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ABSTRACT: The objective was to measure the three aspects of burnout–emotional exhaustion, depersonalization, and reduced personal accomplishment–using the Maslach Burnout Inventory in a sample of health maintenance organization (HMO) pharmacists. The specific objectives were to: 1) investigate the relationship of individual demographic and job-related variables and a career-related variable to the three as-pects of burnout; 2) obtain a profile of the respondents susceptible to the three aspects of burnout; and 3) solicit comments from the respondents about the pharmacist’s job environment and suggestions to improve it.

A survey was mailed to 251 pharmacists practicing in HMO settings from a list supplied by Medicom Inter-national, Inc. The survey collected information about burn-out in terms of emotional exhaustion, depersonalization, and reduced personal accomplishment; information on the individual and career- and job-related characteristics of each respondent; and comments about the HMO pharmacists’ job environment and suggestions to improve it. Eighty-three useable responses were obtained, representing a useable response rate of 33.6%.

Overall, the respondents experienced moderate levels of emotional exhaustion and depersonalization, and high levels of personal accomplishment. Staff pharmacists had significantly higher emotional exhaustion and depersonalization scores than those in a supervisory capacity. Unmarried respondents with lower annual sal-aries had significantly higher emotional exhaustion and depersonalization scores than married/higher-salaried pharmacists, respectively. Respondents with three or more children had lower depersonalization levels than those with no children, while those who had worked for five years or more in their current job had higher emotional exhaustion scores than those who had worked in their current job for fewer years. Respondents who worked between 35 and 40 hours per week in the HMO setting had higher personal accomplishment scores than those who worked 34 hours or less per week.

Profiles of pharmacists most susceptible to the three aspects of burnout were obtained: those who had no children, an annual salary of $49,999 or less, and worked for five or more years in their current job were more susceptible to emotional exhaustion. Respondents who had no children and an annual salary of $49,999 or less were more susceptible to depersonalization. Those who spent 1%—25% of their time processing prescriptions were less susceptible to burnout, while those who worked 34 hours or less were more susceptible to burnout on the personal accomplishment subscale.

Results concerning the relationship of individual, job-related, and a career-related variable to the three as-pects of burnout were obtained. A profile of HMO pharmacists susceptible to the three aspects of burnout also was obtained. This information can be useful in the development of stress management programs designed to minimize the level of chronic stress that can potentially lead to burnout among HMO pharmacists.

Key Words: Burnout, HMO pharmacists, Chronic stress management

J Managed Care Pharm 1998: 495-503

Health maintenance organizations (HMOs) are keystones in today’s managed health care system, playing pivotal roles in reducing the country’s escalating health care costs. National enrollment in HMOs grew from 36.5 million in 1990 to 58.2 million in 1995.¹ As this enrollment grows further, the effective and efficient delivery of pharmacy services through HMOs will become even more critical to the quality of the country’s health care. Tracking and addressing any pharmacy workforce problems, such as burnout, that could possibly impair the standard of pharmacy services rendered to HMO subscribers is of great importance.

Burnout among pharmacists can have severe adverse implications, including reduced quality of care, absenteeism, low organizational commitment, turnover, and job dissatisfaction.^2,3 This does not augur well for the future of HMOs, because a high degree of pharmacist burnout would be detrimental to productivity and could lead to patient dissatisfaction and loss of subscribers. Because the pharmacist is a vital part of the HMO health care team, it is imperative that the extent and nature of burnout among HMO pharmacists be investigated.

Maslach and Jackson have proposed a widely accepted conceptualization of burnout, which results from chronic stress.4 In this conceptualization, burnout is defined as "a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do ‘people-work’ of some kind."4 Emotional exhaustion is the feeling that one’s emotional resources for dealing with clients or patients have been depleted. Depersonalization occurs when one develops a negative, cynical and/or callous attitude toward clients. Reduced personal accomplishment occurs when an individual feels unhappy about what he or she has accomplished on the job.⁴

The Maslach Burnout Inventory, which measures burnout in terms of these three aspects or subscales, has been used in previous empirical studies of pharmacist burnout.^5,6 Its reliability and validity in measuring burnout among pharmacists have been established.⁷ These studies have found that, in general, pharmacists experience a moderate level of burnout. However, the representation of HMO pharmacists in these previous studies has been inadequate.

