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.

What’s In Store : The Future of Pharmacy Practice

Future Up ahead sign

cc licensed ( BY SA ) flickr photo by OTA Photos: http://flickr.com/photos/101332430@N03/9681096812/

 

During an interview last week I was asked what pharmacy practice would look like 5-10 years from now. Seems to be the burning question these days…..change is here (whether we want it or not!)

  • rebates are disappearing
  • financial pressures are increasing
  • alternative reimbursement structures are popping up in every province
  • expanded scope of practice is moving forward
  • new roles for technicians

When the dust settles, where will the practice of Pharmacy end up?

The various points of influence and pressure are propelling pharmacy practice towards the focal point of patient assessment.

Of course, assessment has always been a part of pharmacy, usually coming second to dispensing, but we’re at the cusp of seeing assessment become our driving focus.

What do I mean by that?

Historically, decisions on drug therapy have mostly been made by physicians, dentists and more recently, nurse practitioners. Pharmacists have assumed the prescription was appropriate and should be the best drug for the patient. Our role was to maximize the benefit and reduce the risk for the patient (by checking dosing, drug interactions, counseling and suggesting compliance strategies, etc.)

This jived well with profitability in community pharmacy which has historically been fueled by filling prescriptions as fast as possible. Most pharmacists, overwhelmed with the basic necessities of checking the processing and accuracy of the prescription, have not been given the time or workflow ability to assess the patient.

One of a pharmacist’s main responsibilities has always been to assess whether a drug is appropriate for the indication and is indeed the best choice for that patient. It’s a core standard of practice, but one that hasn’t reached it’s full potential. (A practice consultant at the College of Pharmacists in Alberta recently told me she “almost never” sees a notation on the prescription about the patient’s indication.)

As the pressure to change increases and pharmacy moves forward, what we will see is pharmacists taking on the role more and more of prescriber, and at the core of prescribing is patient assessment.

We are seeing this already in the ability to extend, adapt or change a prescription. This role is expanded in some jurisdictions with the ability to apply for full prescriber or initial prescribing status.

However, the uptake in adapting/prescribing has been slow in provinces where pharmacists have the ability to do so. Billing statistics show that pharmacists will more easily extend (renew) a prescription rather than change one. They will also more easily extend a prescription for one week than for three months. It seems the more assessment required (and the more risk), the less likely pharmacists are to prescribe.

Prescribing DOES involve more risk. It also requires time to assess a patient and do the proper documentation to go along with it. So in an already busy practice, why is this change in practice paradigm coming and why should we care?

Here’s why:

Good for PROFITABILITY

Let’s face it, we don’t have a job if our pharmacies are not profitable. It doesn’t matter if you are independent or corporate, staff or owner. Health care is a business and no business survives running in the red. Right across the country pharmacy sustainability is being shaken up. Profitability of pharmacy has always rested on script count. The more prescriptions we could pump out, the more profitable we were. This led to pharmacists coming out of school, being thrown into primarily a dispensing role, and over the years losing their clinical skills and confidence in patient assessment. Some pharmacists even found themselves being told by employers to “cut down on counseling” to get back to checking.

With rebates disappearing, the profitability of the prescription mill is going down. However, reimbursement for expanded clinical services is increasing. Being reimbursed to extend, adapt, assess, independently prescribe, do med reviews and follow ups, treat minor ailments, etc will put financial pressure on pharmacy practice to change. To provide these services efficiently, our assessment and documentation skills need to be dusted off and sharpened up.

Good for PATIENTS

Pharmacists as prescribers are in a very unique position. We have immense background knowledge of evidence based practice, clinical guidelines, drug availability, plan coverage and clinical experience with patient factors such as kidney function and weight. We can see the entire picture for that patient, for the third party payer and for our practice. Indeed, that puts us in the best position for deciding on drug therapy for our patients.

Pharmacists as prescribers also have the best arsenal to improve patient adherence. The ability to change a patient’s therapy and follow up in a timely manner provides efficient patient care which improves patient satisfaction with their therapy (which increases adherence). Providing short supplies of new medications, following up and then adjusting a patient’s dose, regimen, or switching to an entirely new medication results in a tailored drug regimen that fits with the patient’s lifestyle, expectations, drug coverage and overall medication regimen. This actually goes beyond adherence as you are partnering with the patient to provide shared care.

