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May 14, 2019

Mindfulness and Improv Help Pharmacy Students Cope with Burnout

Filed under: Ambulatory Care,Clinical,Feature Stories,Innovation,Managers,Residents,Specialties,Students,What Worked for Me — Tags: , , , , , , , , , , , , , — jmilford @ 6:54 pm

Anne Graff LaDisa, Pharm.D., BCPS, uses improv to teach student pharmacists about effective communication skills.

IN A QUIET LOW-LIT CLASSROOM, students sit comfortably with their eyes closed and their spines straight. They bring attention to their breathing and imagine that they have a balloon in their stomachs. Every time they breathe in, the balloon inflates. Every time they breathe out, the balloon deflates. With every exhale, the students imagine their daily stresses and frustrations floating away. This isn’t a mindfulness retreat at some hideaway resort or the calming conclusion of a power yoga class. It’s a pharmacy course at the Concordia University-Wisconsin School of Pharmacy, where two professors are teaching students to use mindfulness to cope with burnout both during school and throughout their future careers.

According to Christina Martin, Pharm.D., M.S., Director of Membership Forums for ASHP, pharmacist burnout is a serious concern. A 2018 study published in AJHP reported that more than half of health-system pharmacists surveyed felt a high degree of burnout. In addition, a recent salary survey found that two-thirds of pharmacists experienced increased job stress over the previous year, and that 72 percent said workloads increased from the year before.

“When healthcare providers feel stressed, it can also have an impact on their patients,” said Dr. Martin. Burnout is associated with more medical errors and poorer patient safety outcomes, according to the Agency for Healthcare Research and Quality. “We really have to care for the caregiver and ensure that we’re providing resources and support to those who are caring for patients in very chaotic healthcare times,” she added.

Mindfulness in the Classroom

Elizabeth Buckley, Pharm.D., CDE

Elizabeth Buckley, Pharm.D., CDE, Associate Professor of Pharmacy at Concordia University-Wisconsin School of Pharmacy, often includes the balloon-in-the-stomach exercise in her classes. She first introduced it while teaching a diabetes elective for third-year pharmacy students in the spring of 2017 — and she saw immediate changes. It made a huge difference “on attitude, on calmness, on collegiality,” she said.

It worked so well that in the fall of 2018, she added it to her weekly lectures in the Applied Patient Care I course, which is for first-year pharmacy students. “The tone of the class changed in a significant way. Everyone settled down and the discussion was more robust,” she said. “The mindfulness exercise centered me, and it centered the class.”

Dr. Buckley hopes that teaching pharmacy students mindfulness now will help them avoid burnout in the future. “If you’re going to be in a career where you care for other people, you have to figure out self-care in order to be good at being a clinician,” she said.

Improv Shakes Things Up

Anne Graff LaDisa, Pharm.D., BCPS, Associate Professor of Pharmacy at Concordia University-Wisconsin School of Pharmacy, began teaching an improvisational class to first-year students to help bolster communication and teamwork skills. Improv is a theatrical technique where the characters and dialog in scene or story are made up on the spot. Communication skills learned through improv can help a student become a good pharmacist, she noted. Although she didn’t introduce improv classes for pharmacy students with combating burnout in mind, she explained that improv exercises allow students to be creative and break up a school routine.

Anne Graff LaDisa, Pharm.D., BCPS

Dr. LaDisa began taking improv classes herself in 2003. When she discovered that medical schools were using improv to teach and improve medical students’ communications skills, she became intrigued — even more so when she learned that the University of Arizona has been using improv in its pharmacy school since 2004.

She introduced improv to an existing course in 2015, then taught her first stand-alone elective course for first-, second-, and third-year students in 2017. At the beginning of every class, she reviews the rules of improv, which include always saying “yes, and …” to what your partner is trying to communicate, emphasizing the here and now, being specific, and focusing on characters and relationships.

In Dr. LaDisa’s class, a two-person scene requires the students to follow the rules of improv and may involve a scenario unrelated to healthcare. After the students complete the improv exercise, she asks them questions about how they felt about the activity – what things they found challenging and what skills they felt they had to use to be successful. Finally, the students talk about how to apply those skills to clinical pharmacy practice.

Role-playing in a healthcare or social setting can help pharmacy students improve collaboration and teamwork skills. “Improv training gives students an advantage when it comes to communication, which is a critical skill for all pharmacists,” she said.

By Jen A. Miller

 

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April 6, 2016

International Pharmacy Residency a Challenging, Inspiring Experience

Filed under: Ambulatory Care,Clinical,Clinical Perspectives,Current Issue,Residents,What Worked for Me — Tags: , , — jmilford @ 2:36 pm
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Ishmael Qawiy, Pharm.D., BCACP

Editor’s Note: Author Ishmael Qawiy, Pharm.D., BCACP, is a public health resident with Bristol-Myers Squibb Foundation and Rutgers University.