Only one study has documented self-reported burnout a-mong HMO pharmacists.⁸ The study sample consisted of pharmacists employed in the Northwest Region of Kaiser Perma-nente. Burnout was measured by four questions that inquired whether burnout was a problem; what were the perceived causes of burnout; how the problem of burnout could be solved; and how burnout among colleagues affects one’s work. Based on 67 responses, it was concluded that burnout among pharmacists in that organization should be of concern to management. However, because a standardized conceptualization of burnout was not used in that study, it is difficult to compare the results obtained with other studies.

RESEARCH OBJECTIVES

The present study was conducted to measure three aspects of burnout, using the Maslach Burnout Inventory in a sample of HMO pharmacists. The specific objectives of this study were to 1) investigate the relationship of individual demographic variables, job-related variables, and a career-related variable to the three aspects of burnout; 2) obtain a profile of the respondents susceptible to the three aspects of burnout; and 3) solicit comments from the respondents about the HMO pharmacist’s job environment and suggestions to improve it.

METHODS

Study Design

Extensive correspondence with a number of organizations revealed that a national mailing list of HMO pharmacists did not exist. The Academy of Managed Care Pharmacy referred the authors to Medicom International Inc., which provided a list of 251 HMO pharmacists from 38 states and 178 organizations. Though technically not a random sample, the list was used because there was no better current national list of HMO pharmacists available.

A questionnaire comprising three sections was mailed to all 251 HMO pharmacists on the mailing list in February 1993. A follow-up letter was sent to the nonrespondents a month after the initial mailing. The first section of the questionnaire contained the Maslach Burnout Inventory, which consists of 22 items that measure burnout in terms of emotional exhaustion (nine items), depersonalization (five items), and personal accomplishment (eight items). The frequency with which the respondent experiences each item is measured on a seven-point Likert-type scale anchored by Never (0) and Every Day (6). The scores thus can range from 0—54 on the emotional exhaustion subscale, 0—30 on the depersonalization subscale, and 0—48 on the personal accomplishment subscale. Because of limited psychometric evidence of the relationship between the three subscales, the scores are considered separately and not combined into a single score.4 Higher mean scores on the emotional exhaustion and depersonalization subscales correspond to higher levels of burnout, whereas lower mean scores on the personal accomplishment subscale correspond to higher levels of burnout. Cronbach’s alpha for the three subscales in the present study were 0.92 for emotional exhaustion, 0.83 for depersonalization, and 0.80 for personal accomplishment. Results of a confirmatory factor analysis for the three subscales in this sample are reported elsewhere and showed strong evidence of construct validity.⁹

The second section of the questionnaire consisted of questions to measure the individual, career, and job-related variables specific to each respondent. Individual demographic variables included gender, age, marital status, number of children, and annual salary. Job-related variables included whether the pharmacist was an inpatient or outpatient pharmacist, a supervisory or staff pharmacist; the number of years in the current job; the number of hours worked per week in the HMO setting; and the percentage of time spent on processing prescriptions, on paperwork unrelated to processing prescriptions, and in direct contact with patients. The career-related variable was the total number of consecutive years practiced in the HMO setting. The third section asked for comments about the HMO pharmacist’s job environment and suggestions to improve it.

Statistical Analyses

Frequency distributions for each demographic variable were obtained to characterize the sample of respondents. Analy-sis of variance (ANOVA) was performed to determine the relationship of the individual, career, and job-related variables to the three burnout subscales. For statistically significant results of those variables with more than two categories, multiple comparisons of means were performed using Scheffe post-hoc tests. Stepwise regression models were obtained to identify the combination of individual, career, and job-related variables that account for the most variance in each of the three burnout subscales. The individual, career, and job-related variable categories were dummy coded to facilitate the stepwise regression analyses. To assess the possibility of nonresponse bias, the burnout subscale scores for the first and last 20 respondents were compared using one-way ANOVA. All data analyses were conducted using the SPSSx statistical software package (SPSS Inc., Chicago, Illinois). An a priori significance level of p<0.05 was used for all analyses.

RESULTS

Response Rate and Respondent Characteristics

Of the 251 questionnaires mailed, four were returned as undeliverable. Thus, 247 questionnaires were presumably delivered. A total of 101 responses were obtained, for a response rate of 40.9%. However, 18 of these were excluded from the data analyses either because they were incomplete or because the respondents were not licensed pharmacists currently practicing in a pharmacy affiliated with an HMO. Therefore, 83 useable responses remained, representing a useable response rate of 33.6%.