A quick example: Patients starting on gabapentin for neuropathy often stop therapy due to adverse effects or perceived ineffectiveness. It is time consuming and frustrating to book appointments over and over again with a physician until the dose is adjusted correctly. Patients will often give up due to adverse effects or thinking it just isn’t working for them. If that patient is followed up every week by their pharmacist, the pharmacist can work with the patient to fine tune therapy. (Experiencing too much drowsiness? Slow down on the taper up. Tolerating fine but pain relief not there? Taper up towards max dose.) We can fine tune a patient’s medication, improve adherence and bill for follow up services which makes the service profitable.

Good for THIRD PARTY PAYERS and GOVERNMENT

No shocker here, but government and third party payers want to save money. We’re constantly hearing that drugs are the leading driver of rising health costs. Pharmacists are in an ideal position to save payers HUGE dollars. (Your patient needs an ACEI. Should you choose Mavik or ramipril, both of which have the same therapeutic response?) When most pharmacists consider cost they are usually looking at what it is going to cost the patient. Not as much thought goes into what it is costing the third party payer. (If Mavik and ramipril are both covered, the cost difference to the patient is often minimal. The cost difference to a third party payer over time is immense.) Pharmacists have extensive background knowledge on drug cost and evidence based interchangeability (as opposed to just pharmacokinetic interchangeability). It’s the ability to save the patient and the payer huge dollars. There is a big role for pharmacists that third party payers are missing. The ability for pharmacists to save on drug costs is an emerging partnership that will have greater impact as pharmacist prescribing continues to increase.

We know change is upon us. In a nut shell, we are going from “How do I make someone else’s choice of medication work best for this patient” to “What IS the best choice of medication therapy for this patient” and taking an active role in assessment, prescribing and adjusting patients’ medication therapy.

Guaranteed that every pharmacist could name several barriers to this change in practice. Conversations with colleagues and implementing change in my own practice has uncovered many obvious and not so obvious ones. There is no doubt that much needs changing in the structure of our practices and the environment of health care to facilitate pharmacy moving forward. These will be looked at in “Navigating Change in Pharmacy Practice.”

Picture this: FUTURE PRACTICE

Pharmacist is sitting at an intake desk. Patient sits down and pharmacist proceeds with assessment. “What did you see your doctor for today?” Pharmacist assesses indication, history of chief complaint, and (if not already on file) any allergies, medical conditions and current meds. Pharmacist checks the provincial system for additional information (labs, kidney function, medications), decides the ciprofloxacin being prescribed is not a good choice given patient’s advanced age and medications. As well, the UTI ( without a urine screen) is better treated empirically with cefixime. Pharmacist can adapt the Rx, bill for the assessment and counsel at intake. The patient is handed the pharmacist’s business card and advised to call if any issues crop up with the therapy and the pharmacist enters a phone follow up reminder into the computer software to pop up in 7 days. The pharmacist writes up the adapted prescription and passes the Rx back to a technician and doesn’t see it again. The pharmacist then moves onto the next patient.

This may sound unreal in a busy pharmacy where patients are lined up. However, the current work flow set up with the pharmacist at the back end of dispensing is highly inefficient and unprofitable with the new framework. If a drug related problem (DRP) is uncovered when checking or counseling, or the patient requires additional therapy or it really should be a refusal to fill….. think of all the time wasted inputting, processing, preparing… perhaps for nothing! And all that time the patient waited; only to wait again after you assess their drug related problem and provide them what they REALLY need. The biggest problem with pharmacists at the back end of work flow is that the majority of DRPs are completely missed due to a lack of patient assessment….and so are the billing opportunities.

It requires a paradigm shift in the role of the pharmacist. A lot of time is wasted in pharmacy by the pharmacist only coming in at the end to check and counsel. That time can be put in at the front end. It requires a change in employer and patient expectations. Yes, it may take longer at intake, but that pharmacist may provide professional services billing that exceeds dispensing fees, gains a loyal patient and provides more billing opportunities by scheduling follow ups into the system during assessment. Once used to the change, patients are more than happy to wait when they know they will have a conversation with the pharmacist and be assured their therapy is appropriate.

Assessing a patient can also seem time consuming, especially when you are not accustomed to this type of work flow. However, like anything, the more you assess and document, the more comfortable it becomes and more efficient the process. Pharmacist initial assessment of the patient is necessary for the new framework to be profitable. It cannot be left up to the technician to decide if there is a problem or expanded service billing opportunity. At intake the pharmacist can immediately assess the appropriateness of the prescription in front of them, the needs of the patient, can pull up patient history and determine right then what is needed. Does the patient need an adapt? Do they need an additional drug prescribed? Do they need nothing at all today? Do they need a med review scheduled? Do your previous notes indicate they’re due for an A1C? Was there a missed follow up that can be completed and billed? When was their last blood pressure check?

