The Hurdle of Uncertainty

Hurdles ccMelindaHuntley

“You should check with your doctor on that.”

“Let me just fax your doctor and I will get back to you.”

“This medication interacts with one of your other pills.  I will just call your doctor and see what he wants to do.”

“This dose isn’t quite right. Let me fax your dentist and check with her.”

Pharmacists face many challenges in their day, and solving drug related problems is one of the biggest.  Historically, without the power to enact change for our patients, we abdicated the responsibility for drug therapy problems back to our physician colleagues.   With the changing scope of practice sweeping across the country, many pharmacists are faced with having to use their skills to make clinical decisions which previously they would have deferred to another prescriber.

Pharmacists take patient safety as one of the pillars of practice.  We double and triple check everything, look into more than one reference when we’re unsure and refer when we don’t have a clear picture of the patient’s health.  This tendency towards “needing to be sure” is both an asset and a hurdle.

When I ask pharmacists what barriers they are experiencing that has them directing patients back to another prescriber for drug therapy problems they could easily solve within their scope of practice, I hear things like:  “I’m just not sure.”  “What if it’s something more serious?” “The references don’t agree.”  “I don’t want to take responsibility for that.”  “What if I make the wrong choice?”

While I always advocate for clinicians to care for patients within their scope of knowledge and skill, in many cases pharmacists have both the expertise and the ability and still choose to refer.  It is the hurdle of uncertainty.

Today I heard one of the most impressive explanations of the learning shift that one pharmacist has moved through on the road of practice change.

The most important thing I learned is that uncertainty is a natural part of our clinical decisions and that taking responsibility for our decisions and following up with patients can alleviate the burden of it.

Uncertainty will always be with us as medicine is both a science and an art.  Objective and subjective data collection, patient assessment, making clinical decisions, follow up…. all involve a combination of knowledge, experience and skill and the ability to make a decision that we take responsibility for.  The relationship with the patient and ability to follow up on the results of our decisions not only make us more effective at solving drug related problems, but provides a wealth of additional experience and knowledge to improve our practice and ultimately the care of our patients.

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Beyond Renewal->Adapting

"No matter where you go, there you are." -Buckaroo Bonzai

cc licensed ( BY ) flickr photo by Stefan Andrej Shambora: http://flickr.com/photos/st_a_sh/493343628/

Many colleagues have asked for examples of where they can adapt in their practice.  While expanded scope of practice is in different stages in each province, most provinces already have, or will soon have, changes in pharmacy legistlation to allow for pharmacists to adapt prescriptions.  Before we get into practice examples, let’s define adapting a prescription as the following*:

  • Renewing a current prescription without having a refill authorized by a prescriber.
  • Changing a dose, formulation or regimen of a prescription
  • Substituting another drug that is expected to have a similar therapeutic effect.

*(this most closely matches the legislation in Alberta)

Most pharmacists have no trouble renewing existing therapy.  Usually, the perception being that there is little risk in renewing for the short term a medication the patient is already on.  Where pharmacists hesitate is when they are faced with therapy that they feel is either inappropriate or less than ideal for their patient and making the decision to change therapy.

Caring for patients is complex business.  It requires patient assessment, drawing up of a care plan, making clinical decisions, ensuring any necessary follow up is done and collaboration with other health professionals.  As the level of care and decision making rises, so does risk.  Pharmacists often ask me about how to protect themselves against risk when making decisions.  While there is no fail safe, and there will be at some point a decision you will second guess or perhaps realize was in error, it is important to know that all clinicians make errors.  The primary concern of course is patient safety, and keeping our clinical decisions within bounds of our own personal knowledge and skills is essential.

So where to start?  If you are a pharmacist who hasn’t moved beyond extending prescriptions and is feeling uncomfortable with moving forward in clinical decision making, what do you do?  It is undoubtedly the way of the future, so how do you move forward?

One way pharmacists have moved forward in adapting and even further into independent prescribing is to take on a specialty.  There are many out there, for example: Certified Diabetes Educator, Certified Respiratory Educator, Certificate in Travel Medicine, etc.  These certifications often give pharmacists the confidence to make clinical prescribing decisions.

However, not everyone wants to obtain certification or write an exam.  For those who are in community or hospital practice, the confidence and ability to move forward can be gained, and the way to start is to just jump in.  It can seem overwhelming to look at your entire practice and scope of knowledge and pick out where you need to brush up or improve your skills.  What I often tell pharmacists is to start with ONE area.  Choose a therapeutic area that you are interested in or used to be interested in and start with that.

