A Crisis Is a Really Terrible Thing to Waste

Not since the Great Depression has the United States faced such a convergence of economic crises. As of September 2009, the unemployment rate in the United States was approximately 10% including discouraged workers (those who have given up actively looking for employment), with new unemployment claims reaching over 650,000 in the early months of 2009 – more than twice the number that is considered normal in a healthy economy.^1–3 Additionally, home foreclosure rates increased 81% between 2007 and 2008 (225% between 2006 and 2008), the US median household income decreased by 3.6% between 2007 and 2008, and the poverty rate increased from 12.5% in 2007 to 13.2% in 2008.^4,5 Along similar lines, the nation's gross domestic product experienced declines for 4 straight quarters, and state governments have reduced funding for higher education by approximately 5%, or $4 billion.^6,7 As a result, colleges and schools of pharmacy have undergone significant budget cuts, with many resorting to quick fixes to meet their financial woes, such as increased student enrollment, tuition hikes, faculty and staff layoffs, and choosing not to fill vacant positions. Although it may be a reasonable supposition that increased pharmacy student enrollment and/or tuition will generate funds to support immediate financial needs, and in some schools increase profit margins, one should be mindful of the risks of this approach: these quick fixes are not “cures” and do not usually become long-term, beneficial solutions.

Similar to pharmacy education, the pharmacy profession, which has so often taken pride in the booming job market for pharmacists, has not been immune to the effects of these challenging economic times. Although there remains a shortage of pharmacists in the workforce, this shortage has shifted, resulting in a reduction in demand and increased competition for pharmacists wanting positions in many areas.⁸ Reasons for this decline in demand include increased use of automation and technology, high pharmacist salaries, and expanded pharmacy technician responsibilities.⁸ The difficulty in filling pharmacist positions, particularly with mean pharmacist salaries at 6 figures, has contributed to the decline in demand, with health care organizations and retail pharmacies seeking alternate solutions to meet the needs of the public, such as regional prescription refill centers. Applying economic laws of supply and demand, if the demand for pharmacists significantly decreases or shifts while the supply increases due to excessive enrollment in colleges of pharmacy, it would not be inconceivable to see a decrease or at least some type of stabilization in pharmacists' salaries. This effect potentially will have “downstream” implications for the profession as well as pharmacy education, including fewer students matriculating and possibly more attrition in colleges of pharmacy. To safeguard its sustainability in this era of uncertainty, pharmacy education and the profession must face the current economic crisis directly and identify points of long-term opportunity rather than settling for quick fixes alone. As Stanford economist Paul Romer once stated “a crisis is a terrible thing to waste” – a sentiment echoed by both Secretary of State Hillary Clinton and White House Chief of Staff Rahm Emanuel.^9–11

Merriam-Webster defines “crisis” as “an unstable or crucial time or state of affairs in which a decisive change is impending.”¹² This definition implies that during times of uncertainty or instability, opportunities, ie, moments of “decisive change,” may arise. In times of crisis, opportunities emerge, and creativity, innovation, and entrepreneurship are inspired. For example, commonplace items in today's world, such as supermarkets, laundromats, the car radio, the chocolate chip cookie, the electric dry razor, and the boardgame Monopoly, were invented during the Great Depression.¹³ The polio epidemic of 1952/1953 spurred the production and licensure of the first polio vaccine in 1955.¹⁴ The tragic experiments on concentration camp prisoners conducted by Nazi doctors and scientists resulted in the development of the Nuremberg Code, a seminal document that delineated and advanced the rights of human subjects in scientific research, and provided the foundation for later legal regulations governing federally funded research.¹⁵ Mention of the word “crisis” generally evokes images of hardship, destruction, and/or turmoil. Yet the preceding examples provide evidence that crises may also serve as catalysts for positive events, significant learning moments, inventions, innovations, policies, or other changes that are beneficial to society. In other words, crises help birth progress.

In times of prosperity, it is more difficult to engage interest in change and progress since prosperity is generally equated with stability, affluence, and thriving. There is no need to change or rock the boat. A crisis forces a shift in mindset: to retain or regain prosperity, change, progress, and identification of new opportunities become a necessity. There are at least 5 key principles that signify a time of crisis may be a time of opportunity:

A crisis challenges “business as usual” and produces an urgency for change. For example, to combat the negative impact of the Great Depression on the Tennessee Valley, an area already suffering economically prior to the Depression, President Franklin Roosevelt created the Tennessee Valley Authority (a hydropower agency) at a time when private, rather than public or government, ownership of utilities was the norm.¹⁶ Today, the Tennessee Valley Authority is the country's largest public power company and federal management of hydropower is commonplace.^16,17

A crisis reduces peoples' ability to remain within their “comfort zones,” thus giving them the impetus to explore options that previously were viewed as unworthy, unrealistic, or too difficult prior to the crisis. For example, the current economic crisis, with its detrimental impact on employment opportunities in certain sectors, has compelled individuals who dropped out of high school or did not pursue higher education to complete their education.¹⁸ As a result, states are experiencing increased enrollment in community colleges and longer waiting lists for adult education and general education development (GED or high school equivalency) classes.¹⁸