The demographic characteristics of the respondents are presented in Table 1. The individual demographic characteristics of the respondents showed 68.7% (n=57) were male; 88.0% were married (n=73); 45.8% (n=38) were in the 36- to 45-year age group; 32.5% (n=27) had two children, while 28.9% (n=24) had three or more children; and 40.2% (n=33) had annual salaries of $60,000 or more. For the career-related variable, 71.1% (n=59) had practiced in the HMO setting for nine or fewer consecutive years.

The job-related characteristics for the respondents showed that 89.9% (n=71) practiced in the outpatient setting; 92.8% (n=77) held supervisory positions; 64.6% (n=53) worked 41—50 hours per week in the HMO setting; 59.8% (n=49) spent 25% of their time or less processing prescriptions; 53.6% (n=44) spent less than 50% of their time on paperwork unrelated to processing prescriptions, while 29.3% (n=24) spent 76%—100% of their time on this activity; and 86.7% (n=71) spent less than 50% of their time in direct patient contact. The 83 respondents represented 36.5% (65/178) of the organizations in the sample of 251 pharmacists to whom the questionnaires were mailed.

The mean total subscale scores for the useable responses were 19.42 (SD=11.26) for emotional exhaustion, 7.55 (SD= 6.21) for depersonalization, and 39.66 (SD=5.97) for personal accomplishment. Comparison of these scores with the standardized categorization for the Maslach Burnout Inventory subscale scores shows that HMO pharmacists in this sample experienced a moderate level of burnout, as reflected by their scores on the emotional exhaustion and depersonalization subscales. On the personal accomplishment subscale, however, their scores indicated a low level of burnout.4 The burnout subscale scores did not differ for the first and last 20 respondents, indicating that nonresponse bias may not be a problem.

Relationship of Individual Demographic Variables, Job-Related Variables, and the Career-Related Variable to the Three Aspects of Burnout

Emotional Exhaustion

On the emotional exhaustion subscale, significant differences were seen in the category means for two individual demographic variables: marital status and annual salary (see Table 2). Married HMO pharmacists experienced a significantly lower level of emotional exhaustion than unmarried pharmacists. Scheffe post-hoc test results indicated that HMO pharmacists who earned $49,999 or less per year had significantly higher levels of emotional exhaustion than those with annual salaries of $60,000 or more. Statistically significant results for emotion-al exhaustion scores also were obtained for two job-related variables: work capacity and number of years in the current job. Supervisory pharmacists showed significantly lower levels of emotional exhaustion than staff pharmacists. Visual observa-tion of the trend for the category means showed that as the number of years in the current job increased, the reported level of emotional exhaustion also increased. Results of the Scheffe post-hoc test showed that the level of emotional exhaustion for pharmacists who had worked for five to 10 or more years in their current job was significantly higher than that of those who had worked in their current job for less than four years.

Depersonalization

On the depersonalization subscale, three individual demographic variables had significantly different category means: marital status, number of children, and annual salary (see Table 3). Married HMO pharmacists experienced significantly lower levels of depersonalization with their patients than unmarried pharmacists. Interestingly, the Scheffe post-hoc test results indi-cated that HMO pharmacists with no children had significantly higher levels of depersonalization than those with three or more children. Pharmacists who earned $49,999 or less per year had significantly higher levels of depersonalization than those who earned $60,000 or more per year, according to the Scheffe post-hoc results. One job-related variable, work capacity, also had significantly different category means on the deper-sonalization subscale. Staff pharmacists had significantly higher levels of depersonalization than supervisory pharmacists.

Personal Accomplishment

Personal accomplishment levels differed significantly only for one job-related variable: average number of hours worked per week in the HMO setting (see Table 4). The Scheffe post-hoc test indicated that HMO pharmacists who worked between 35 and 40 hours per week had significantly higher personal accomplishment scores, and hence lower burnout, than those who worked 34 hours or fewer per week in the HMO setting.

Profile of Respondents Susceptible to the Three Aspects of Burnout

The one-way ANOVA results described above provide useful information about the relationship of single independent variables to the three aspects of burnout. The next step was to identify a set of variables that best accounts for or predicts the three aspects of HMO pharmacist burnout. Moreover, the relative importance of each variable in explaining or predicting burnout scores also needed to be determined. Stepwise regression models were obtained to identify a set of independent variables that would best predict emotional exhaustion, depersonalization, and personal accomplishment scores. Results of the stepwise regression analyses are presented in Table 5.