If you happen to have an interest in cardiovascular meds then choose learning in that area and focus on it.  Become familiar with the CCS guidelines for atrial fibrillation, dyslipidemia, heart failure, etc.  Or start with the newest hypertension guidelines.  Then, the most important step is to start applying your knowledge to your patients.   If it’s hypertension you have chosen then make a point of talking with every patient on an antihypertensive to see if they know what their goal blood pressure is.  Ask if they home monitor and teach them what their goal should be.  Ask patients to bring in a history of their home blood pressure monitoring numbers so you can assess whether their therapy is working for them. Once you start engaging patients and are confidant in your knowledge of the current guidelines, it will flow naturally to be assessing whether their antihypertensive therapy is appropriate and keeping them at target.  From there you will find yourself making clinical recommendations for changes in therapy.  So many patients fall through the cracks in pretty much every therapeutic area that there will be no lack of opportunity to make drug therapy decisions.

If you don’t know what your passion is, I usually suggest you start with something like pediatric dosing of antibiotics.  This is an easy foray into adapting doses with fairly clear guidelines for therapy.  Start with every pediatric otitis case you see and check if the drug being prescribed is actually indicated for otitis and whether it is indeed being prescribed at the correct dose.  Make ‘Bugs’n Drugs’ your best friend and double check in a second or even third resource when you start out.  It won’t be long before you won’t have to look up when to use high dose amoxil and what the dose actually is.  In a busy practice you will find yourself seeing many prescriptions that require adapting and it will soon become second nature for you to adapt them.  The first few times you may struggle on the wording of your notification to the prescriber, but soon it becomes second nature.

“Dr._______  I adapted the dose of amoxiciliin to 90mg/kg/day x 5 days for this patient with otitis media; she had antibiotic exposure two months ago and attends daycare (as per Bugs & Drugs 2012).  I have advised the mother on possible adverse reactions and will follow up with her in 5 days to see if symptoms have resolved.   Patient weight= 15kg”

Amoxicillin 450mg tid x 5 days

Joe Pharmacist BscPharm

December 13, 2013

Of course, taking responsibility for the clinical decision and prescribing means you have assessed the patient adequately.  This doesn’t take as long as you might think and becomes quicker and seamlessly part of your work flow the more you do it.  After assessing and adapting the prescription, the part where most pharmacists groan is in documentation.  Yes, you have to notify the prescriber (example above) and document your decision in the patient record.  Again, the more you do it the easier it becomes and the less time it takes.   Pharmacists document in all sorts of ways: DAP, SOAP, narrative, etc.  Something as simple as:  “Patient seen today with chief complaint of otitis media.  Has had one course of cefixime two months ago, attends daycare.   Rx was written at 30mg/kg/day x 10 days.  I adapted dose to 90mg/kg/day x 5 days as per Bugs and Drugs.  Follow up scheduled for 5 days for efficacy and ADRs.”

Of course you must ensure you follow all the regulations and Standards of Practice for your particular province.  Make yourself familiar with them and figure out how to meet requirements in an efficient manner that puts the least amount of stress on your work flow.

Moving out of our comfort zones is scary…that’s why they’re comfort zones, because we’re nice and comfortable where we are.  But guaranteed, once you start expanding your practice, professional satisfaction grows incrementally along with great patient care.

Navigating Change in Pharmacy Practice

Full ahead

cc licensed ( BY SA ) flickr photo by Maciej Lewandowski: http://flickr.com/photos/macieklew/336716711/

We all know change is upon us. The various pressure points prodding at pharmacy practice can seem overwhelming. Disappearing rebates and pharmacy profitability shifting to professional services means that filling prescriptions at top speed is no longer fueling profit and focus is shifting to billable professional services. Undoubtedly, much has to change in our practices to move forward into a new practice paradigm. What’s the path and how do we get there?

Conversations with colleagues and implementing change in my own practice has brought forward five main “change points”:

Work flow

Workflow as it currently is in most pharmacies is highly inefficient for the new era of pharmacy practice. We mostly see pharmacists at the back end of work flow checking and counseling patients. This is highly inefficient as problems are often not discovered until the prescription has been inputted, processed AND the patient has waited for “x” amount of time. If the pharmacist finds a problem at checking or counseling, the entire process starts over again. In addition, there is no assessment of the patient’s indication, possible drug related problems, or an efficient tagging of possible clinical services (ie: billing opportunities). The skill of being able to quickly pin point what clinical services we can bill for at each patient encounter is becoming more and more critical as profitability in product decreases and profitability in expanded services increases. (More on this in The Future of Pharmacy Practice.)