A crisis is a driver for making hard decisions. Losing autonomy is difficult, whether at an individual or organizational level, yet this was the situation facing the Wachovia Corporation in late 2008. On the verge of collapse due in part to overdue mortgages, Wachovia was forced to consider merger offers from more stable companies.¹⁹ To preserve the integrity of the company and promote the best interests of their shareholders and customers, Wachovia ultimately agreed to merge with Wells Fargo.²⁰

A crisis forces those involved to examine the history of events that led to the crisis, and take steps to reduce the likelihood of a recurrence. Prior to the stock market crash of 1929 that precipitated the Great Depression, “there was little support for federal regulation of the securities markets,” and as a result, the market went largely unregulated.²¹ After the crash, the public lost trust in the market. To restore investor confidence and increase regulation of the market to prevent future crises similar to the crash of 1929, the federal government passed several key pieces of legislation, among them the Securities Exchange Act of 1934, which created the Security and Exchange Commission to protect investors and maintain fair markets.²¹

A crisis forces the elimination of repetitive, inefficient, wasteful, problematic, and/or unprofitable activities (products, services, policies, etc), and in some cases, promotes fierce competition for resources and establishment of unique/innovative activities, services, products, policies, etc. Take, for example, the Apple financial crisis in the mid- to late-1990s. Among the problems facing Apple were confusion surrounding its product line (numerous models with little clarity as to which model would work best for a specific customer), a new laptop that had a number of software and hardware issues (thus damaging Apple's reputation), and a cloning program (wherein Mac OS was licensed to third party hardware vendors) that resulted in faltering sales due to increased costs.²² To revitalize Apple, several changes were made including an effort to simplify its problematic product line by using 2 product categories, professional and consumer.²² Additionally, a new product, the iMac, was created for large-scale consumer appeal. Critical to the success of this endeavor was the iMac's stylish design which helped to set it apart from other personal computers.²²

Each of these principles comes into play as we consider the current crisis and its effects on the pharmacy profession. The role and number of job positions for dispensing pharmacists may shift due to the implementation of automation and other technology. Business as usual is changing, and we as a profession must evolve. The obvious next step for the profession is to expand outside the comfort zone of the dispensing role and secure our role in direct patient care services, as the value of pharmacists performing direct patient care services has been demonstrated across multiple disease states and health care settings (Chisholm-Burns et al, unpublished data, 2009). The success of achieving a greater role in direct health care provision, however, requires serious, dedicated advocacy for change in state and federal laws and regulations regarding pharmacists' ability to practice independently and be reimbursed for patient care services. It also requires a change in how we approach pharmacy education.

The questions we must ask ourselves are: “What strategies can we put in place today, in the midst of chaos, that will allow our profession and education programs not only to survive but to thrive?” “How do we facilitate progress in education in the face of increasing budget cuts and more limited resources?” “How do we cope with economic realities without sacrificing quality in our education programs?” We must begin by radically reforming the delivery of pharmacy education. For example, is it feasible to share resources among colleges and schools of pharmacy? Perhaps pharmacy academics should consider “packaging” master lectures for certain courses that are developed by content experts and made available nationally. This would facilitate standardization of information provided to students and help relieve some resources. These resources then could be invested in other educational needs and innovations. Technology will play a significant role in reforming education delivery. The use of the Internet and technology such as video-conferencing allows for greater interdisciplinary education and the increased utilization of distance and nontraditional learning formats for those individuals who are unable to attend daily classes, such as working adults who are returning to school to advance their education or individuals who reside in remote rural geographical areas.

In addition to reforming education delivery, we must also alter pharmacy curricula in such a way that quality is not merely maintained but enhanced, while at the same time offering cost-effective changes to reflect the evolution of the profession. If we are to move the profession in a direct patient care direction, we must educate and prepare our students to assume direct patient care responsibilities. This requires expanding the curriculum to provide a more intensive focus on knowledge and skills related to direct patient care services which may come in many forms, including greater experiential training while in school and additional training after graduation (eg, postgraduate training with emphasis on residencies, certifications, etc). We must also design continuing education programs for those pharmacy professionals who did not have the opportunity to receive this additional direct patient care training while in school. An innovative and less implemented new direction for pharmacy curricula is the inclusion of interdisciplinary coursework, which would involve pharmacy, nursing, and medical students sharing common foundation courses. Pharmacy students should interact and work with students in other health care disciplines early and often. This early exposure to other disciplines, beginning in the classroom and extending to patients' bedsides, will promote relationships and facilitate strong interdisciplinary collaboration to improve patient care. Furthermore, pooling of educational resources may offer a possible solution to economic hardships facing health care professional schools and colleges at universities across the United States.

Out of crises, numerous innovations, services, products, and policies have emerged. What would our lives be like without supermarkets, the car radio, formal human subjects rights protections, or chocolate chip cookies? We must challenge ourselves not to be so submerged in this crisis that we are paralyzed, unable to identify and engage in beneficial opportunities by thinking “outside the box.” A crisis is a really terrible thing to waste. We, as a profession and academy, should not waste this crisis, but adapt, evolve, grow, learn, and improve to facilitate long-term sustainability and viability.

• © 2010 American Journal of Pharmaceutical Education