A quick example: If you’re at intake, it’s easy to assess a patient who has high cardiovascular risk being prescribed diclofenac for acute pain as benefiting from a change to naproxen. Adapting that Rx is within every pharmacists’ scope of practice in Alberta (and most provinces, if not now, then in the future). So you’ve improved patient care, reduced risk, and billed for a professional service. (And that Rx was handed off to the tech, and given to the patient on the back end because you’ve already counseled them during your assessment.)

As pharmacists get more used to documenting and triage this takes less and less time. The pharmacist can then write up a prescription (and note which clinical service to bill), or if deemed the Rx is fine, send it back to the tech to prepare and have it checked by a registered technician. Technicians on the back end of pharmacy makes sense. Technicians can teach patient devices like inhalers, blood pressure and blood glucose meters, how to draw up liquid medications, etc. These are all technical functions. When fortunate enough to have pharmacist overlap, the second pharmacist can handle any unanswered questions. Most often, with this type of patient care, additional questions or problems that may come up can be answered in a phone or email follow up (and billed as a follow up service).

It can be comfortable being in the back of the dispensary, being called forward by a technician for counseling or if they encounter what they determine to be a problem. Assessing at intake can seem daunting if you feel out of practice or it’s out of your comfort zone. However, steps can be taken to develop skills, knowledge and confidence while pharmacists are still at the back end, to prepare for the shift to more focused patient assessment.

I would argue that pharmacists are returning to the role they were trained for. Pharmacy schools are preparing their grads for patient assessment and drug therapy decision making. Many of them are coming out ready to embrace that role. What they are finding is that the the majority of practices have not changed.

However, the financial pressures and changing reimbursement and scope of practice structures will force change. We MUST change for the profession to be viable. Technicians can dispense, check prescriptions, teach devices and manage inventory. More and more patients use mobile devices or the internet to learn about their drugs. Assessing drug therapy, tailoring a patient’s drug regimen, solving drug related problems and providing timely follow up is a pharmacist’s expertise, and an essential component of health care that cannot be replaced.

Worth It

ccFlickr shared by Eduardo Llanquileo

It’s been awhile since I’ve been here…..I sat down today and thought about what had changed and why I haven’t been writing.

I guess I have just been tired… It has been an overwhelming couple of months with many changes.   Changes that have taken the pharmacy practice I love into the scary place of perhaps not being sustainable.  Government decisions, which have been short sighted and without consultation with the front line health professionals who are affected, have been devastating.  Even as the government back pedals in an attempt at damage control, the changes will continue and have a vast impact on the health of Albertans’ and the sustainability of pharmacy.

The emotional roller-coaster of connecting with hundreds of other pharmacists across Alberta who are in the same position has been both inspiring and enhausting.  I have met so many professionals who are utterly committed to their patients; but it is heartbreaking to hear of some colleagues, near retirement, who may lose the value of their practices they spent years building.

I am many years from retirement and am hopeful this will not be the case for me, but there have been days I have walked into the place I love and found it difficult.  Wondering if decisions, which are in government’s hands, would take away what I have been building.

Then yesterday I received a letter from the College of Pharmacists that I have been anxiously waiting for.  For over a year I’ve been putting together my case to apply for prescribing rights.  I finally completed the process and sent it off.

While I have had limited prescribing rights for years, there have been many times when caring for patients that I have felt like I had my hands tied when I couldn’t prescribe what I knew they needed.

My son handed me the letter from the College, and when I opened it he asked me why I was grinning.

I had received my prescribing authority; and it was more than the expanded ability to serve my patients that had me grinning.  It was hope.  I could see that I had been losing my joy…the reason I was building my practice in the first place.  This affirmation caused me to take a step back and realized that I am exactly where I always wanted to be.  I practice with colleagues whom I highly value and continue to learn from and I am in my own pharmacy able to care for my patient’s exactly as I want.  Definitely worth it.

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Worthy Praise

CCflickr shared by Avard Woolaver

Some of us are better at recognizing our own gifts and talents more than others.  Most people, if pressed, could list two or three of their own talents.  Usually they are obvious ones; personal skills or expertise that has contributed to our career, or positive personality traits we have developed.

What might not be obvious are the gifts you have that impact other’s lives.  Just like those around us may not be aware of the gifts we feel they have.  Humans can be slow to praise and general in our thanks.