Responsibilities

We have been hearing for years that technicians need to take on more roles and responsibilities in the dispensary. In many provinces, technicians can check another technician’s work. For the new era of pharmacy practice, this is essential. Pharmacists will be more hands off in dispensing leaving the preparing and checking of prescriptions to their technicians. The availability of qualified pharmacy technicians and change in their scope of practice is paramount to change in pharmacy practice.

Software

Pharmacy software historically has fallen short in allowing clinical documentation. In saying that, most pharmacists haven’t been using or searching for this function. We need software developers to move forward in this area. (This may involve pressuring your software company for further change.) However, some software you can actually work with. It just may take some figuring on how to maximize your software functions for your documentation needs. Software incapabilities should not be used as a reason to not move forward with practice change. Move forward, work with what you have, and push for software updates to make documentation and collaboration requirements (ie: copious faxing) seamless in your practice.

Confidence

Pharmacists that I have worked with and/or mentored in practice change, often confess that they just don’t have the confidence to “make the call” when it comes to drug related problems. They’d rather put the ball back in the physician’s court to make decisions. Even when they are SURE that there is a better drug or regimen or dose for their patient, they send a fax so the physician can make the change. There are many reasons for this, better addressed in a separate post, but most pharmacists cite a lack of confidence, perceived or real lack of knowledge, and lack of time to feel comfortable assessing the patient and making the decision.

Most pharmacists are on the back end of dispensary workflow, being called forward by a technician for counseling or if they encounter what they determine to be a real problem. But there’s the problem. We are depending upon our technicians to identify problems or patient needs rather than assessing for ourselves whether the patient has a drug therapy problem. This workflow arrangement misses countless problems, and with the new billing framework, countless opportunities to bill for patient care services.

Tackling a lack of confidence and knowledge/skills can seem overwhelming but in fact it is not. It can be done in a step by step manner with each step building upon the previous one. Assessment and prescribing skills can be sharpened and confidence builds with the applying of new skills. The amount of time spent documenting, assessing and following up with patients also becomes shorter as comfort and skill level increases.

Expectations

Pharmacists’ relationship with physicians and patients is changing. Physicians are receiving more “notifications” of prescription changes and pharmacist prescribing rather than “requests” or recommendations. (And yes, this is causing some tension and confusion between the professions.) Patients, on the other hand, are experiencing a higher degree of care and assessment. While patients have to become accustomed to waiting longer to see a pharmacist, most will realize, through experience, that when they do see their pharmacist their drug therapy is ultimately improved.

Within each of these change points there are individual barriers unique to each pharmacists practice setting. How we address our barriers and move forward will ultimately determine the sustainability of pharmacy practice.

Disillusioned?

ccFlickr shared by MacQ

I remember the day I realized I was caught in the prescription mill and it seemed there was no way out. I was standing in the pharmacy, just a couple years out of university, with some of Linda Strand’s writing in my hand. I knew without a doubt that “Pharmaceutical Care” was what I should be doing. I also knew that I had no idea how to “do” medication management. I didn’t know any pharms who were doing it, was not really taught it in university, and I had ALL these prescriptions to deal with non-stop all day.

Okay, so that was 1996… but I know I’m not the only one who had a rude awakening once they started their professional practice. Wasn’t I supposed to help patients manage their medications and optimize their therapy? Make sure patients who needed drug therapy received it and those that were receiving unnecessary drugs were identified?

Yup, that’s really our job. The prescription mill? A trained tech can produce an accurate Rx from a hard copy. As a matter of fact there’s probably a computer out there that can read an Rx and spit out an accurate product. It’s not rocket science.

But looking at the over all picture of a patient from their labs, self reporting of chief complaint, previous response to meds and current drug therapy, etc. and deciding whether the Rx in front of you is really the BEST therapy for that patient…or if they really even need drug therapy at all? That’s the art and science of Pharmacy. Making the clinical decision to adapt (change) that prescription or prescribe for that patient, when you know therapy can be improved, then following up on that care…no machine can manage that. It takes knowledge, clinical experience, triage skills, sourcing of info, patient interview skills, ability to refer and knowledge of your own personal skill set and boundaries.