Profile of Pharmacists Susceptible to Emotional Exhaustion

Three variables accounted for 29.62% of the variance in the emotional exhaustion scores; the overall model was significant (F=0.38, p<0.0001). The job-related variable (being in the current job for less than four years) was the strongest predictor and was negatively related to emotional exhaustion scores (ß=-0.3694). Two individual demographic variables (having an annual salary of $49,999 or less and having no children) were positively related to emotional exhaustion scores (ß=0.3062 and ß=0.2509, respectively). Therefore, HMO pharmacists who were in their jobs for four years or fewer, compared to those in their jobs for 10 or more years (dummy coding reference category) were less susceptible to emotional exhaustion. However, those who had annual sal-aries of $49,999 or less compared to those with salaries of $60,000 or more (dummy coding reference category), and those with no children as opposed to those with three or more children (dummy coding reference category) were more susceptible to emotional exhaustion.

Two individual demographic variables–having no children and earning $49,999 or less–accounted for 15.35% of the variance in the depersonalization scores; the overall model was significant (F=6.80, p=0.0019). The regression model indicated that HMO pharmacists with no children, compared to those with three or more children (dummy coding reference category), and those with salaries of $49,999 or less, compared to those with salaries of $60,000 or more (dummy coding reference category), were more susceptible to depersonalizing their patients (ß=0.2788 and ß=0.2546, respectively).

Profile of Pharmacists Susceptible to Reduced Personal Accomplishment

Two job-related variables–spending 1%—25% of their time processing prescriptions and working 34 hours or fewer per week in the HMO setting–accounted for 15.63% of the variance in the personal accomplishment scores; the overall model was significant (F=6.95, p=0.0017). The regression model indicated that HMO pharmacists who spent up to 25% of their time processing prescriptions had higher personal accomp-lishment scores (ß=0.2623) and therefore were less susceptible to reduced personal accomplishment, compared to those who spent 76%—100% of their time processing prescriptions (dum-my coding reference category). In contrast, those who worked 34 hours or fewer per week in the HMO setting were more susceptible to reduced personal accomplishment (ß=-0.2378) than those who worked 50 hours or more per week in the HMO setting (dummy coding reference category).

Summary of HMO Pharmacists’ Comments

The most common comments about the HMO pharmacist’s job environment addressed the very demanding workload. Shortage of staff, among both pharmacists and technicians, was cited most often as the cause of the increased workload. On a positive note, many respondents who provided written comments seemed very satisfied with their jobs. One wrote, "HMO pharmacy is the best pharmacy practice area I have experenced." Another pharmacist stated that it "was gratifying to be working in a system which is striving for cost containment."

Other comments noted that there is tremendous responsibility for patient care; there are opportunities to do much more than retail pharmacists; the work schedule is predictable; and pharmacists have opportunities to interact with other health care providers within the HMO. One clinical pharmacist felt that in relation to patient care, drug-use policy, and formulary matters, it is the "best possible environment to work in."

Regarding suggestions for improving the HMO pharmacist’s job environment, many HMO pharmacists commented that they were underpaid for the amount of work they did. Better reimbursement for overtime and patient counseling were suggested. To combat the problem of workload, respondents suggested hiring adequate professional and support staff. Hiring levels should take into consideration not only the number of prescriptions filled, but also other factors such as counseling, paperwork, and interaction with other health professionals. Involvement in nondispensing roles such as drug utilization management, formulary development, drug information education, and direct patient care in the form of more clinical opportunities also were called for.

DISCUSSION

Based on the standardized categorization of burnout levels for subscale scores proposed by Maslach and Jackson,4 the respondents in this sample experienced moderate levels of burnout on the emotional exhaustion and depersonalization subscales. However, personal accomplishment levels for this sample of HMO pharmacists were high, indicating a low burnout level. Previously reported research using this sample of HMO pharmacists indicated that the personal accomplishment subscale scores were significantly higher than those in a nationwide sample of pharmacists who did not practice in the HMO setting.9 The evidence of high personal accomplishment levels seemed to correlate with satisfaction reported by many pharmacists working in the HMO setting.