The people we work alongside, those we run into day-to-day, probably have no idea that we appreciate them or recognize their contribution and hard work.  I was involved in a virtual chat with health leaders/practitioners across the globe (although mostly North American) and we were tossing around what the essential qualities were for showing appreciation and thankfulness.  Some of the prevailing thoughts were that praise should be:

  • Genuine:  Praise that is not genuine feels contrived.  If you don’t actually recognize the value of and appreciate the person, don’t say it.  This involves some reflection on our part, as everyone has value and talents.
  • Specific:  One of the most meaningful compliments I ever received was being told that I put people at ease, help them feel  comfortable.  That’s specific, and something I didn’t know. Referencing a specific incident or particular skill is valuable when offering praise.  It shows you recognize specific qualities and often encourages personal growth for the person being praised.
  • Generous Praise to colleagues, staff and friends should come with no strings attached, no “to-do” list at the end.  It should just be what it is, an acknowledgment of hard work, contribution, or talent.
  • Personal  What came up over and again is that praise which is personal means more.  Praising colleagues or staff publicly in newsletters, staff meetings, in posts online, all are important.  But so is the handwritten note, or the phone call or the one-on-one thanks.

We all need to feel acknowledged and appreciated.  Remembering to show gratitude or praising our colleagues and staff is an important part of team and community building.

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.

Patient Gratitude

A few weeks ago a colleague warned me that in the first year of owning and running a new pharmacy I would conclude that I had made a huge mistake.

Yup….that happened well before turning the sign to “open”!

The two weeks leading up to my opening day were chaos.  I’ve never slept so minimally, had my “to do”list grow so fast, nor seen my children so little.  As I heard repeatedly, “Mom, are you coming home late again today?” I figured I had made a mistake.  I am a clinician; I love the “care” part of health care, and here I was, steeped in putting a business together. Spending hours on end away from my family, and even when with them my mind was racing with all the things I needed to handle.

So when I walked into my brand new pharmacy on day one and flipped the sign to open, I wondered whether I had jumped into something I would resent, or at the very least not enjoy.

Then came patients through my door.  Just a few at first, and a few more each day, and I found myself in a place of privilege.  As I provided health care, I heard their stories.  Stories about caring for terminally ill spouses, stories of how difficult it is to live with chronic pain, journeys through chemo and disappointment with the system.  Even stories of past jobs and places they had visited in their life time.  As I immunized many against the flu I also shared a lot of my own story.  How I came to be in this new pharmacy, growing up in Saskatchewan, how I had started a pharmacy in Chemainus when I was very young.

It struck me once again that the connection made and the care given are what brings me joy.  Having my own pharmacy means I can structure and set up to practice the way I want.  I have control over how I care for the people who walk through my door.  There is no one to tell me I must meet a certain quota or promote sketchy treatments or unproven products.  In the end, it is worth all the headaches that I am sure will come.  So it is to the people who came through my door this week that I am grateful to, for reminding me what it’s all about.

Care of the Patient

cc Flickr shared by By Pulpolux !!!

This post has stuck with me for weeks, and while I blogged about it on my personal site, I feel it has a lot to say to me as a health professional.  So often, as we concentrate on our patient’s heath issues, solving drug related problems and working to optimize their therapy, we can overlook the big picture.  We forget that what is simple to us can often be overwhelming or beyond understanding for our patient.

A Reason To Celebrate

–posted by Dodo on Jul 7, 2012

Numbly, I left my husband, Marty, at the hospital where I had been visiting two of my children and headed for the grocery store. Since it was eleven p.m., I drove to the only store I knew was open twenty-four hours a day. I turned my car motor off and rested my head against the seat.

What a day, I thought to myself. With two of my young children in the hospital, and a third waiting at Grandma’s, I was truly spread thin. Today I had actually passed the infant CPR exam required before I could take eight-week-old Joel home from the hospital. Would I remember how to perform CPR in a moment of crisis? A cold chill ran down my spine as I debated my answer.

Exhausted, I reached for my grocery list that resembled more of a scientific equation than the food for the week. For the past several days, I’d been learning the facts about juvenile diabetes and trying to accept Jenna, my six-year-old daughter’s, diagnosis.  In addition to the CPR exam I’d spent the day reviewing how to test Jenna’s blood and give her insulin shots. Now I was buying the needed food to balance the insulin that would sustain Jenna’s life.