ONE OF THE MOST EXCITING OPPORTUNITIES available to practitioners today is the chance to be a part of the evolution of pharmacists’ patient care roles in other countries.

I was lucky enough recently to do an international Bristol-Myers Squibb Foundation & Rutgers University public health residency.

I wanted to improve public health and explore how economic and cultural factors impact health outcomes. Community-centered pharmacy, in particular, appealed to me because of its reliance on a comprehensive approach to tackling healthcare disparities.

Beginning in July 2015, I worked in sub-Saharan Africa for six months as part of the foundation’s Secure the Future initiative. This cross-cultural program is an immersive experience in which participants address health inequities by working with indigenous people and their healthcare systems.

A Professional Shift

I arrived in Johannesburg, South Africa, excited and optimistic about making my mark in community healthcare. After being trained on the position’s scope of work, I traveled to Ethiopia, Swaziland, and Lesotho to work with grantees who are trying to reduce the incidence of cancer in women and lower the transmission of HIV.

This residency posed quite a professional shift for me, as I had previously been more comfortable doing medication management and health education. But the work was particularly exciting given the new focus on chronic disease management generally, and oncology in particular, that is currently taking place in Africa.

Dr. Qawiy poses with nurse Birhanu Moges.

Dr. Qawiy poses with nurse Birhanu Moges.

I was lucky enough to be able to work directly with the leaders of several community-based health organizations, including the African Medical and Relief Foundation (AMREF) and the Mathiwos Wondu-Ye Ethiopian Cancer Society (MWECS). These groups are on the front lines of providing care to underserved populations throughout Ethiopia.

In Ethiopia, I developed educational health materials for patients that were translated into the local language and distributed at community mobilization events. During my residency, I also created medication safety protocols and medication-handling procedures, and I developed an electronic patient database to collect and streamline reporting and improve operational efficiency.

The Reality of Healthcare in Developing Nations

During my time in Africa, I learned that it’s important to be realistic about the kinds of care you can provide when working in a developing nation with limited resources. For example, I found that standards of pharmacy practice vary from country to country. I also witnessed the fact that clinical and regulatory guidelines developed in the U.S. or in Europe weren’t well-suited for a low- or middle-income country with limited numbers of specialists and patient access to resources.

In Lesotho, for example, pharmacy technicians and nurses have the ability to dispense medications without the supervision of a pharmacist. This may raise some red flags in wealthier countries, but in low-resourced communities, building healthcare capacity by educating and training available personnel is often the most viable option. In many sub-Saharan countries, access to drugs — particularly, chemotherapy agents and pain medicines — is limited. Clearly, this negatively impacts patients’ quality of care and survivorship.

11809902_433888716818578_1803379262_nAs a public health resident, I worked on a number of different projects. For instance, I gave presentations to medical staff and hospital administrators on drug interactions and developed a framework for a drug and therapeutics committee.

I also helped create a protocol used to assess baseline awareness of cancer and met with officials with the local Ministries of Health to discuss their goals for combatting HIV and other communicable diseases.

The work was so inspiring because it made me challenge my own biases and begin to look at the world through a more culturally sensitive lens.

The Vital Role of Pharmacists

It’s important to know that if you choose to do a public health residency such as this one, it can be both professionally gratifying and emotionally taxing. During my time in Africa, I saw that health disparities can be systemic and embedded deeply in a society’s very fabric due to failed health policies, poor governance, or both. Creating equity in healthcare requires contributions from every part of society, including policymakers, healthcare providers, and the community.

I was fortunate during my residency to meet people from different walks of life and enjoy the local culture. I also found that pharmacists can contribute in significant ways to ensuring that the disadvantaged receive appropriate healthcare. Now that I’m back in the United States, I look forward to using this life-changing residency experience to explore the difference I can make in the lives of my patients.

–By Ishmael Qawiy, Pharm.D., BCACP

September 11, 2014

Lessons from My Uncle: Creating Relationships Across the Continuum

Filed under: Ambulatory Care,Clinical,Current Issue,Uncategorized,What Worked for Me — Kathy Biesecker @ 4:26 pm
Far right, Daniel M. Riche, Pharm.D., advises fellow cardiometabolic clinic team members about the best medications for patients under their care.

Far right, Daniel M. Riche, Pharm.D., advises fellow cardiometabolic clinic team members about the best medications for patients under their care.