When subscale scores were compared by categories of the independent variables, staff pharmacists had higher scores than their supervisory counterparts on both the emotional exhaustion and depersonalization subscales. This is consistent with the results obtained by Lahoz and Mason using a nationwide sample of pharmacists.6 Some of the reasons that have been proposed to account for higher job stress and, ultimately, burn-out among staff pharmacists include lacks in several areas: con-trol over practice, participation in decision making, challenge on the job, constructive feedback from supervisors, opportunity to advance, and adequate job policies and procedures.10,11 Additionally, time pressures, job interruptions, understaffing, and heavy workload also may contribute to staff pharmacist burnout.10,11 Respondents mentioned some of these factors when asked for suggestions on ways to improve the HMO pharmacist’s job environment.

Respondents with lower annual salaries had significantly higher scores on the emotional exhaustion and depersonalization subscales than those with higher annual salaries. This could be explained by Herzberg’s two-factor theory of motivation.10,12 Respondents’ comments indicated a need for more involvement in clinical activities such as drug information education and drug utilization management. According to Herzberg’s theory, when higher-level needs, or motivators such as the opportunity to use one’s clinical training, are not being satisfied, frustration and stress can set in. Frustrated by unmet higher needs, the person may place more emphasis on lower-level needs, such as money.10 When the person finds that this need also is unsatisfied, he or she may lose interest in the job.

Married respondents exhibited lower levels of emotional exhaustion and depersonalization than those pharmacists who were unmarried, while respondents with three or more children had lower depersonalization levels than those with no children. It is possible that family support and diversion after work hours might help pharmacists cope with burnout. Also, family life and the presence of children could have a positive effect among the respondents, thereby making them less de-personalizing and more caring toward their patients.

Respondents who worked for five or more years in their current jobs had higher emotional exhaustion subscale scores than those who had worked in their current jobs for fewer than five years. This result could be explained as the consequence of a demanding workload over an extended period of time that has caused the respondents to become emotionally exhausted.2

It was interesting to note that respondents who worked 35—40 hours per week in the HMO setting had higher personal accomplishment subscale scores than those who worked 34 hours or fewer per week. Lahoz and Mason found that pharmacists who worked more hours per week had lower personal accomplishment subscale scores.6 However, pharmacists who worked in the HMO setting were not represented in that study. It is possible, as the comments of many respondents in this study indicated, that working in the HMO setting is more satisfying than working in other practice settings. Another interesting point to note is that the career-related variable–the total number of consecutive years practiced in the HMO setting–was not related to any of the three subscales of burnout.

The variations found in the relationship of individual and job-related variables to burnout, as discussed above, are important for obtaining clues about the possible antecedents of burnout.13 Also important is the profiling of pharmacists susceptible to burnout. This was accomplished by using stepwise regression analyses to identify the variables that explained a significant amount of variance in the three aspects of burnout.

Respondents who had no children, earned an annual salary of $49,999 or less, and had worked for five or more years in their current job were more susceptible to emotional exhaustion. Two of the variables that significantly predicted emotional exhaustion scores were also significant predictors for depersonalization scores. Respondents who had no children and earned an annual salary of $49,999 or less were more susceptible to depersonalization. On the personal accomplishment subscale, respondents who spent between 1% and 25% of their time processing prescriptions were less susceptible to burnout, while those who worked 34 hours or fewer in the HMO setting were more susceptible to burnout.

At this stage the question that may be asked is: "What can be done with these data that profile HMO pharmacists more susceptible to specific aspects of burnout?" Gupchup has suggested that if pharmacists can be classified into groups with similar demographic characteristics, specific stress management programs can be developed for each group.14 This would avoid the common pitfall of many stress management programs that attempt to treat everyone identically. Stress management programs designed for individuals with specific characteristics could be expected to be more effective in helping these individuals combat the effects of chronic stress, eventually reducing burnout.

Though this study yielded some very useful results, it does have some limitations that should be addressed in future studies. Although the mailing list used was the best available national list of HMO pharmacists, it may not represent the population of HMO pharmacists in the country. A concerted effort is required to establish a national listing of HMO pharmacists to enable generalization of future research in this area to the entire population. As with any mail survey study, one cannot say with certainty whether nonresponse bias is a problem. However, a late respondent analysis did not indicate any significant differences in the burnout scores of the first and last 20 respondents. Based on the assumption that the late respondents resemble the nonrespondents, nonresponse bias may not be a problem. One variable that could possibly affect the results obtained in this study is the predominance of supervisory-level pharmacists among the respondents.