“Let’s go, Janet,” I mumbled to myself while sliding out of the car. “Tomorrow is the big day! Both kids are coming home from the hospital. … It didn’t take long before my mumbling turned into a prayer.

“God, I am soooo scared! What if I make a mistake and give Jenna too much insulin, or what if I measure her food wrong, or what if she does the unmentionable—and sneaks a treat? And what about Joel’s apnea monitor? What if it goes off? What if he turns blue and I panic? What if? Oh, the consequences are certain to be great!”

With a shiver, my own thoughts startled me. Quickly, I tried to redirect my mind away from the what ifs.

Like a child doing an errand she wasn’t up for, I grabbed my purse, locked the car, and found my way inside the store. The layout of the store was different than what I was used to. Uncertain where to find what I needed, I decided to walk up and down each aisle.

Soon I was holding a box of cereal, reading the label, trying to figure out the carbohydrate count and sugar content. “Would three-fourths a cup of cereal fill Jenna up?” Not finding any “sugar free” cereal, I grabbed a box of Kellogg’s Corn Flakes and continued shopping. Pausing, I turned back. Do I still buy Fruit Loops for Jason? I hadn’t even thought how Jenna’s diagnosis might affect Jason, my typical four-year-old.  Is it okay if he has a box of Fruit Loops while Jenna eats Kellogg’s Corn Flakes?”

Eventually I walked down the canned fruit and juice aisle. Yes, I need apple juice, but, how much? Just how often will Jenna’s sugar “go low” so she will need this lifesaving can of juice? Will a six-year-old actually know when her blood sugar is dropping? What if…? I began to ask myself again.

I held the can of apple juice and began to read the label. Jenna will need fifteen carbohydrates of juice when her sugar drops. But this can has thirty-two.  Immediately I could see my hand begin to tremble. I tried to steady the can and reread the label when I felt tears leave my eyes and make their way down the sides of my face. Not knowing what to do, I grabbed a couple six-packs of apple juice and placed them in my cart. Frustrated by feelings of total inadequacy, I crumpled up my grocery list, covered my face in my hands and cried.

“Honey, are you all right?”  I heard a gentle voice ask.  I had been so engrossed in my own thoughts that I hadn’t even noticed the woman who was shopping along side of me. Suddenly I felt her hand as she reached towards me and rested it upon my shoulder. “Are you all right? Honey, are you a little short of cash? Why don’t you just let me…?”

I slowly dropped my hands from my face and looked into the eyes of the silvery haired woman who waited for my answer. “Oh, no, thank you ma’am.” I said while wiping my tears, trying to gather my composure. “I have enough money.”

“Well, Honey, what is it then?” she persisted.

“It’s just that I’m kind of overwhelmed. I’m here shopping for groceries so that I can bring my children home from the hospital tomorrow.”

“Home from the hospital! What a celebration that shall be. Why, you should have a party!”

Within minutes this stranger had befriended me. She took my crumpled up grocery list, smoothed it out, and became my personal shopper. She stayed by my side until each item on my list was checked off. She even walked me to my car helping me as I placed the groceries in my trunk. Then with a hug and a smile, she sent me on my way.

It was shortly after midnight, while lugging the groceries into my house, that I realized the lesson this woman had taught me. “My kids are coming home from the hospital!” I shouted with joy. “Joel is off life support and functioning on a monitor. Jenna and I can learn how to manage her diabetes and give her shots properly. What a reason to celebrate.” I giggled to myself. “I have a reason to celebrate!” I shouted to my empty house.

“Why you should have a party,” the woman had exclaimed.

And a party there will be!

The human side of patient care cannot be learned in school.  It can only be taught to us by those we care for… our patients. 

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.

Burn out

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Burn out …. who hasn’t experienced it working in health care?  We are under the gun, trying to deliver health care to the maximum amount of patients in the least possible amount of time.

I recently read a great post written by Dike Drummond on “Compassion Fatigue”. I had never heard the term before, but it resonated with me as a truth. Compassion fatigue is a signal that burn out is approaching. What struck me was the way it was described. Not the typical symptoms of just being tired and unenthusiastic.

Compassion fatigue is when you find yourself challenged to care about your patients in the way you know is proper and expected in your position. One of the key components of quality healthcare is the ability for you to connect with your patients and for them to sense that connection….

Cynicism, sarcasm and feeling put upon are the first signs

If you find yourself being cynical or sarcastic about your patients you have compassion fatigue. It can come in the little voice in your head, or mumbling under your breath or “venting” to your colleagues or staff.

