ambulatory care pharmacists identify adherence issues and adverse drug events more commonly. 58 The proactive identification of possible adverse drug reactions or drug interactions by inpatient pharmacists and adherence issues by ambulatory care pharmacists found in these studies are critical to prevent MTPs from occurring, thus optimizing drug therapy.
In addition to MTPs being at the core of the professional identity of the pharmacist, MTPs are also the unique metric that captures the contributions of the pharmacist as the medication specialist on the healthcare team. The use of MTP prevention and resolution as key accountability metrics for pharmacist contribution can also serve as a strong, foundational basis for practice-based research, something the profession is currently lacking. MTPs would serve to demonstrate pharmacy's distinctive impact on the quadruple aim of healthcare: improving patient outcomes, reducing healthcare costs, improving provider satisfaction, and enhancing patient experience. 42,60 Focusing our practice-based research on MTPs, and how their prevention, identification, and management contribute to the quadruple aim, would give coherence to an identifiable body of evidence to ensure our status as a professional discipline.
Nevertheless, to give this practice-based research meaning and its unique space within the healthcare literature, as a profession we must apply theory and subsequent research to how pharmacists identify, prevent, and manage MTPs. Using theory to support pharmacy practice will allow for more consistency in our practice and form the basis for a lifetime educational model. In fact, in his 1980 Harvey A. K.
Whitney Award lecture, Donald Brodie advocated for a need for a theoretical base for pharmacy practice, indicating pharmacy has never been challenged by the idea that there is a theoretical basis to pharmacy practice and having tools necessary to direct the future course of the profession. 17 The lack of a professional identity may have impacted the ability to move forward his call to action in 1980. We propose that the primary purpose of theory in the profession of pharmacy is to improve and advance practice by influencing the health and quality of life of patients through identifying, preventing, and managing MTPs or by "Drugs and the People" 15 and to differentiate pharmacy as a profession. 61 This gives pharmacists the opportunity to organize principles that will help evaluate patient care and improve our MTP interventions based on the evaluation findings. The theories F I G U R E 1 Medication therapy problems as the link among pharmacy practice, research, theory, and education for a unique professional identity and identifiable body of evidence around MTPs can also provide pharmacists with basis or rationale for making decisions. The theories, rooted in the pharmacist's professional identity, developed by practice-based research, and validated in clinical practice then serve to inform the educational requirements and standards for not only student pharmacists about to enter the profession, but post-graduate trainees and continuing professional education and development as well. This work has been started by the American Association of Colleges of Pharmacy (AACP) core entrustable professional activities for pharmacy graduates, 62 but has yet to be expanded into post-graduate and continuing professional education. However, when evaluating the current level of evidence, there appears to be a practice-research-theory-education gap, especially when focusing on MTPs. It is essential that we understand and value the relationships between practice, research, theory, and education and bridge the gaps to drive us towards best practices centered around our professional identity. If pharmacy, as a profession, wants to evolve from good to great, we must "confront the brutal facts" plaguing our profession. 23 In his 1996 Harvey A. K. Whitney lecture address, William A. Zellmer stated pharmacy tends "to deny the true state of pharmacy practice." 13 Now, two and a half decades later, pharmacy is still denying its true, unique, and important contribution to patient care and the healthcare system at large. The "fate of pharmacy practice in all settings in interlinked" 13 through our unique professional identity: medication specialists whose primary role is to prevent, identify, and manage medication therapy problems and their root causes. Medication therapy problems are and have been the profession's unique lens through which we approach patient care, ensuring safe and effective medication use since our early days as apothecaries. Although the profession has experienced many evolutions, preventing and managing actual or potential MTPs has remained a focus of the pharmacist's daily practice of recommending, monitoring, and dispensing medications. It is time for the profession to fully embrace MTPs as core to our unique professional identity. Once pharmacy differentiates itself from other health professions and creates a link between our practice, theories, research, and education we can clearly articulate the important role of pharmacy in healthcare distinctly different from all other disciplines. This clear and unifying identity across all areas of pharmacy practice will allow for meaningful practice-based research to advance the profession forward by assessing the true impact of pharmacist-provided care to the healthcare system.