In considering all that, what I often hear from colleagues is that it isn’t possible. We have no time, not enough support staff, our software isn’t capable of what we need it to do, it takes too much paperwork, etc.

And really…when you’re stuck churning out hundreds of scripts a day it’s easy to slowly drift into apathy, or feel burnt out…tuck your head down and do a great job of at least searching out drug interactions (or assessing the clinical validity of the ones the computer caught), checking doses that look way out there, answer patient’s questions… Just be accurate, make no mistakes and go home.

Over the years as I worked at top speed in the mill, I lost a lot of my clinical skills. What you don’t use you lose, right?  I hadn’t looked up an A1C on a patient or applied the newest Otitis guidelines in so long I was afraid to start.

If I was given the perfect circumstances, all the time I needed, the ideal practice setting…would I be able to do the job I wanted to? Could I take responsibility for a patient’s medication management, make recommendations on drug therapy, solve complex drug related problems? Well…I wasn’t sure.

We know that care of the patient is our primary task.  Pharmacists have no problem putting patient’s first. I see it every day. We’ve never been paid to talk to patients or assess medical issues and make recommendations, but we do it.

Where we can be our own worst enemy is in lacking the confidence to make the shift into medication management:  to take responsibility for clinical decisions, make the call, sign our name to the decision.  And sometimes we know that our skills need to be sharpened and our knowledge refreshed but we don’t know where to start.

Mentorship and good learning opportunities are essential for practice change;  Assessing for yourself what you need in order to shift your practice and feel comfortable doing it, and finding the energy and passion to embrace change.

We now have the framework, have a start at being paid to manage patients’ medication therapy, not just handle prescriptions; and it’s up to us as a profession whether we take it up, change our mind set, our focus and move forward.

Starting Out

cc licensed flickr photo shared by stevendepolo

Lately I’ve had several colleagues ask me about practice change.  How do we boldly move forward in a new era where we are taking responsibility for drug therapy decisions and prescribing for our patients?  How do we brush up on our clinical skills and learning if we feel unprepared or not knowledgeable enough to take on this role?

I don’t know about you, but for many years I would do the basic CEUs, get them done for credit, and move on.  Need 15?  Got ’em.  I may have picked up the odd lesson in something I’m interested in or read a monograph for a new drug out of necessity because I was dispensing it more, but the learning often didn’t translate into my practice.  After the credit, much of the learning is forgotten.

What I have discovered in the course of changing my practice is that learning has to be relevant and integrated into my daily work for it to be useful.  For example, I don’t know how many CEUs I’ve done over the years on Diabetes…but I never could remember the incretin system.  DPP4 Inhibitor verses incretin mimetic?  Nada… Until I had a patient I was managing who was started on one.  Then when I re-read the guidelines, the monographs, re-learned the incretin system, etc.  I never forgot it again.  I had probably looked up the product monographs of each of the gliptins and liraglutide a dozen times when needing to counsel a patient, but it stuck with me now because it mattered.  Because I wasn’t simply counselling on side effects, I was making decisions regarding drug therapy for the patient.  I had chosen to take on the responsibility of medication management  which involved making changes in therapy. ie/ the buck stopped with me.  It created a learning curve that I had to dive into.  But now I make those type of recommendations on a regular basis.  And when I follow-up with those patients, find out how my therapy changes have affected them both for outcome and ADRs, my learning is multiplied.

What I am saying is that it has to start somewhere.

In the course of talking with colleagues I always ask them what their passion is within pharmacy.  If they don’t know, I ask them what medical condition or drug class is most interesting to you.  Did you love microbiology? (I hated it!)  But if you do, then start there.  Find out what the indication is for the antibiotic prescriptions you are dispensing (a convo with the patient will usually do) and create a learning curve for yourself.  The first few times you may need to look up the empiric therapy for a pediatric bladder infection.  But after a few, it will be automatic to adapt an Rx from Amoxil to Suprax for a child who had no urinalysis done.  After engaging that parent and making the choice to take that responsibility, you’ll never forget what you’ve learned and will apply it to other patients.

That’s the beginning of practice change.  Will you make some mistakes & occasionally feel foolish or incompetent?  Sure you will.  Think of all the mistakes from other prescribers you make calls on every day.  Our entire career we keep learning and improving, but the end result is better health care and knowing that you are making a huge difference in the lives of your patients.