There have definitely been times in my professional life when I have felt this way. When an “interruption” by a patient was a bother while I was trying to complete other work.  There are times when I have definitely felt my empathy was out of reach.

Sometimes the signs are there, but I don’t recognize them. It’s easier to just keep going, be exhausted, unenthusiastic and get through the week.  Easier to stay in the place where you aren’t happy doing what you’re doing, can’t be in the moment, and wish you were anywhere and doing anything else.

At those moments I’ve lost the passion for my work, that spark, the reason I got into this gig in the first place.

And mix that with being physically exhausted and feeling like your work has no bigger purpose or meaning…that’s burn out.

Drummond has many suggestions for battling compassion fatigue including scheduled rest, exercise and personal time.  I would also add that as health professionals we need to feel our work is making a difference.  If we feel we are simply handing T3s to the next addict, managing drug shortages and talking to insurance companies… it is difficult to see the real difference we are making in the lives of our patients.  That can leave us unenthusiastic and just plain tired.

So, I would add to Drummond’s suggestion that as health professionals we need to find meaning in our work.  We need to see tangibly that we are making a difference for our patients.  The easiest way to do this is by being as involved as possible in patient care.  Get involved in improving patient  therapy, not just the solving of all the technical problems.  We need to rediscover our role as experts in medication management., carve out minutes in our days for those follow up phone calls, and keep on learning as we move forward in our practice.

E =

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E = EXACT

Health Care is not an exact science.  That’s right.  We want it to be…and I see much frustration, disappointment and even desperation because of this fact, but it’s the truth.  Despite all the medical advances and advertising of drugs that seem to point to the opposite, there really isn’t a “pill” for every illness or a test to diagnose every medical condition.  Sometimes there is no clear cut answer to a health problem, nor a solution.

Medicine and Pharmacy are applied science which means we take science and apply it to people.  We take everything we know about anatomy, microbiology, pharmacology, biochemistry, therapeutics, etc., and apply it to individuals who have their own unique physical, biological and genetic differences (not to mention the social, cultural, and psychological aspects).  From this application of knowledge to each individual situation, diagnosis is made and treatments are decided upon.

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E = ERRORS

This applying of science also means that medical care is not perfect.  Combine that with the speed at which this knowledge needs to be applied to patients and situations, errors are inevitable.  Here’s a quote from Dr. Brian Goldman that had me thinking this week.

What I’ve learned is that errors are absolutely ubiquitous. We work in a system where errors happen every day.  Where 1 in 10 medications are either the wrong medication given in hospital or the wrong dosage…  In this country as many as 24,000 Canadians die  [every year] from preventable medical errors. [which is a gross underestimate]

We all know someone who has had sub-optimal medical care or errors made in their care.  Often there is anger towards the professionals that made the mistake.  I’ve been on both ends of that situation.

There is an expectation of perfection in health care.  As patients we expect our health professionals to be competent, and so we should.  But as a health professional I know we are all human and lack perfection.  We all fall short and can make mistakes.

I’ve made mistakes in my career and will most likely make a few more before I am done.  Fortunately I have never made a mistake that has seriously harmed someone or caused a death.  But I know each time I put my lab coat on it is a real possibility.

cc licensed flickr photo shared by chrisinplymouth

E= e-PATIENT

The possibility for error is why I continually encourage people to be engaged in their health care.   Not because you shouldn’t trust your health providers.  Quite the opposite.  You need to be an active partner so a trust relationship is essential. Working as a team is the best way to ensure optimum health care.  How can you do this?  Get to know your own body, your medical conditions, your medications.  Ask questionsWe need you to be as educated as possible.

More and more patients are getting health information over the internet.  (Interestingly, Health Professionals are often divided over this.  Some thinking this is great and others not so much).  I think the more knowledge you acquire about your own health the better.  And this is where the trust relationship comes into play.  Yes, there can be some bad information out there.  So you check it out with your doctor or pharmacist.

Last week I had a patient in tears because she had read on the internet that her diabetes medication could give her seizures and she didn’t know what to do.  Was that good information?  No.  It wasn’t true.  But I didn’t advise her to stay away from internet health information.  I provided her with some reputable sites and encouraged her to learn more about her disease and contact me in a week to go over what she had learned.   As one e-patient says in this video, “When push comes to shove you check with your [health professional]. They’re there for a reason”

Here’s an example of the growing movement of “e-patients.”  As you’ll see, the “e” stands for many great attributes that can lead to a safer, more participatory, less paternalistic model of health care.