The respondents represented 36.5% (65/178) of the organizations in the sample of 251 pharmacists to whom the questionnaires were mailed. However, the type of HMO (e.g., staff model, group model) to which each pharmacy was affiliated was not documented. This limitation should be addressed in future studies of this nature. In addition to the individual, job-related, and career-related variables included in this study, future studies also should include other important variables such as personality variables and coping strategies.14 The inclusion of these variables in future studies of burnout among HMO pharmacists will help clarify the psychological basis of burnout, leading to the development of better stress management programs for these pharmacists. The inclusion of personality variables and coping strategies, coupled with the profiles of HMO pharmacists susceptible to burnout as identified in this study, can help in the development of more specific proactive stress management programs. Considering the limitations outlined above, the results of this study should be generalized beyond the sample of respondents with caution.

CONCLUSION

Some important results concerning the relationship of individual variables, job-related variables, and a career-related variable to emotional exhaustion, depersonalization, and reduced personal accomplishment were obtained in this study. Moreover, the study also revealed a profile of HMO pharmacists susceptible to the three aspects of burnout. This information is useful for the development of stress management programs that can be designed to minimize the level of chronic stress that can potentially lead to burnout among HMO pharmacists. Any potential HMO pharmacist workforce problems that could arise due to burnout and lead to reduced productivity then could be proactively managed.

1. Gabel J. Ten ways in which HMOs have changed during the 1990s. Health Affairs 1997; 16: 134-44.
2. Gupchup GV. A national study of burnout among health maintenance organization pharmacists [thesis]. Toledo, OH: University of Toledo, 1993.
3. Lahoz MR. Burnout among pharmacists: the influence of individual and job characteristics [dissertation]. West Lafayette, IN: Purdue University, 1987.
4. Maslach C, Jackson SE. Maslach Burnout Inventory 2nd ed. Palo Alto, CA: Consulting Psychologists Press, 1986.
5. Barnett CW, Hopkins WA, Jackson RA. Burnout experienced by recent pharmacy graduates of Mercer University. Am J Hosp Pharm 1986; 43: 2780-84.
6. Lahoz MR, Mason HL. Burnout among pharmacists. Am Pharm 1990; NS30: 460-64.
7. Lahoz MR, Mason HL. Maslach Burnout Inventory: factor structures and norms for USA pharmacists. Psychol Rep 1989; 64: 1059-63.
8. Johnson RE, Reid LD, Robertson N. Self-reported burnout among HMO pharmacists. J Pharm Market Manage 1987; 2: 107-27.
9. Gupchup GV, Lively BT, Holiday-Goodman M, Siganga WW, Black CD. Maslach Burnout Inventory: factor structures for pharmacists in health maintenance organizations and comparison with normative data for USA pharmacists. Psychol Rep 1994; 74: 891-95.
10. Wolfgang AP, Kirk KW, Shepherd MD. Job stress in pharmacy practice: implications for managers. Am Pharm 1985; NS25: 446-49.
11. Ukens C. The tragic truth. Drug Top 1995(Nov 6); 139(21): 66-68, 70-72, 74.
12. Herzberg F. The motivation to work. 2nd ed. New York, NY: John Wiley and Sons, 1959.
13. Jenkins R. Demographic aspects of stress. In: Cooper CL, Payne R, ed. Personality and stress: individual differences in the stress process. Chichester, UK: John Wiley and Sons, 1991: 107-32.
14. Gupchup GV. Pharmacists’ job stress as a transaction and a process [dissertation]. West Lafayette, IN: Purdue University, 1996.

AUTHORS

Gireesh V. Gupchup, Ph.D., is Assistant Professor of Pharmacy and Concen-tration Chair, Pharmacy Administration Graduate Program, University of New Mexico Health Sciences Center, College of Pharmacy, Albuquerque, NM; Puneet K. Singhal is a Graduate Student in Pharmacy Administration, University of New Mexico Health Sciences Center, College of Pharmacy; Ernest J. Dole, Pharm.D., Ph.C., F.A.S.H.P., is Assistant Professor of Pharmacy/Geriatrics, University of New Mexico Health Sciences Center, College of Pharmacy; Buford T. Lively, Ed.D., is Professor of Pharmacy and Health Care Administration, The University of Toledo College of Pharmacy, Toledo, OH.

Author Correspondence: Gireesh V. Gupchup, Ph.D., University of New Mexico Health Sciences Center, College of Pharmacy, Albuquerque, NM 87131-1066.

Copyright© 1998, Academy of Managed Care Pharmacy, Inc. All rights reserved.