By Min Kwon, Pharm.D., PGY1 Pharmacy Practice Resident, Johns Hopkins Hospital
I remember the day I found out that I got internal medicine as my first rotation as part of my advanced pharmacy practice experiences. I was so excited! I remember spending a month before the rotation reviewing all of my notes from the previous 3 years in pharmacy school. I looked over all the disease states. I memorized which medications were 1st line and what side effects to look for. I felt so prepared and ready to apply what I’ve been learning to actual patients. But I was not prepared for what happened next.
On the first day, my preceptor brought me up to the medical resident’s office and told me this would be the team I would be rounding with and introduced me to the team. The team consisted of 2 medical students, two interns and one post-graduate year 3 (PGY3) medical resident. They all said “hi” and immediately returned to what they were doing. It wasn’t exactly the warm open arm welcome I was expecting, but I tried to stay positive. As we started rounds, the students or interns started to present patients and they would discuss different aspects of each patient’s disease course and medications. I noticed that one medication needed renal adjustment and therefore, after rounds I discussed it with my preceptor. With my preceptor’s approval, I felt confident about the recommendation - so I went to find the intern taking care of the patient. I approached the intern and asked if she would change the dosing on the medication based on the patient’s poor kidney function (as evidenced by her estimated creatinine clearance). The intern looked at me with dismay and said “I am not going to change anything and don’t tell me how to manage my patient’s medications.” I was in a state of shock … disbelief. I couldn’t believe she wasn’t even going to consider my recommendation. Why didn’t the medical intern understand my role as a pharmacist on the team?
As a background, I went to school in New York and had most of my rotations in city hospitals. In New York, many feel that clinical pharmacy practice still lags behind many other places in the US. Even after 10 years of pharmacists going to the state legislature in Albany to advocate for collaborative drug therapy management, laws permitting this practice still had not passed. Pharmacists just received the right to vaccinate in the past year. Many physicians in New York are not aware of what clinical pharmacists can bring to the team. After 3 years of pharmacy school, no one ever told me that I might get push back from physicians or how I should handle these types of situations. I went into my clinical rotations assuming that the medical team would be embrace me. I assumed they knew my role on the team. Well that was definitely not the case. Instead, I found myself routinely demystifying all their beliefs about pharmacists. Some of the medical students assumed pharmacists went to school the same length of time as nurses and that pharmacists only worked in retail settings or in the basements of hospitals.
When looking back at my pharmacy curriculum, I realize that all the pharmacology and therapeutics courses did not prepare me one very important tool needed as a clinician. I needed to learn how to build collaborative relationships on a multidisciplinary team. As I neared the end of my Doctor of Pharmacy curriculum, I realized that the dynamics of developing collaborative working relationships between pharmacists and physicians is not straightforward. It requires a lot of thought and dedication.
Pharmacists are aware of the expertise we can provide the medical team to improve a patient’s drug therapy. However, physicians and other health professionals often are not. As a student, resident, or a new practitioner, it is less important to understand what pharmacists can bring to the team but rather knowing where to start in building a relationship with the team.
The American College of Clinical Pharmacy (ACCP) recognizes that the delivery of interprofessional education (IPE) in the classroom and clinic can be difficult. A white paper by ACCP on IPE on addresses the terminology, levels of evidence, environment-specific models, assessment methods, funding sources, and other important implications and barriers as they apply to interprofessional education (IPE) and clinical pharmacy. In discussing IPE implementation, ACCP describes that deployment of a multidisciplinary team in which professionals from different disciplines work independently of one another, is not considered an interprofessional approach. This was the type of multidisciplinary practice I saw most commonly during my Doctor of Pharmacy curriculum. On my first day of internal medicine, my preceptor brought me up to the floor, introduced me to the team and left. Being the only pharmacy member on the team, I was not sure what my role was on the team, nor did the team. Later I found out that the preceptor never rounded with any of the teams. Therefore, there wasn’t an established relationship between the clinical pharmacist and the medical team. Even though I would present the patients to my preceptor after rounds and we would review and discuss patient’s profiles from a pharmacy perspective, it was independent from the medical team. In order to teach IPE, it is important to begin in a setting where there is a solid foundation and established relationships between the pharmacy preceptor and other members of the team. This allows for students to role model what they observe and for them to understand what is expected. Discussions between pharmacy preceptors and students should include not only the patient’s medication therapy but also how the student should approach, interact, and communicate with the medical team.
In an article by McDonough and Doucette (J Am Pharm Assoc 2003; 43(5 Suppl 1): S44-5), the authors comment on several methods for fostering the pharmacist-physician relationship. They recommend that the first initial steps should be taken to introduce and to establish yourself as a valuable resource. You should always be prepared to defend your response and recommendation toward drug therapy with reliable literature. Next they recommend reaching out to physicians, by inviting them to pharmacy-related meetings. Third, they recommend getting involved, by joining committees, groups, or other organizations. This creates a great forum for your presence to be seen and voice to be heard. Sometimes, your input may not be sought but rather initiative is required to build awareness and to demonstrate your desire to collaborate.
As a resident, I came in knowing that not everyone on the medical team will appreciate my role and accept my recommendations. But I have implemented many of the recommendations described in the ACCP White Paper and the article by McDonough and Doucette. By developing collaborative relationships with physicians and other health professionals, I know I can make a difference in patient care.
[Editor's Commentary: Developing relationships based on mutual respect and trust, not only with physicians and other health professionals but also with patients and peers, is the cornerstone of our professional lives. These relationships are built one-on-one and require the tincture of time. Through personal initiative and commitment, many pharmacists have forged strong collaborative relationships with physicians, nurses, patients, and caregivers. Trust and confidence is not automatically bestowed on every member of the medical team. Collaborative professional relationships, like friendships in our personal lives, are nurtured through a series of events. Like friendships, these relationships can be enhanced or destroyed by our actions. Zillich, McDonough, Carter, and Doucette examined factors that influenced the development collaborative relationship between physicians and pharmacists (Ann Pharmacother 2004; 38: 764-70). Not surprisingly, relationship initiation, trustworthiness, and role specification were strong predictors. Moreover, regular interaction/communication between the physician and pharmacist pair was critical. None of this should be surprising. Collaborative professional relationships are like any other human relationship. Indeed, we need to spend more time teaching people how to initiate and sustain productive professional (and personal) relationships as a core element of our curricula. While some didactic instruction may be helpful, role modeling of successful collaborative relationships is ultimately the key. -S.H.]