MY UNCLE CLAUDE OWNED AND RAN A PHARMACY in southern Louisiana for over 40 years. As a boy, I remember going into the pharmacy, and Uncle Claude would always say (at the top of his lungs), “Well, hair low der!” (which translates to “hello there” in English; my family is not just southern, but Cajun).

This gesture was a small outreach to his patients, intended to establish a rapport and, ultimately, develop a relationship. The best evidence of how successful my uncle was in this regard occurred on the day of his funeral.

The pharmacy was closed on a weekday for the first time in 40+ years. After the service, we drove by the pharmacy. There were so many flowers placed on its steps that it took several trips loading them onto the truck before we could even open the front door.

I’ve always tried to establish the same kinds of meaningful relationships that my uncle had with his patients. As a certified diabetes educator and in my work treating patients with all types of metabolic diseases, I see how my knowledge and experience benefits patients.

I believe that they live healthier lives because a pharmacist is involved in their care. But does anyone outside of my personal and professional circles truly know what I do every day to improve my patients’ outcomes?

Getting Outside of Our Comfort Zones

As professionals, we do an excellent job of establishing ourselves and expanding within pharmacy and our own circles. But we often don’t see the opportunities that exist to extend that influence.

After stretching our limits and relying on our relationships, there must be more than simply doing it again and again. What is next? How can we get outside of our own comfort zones and make new impacts on healthcare in general and our patients in particular?

To that effect, I recently took advantage of an opportunity to present at the Cardiometabolic Health Congress for leaders in my professional area. I will be the first pharmacist invited as a distinguished faculty to this prestigious meeting. My topic is “Integrated Management of the Complexities of Cardiometabolic Diseases: A Patient-Centric Team Approach” with a focus on pharmacist intervention.

Even though this presentation is a small step, I’m very excited about helping to further the concept of pharmacist integration. This type of high-visibility outreach serves a larger purpose of expanding the impact of pharmacists across the entire healthcare continuum. Hopefully, it will also help to strengthen our profession’s case for provider status recognition.

As pharmacists, we all have established key relationships with our patients and across healthcare teams and settings. Now I believe that we need to expand our individual footprints so that the entire profession can benefit. To that end, it’s critical to ensure that people know that you make a big difference in the outcomes of patients under your care. Shout it from the rooftops, if you need to!

By disseminating the knowledge we have and expanding our relationships, we each can help to grow the influence that pharmacy has and improve the impact of our services.

–By Daniel M. Riche, Pharm.D., associate professor of pharmacy practice and associate professor of medicine, University of Mississippi School of Pharmacy, Jackson; driche@umc.edu

April 4, 2014

The Importance of Staying Current on New Guidelines

Filed under: Clinical,Current Issue,Residents,Students,Uncategorized,What Worked for Me — Kathy Biesecker @ 3:04 pm

Bryan P. White, Pharm.D.

AS A NEW PRACTITIONER at a 250-bed hospital, working the weekends can be intimidating. Fewer pharmacy staff work on weekends, and clinical and administrative support is only available via paging. The punctuality of a call back can vary widely.

On the weekends, you also receive many verbal orders and admissions from on-call physicians, a concern because increased error rates with verbal orders have been well documented.1 As an evening pharmacist, I often work two and half hours alone. Pharmacists must always be vigilant to ensure the best patient care, but the need to have heightened safeguards is even more important when you practice under low-staffing conditions.

Questioning a Verbal Order

Working in this environment builds your confidence, but the first year is difficult. Interventions can happen at any time. Late one Saturday night, I received a verbal order for “low-dose dopamine titrate to systolic blood pressure greater than 90 mm Hg” for a patient in the ICU.

Two blood cultures were also ordered by the same physician. I called the nurse to ascertain what was going on with the patient. The patient was hypotensive with mean arterial pressures less than 65 mm Hg and possible sepsis. Because new “Surviving Sepsis” guidelines2 indicate that norepinephrine was the vasopressor of choice, I wanted to ensure that the ordering physician had a specific reason for placing the patient on this particular regimen.

Interventions can be a great opportunity to educate fellow health care professionals about what pharmacists know and why we do what we do.

I paged the physician and discussed with him the current guidelines that show dopamine had higher mortality and supraventricular and ventricular arrhythmias when compared to dopamine. Because the guidelines had just come out, he was unaware of the new recommendations and thanked me for calling this to his attention. He went on to give me a new verbal order to change the patient to norepinephrine.

I walked up to the ICU and wrote the verbal orders to discontinue the dopamine drip and start a norepinephrine drip. I also spoke with the patient’s nurse and another nurse on the floor about the current “Surviving Sepsis” guideline recommendations on vasopressors.

An Opportunity to Build Relationships

The extensive time that it takes new knowledge to disseminate is well-documented in the literature. (It typically takes about 17 years before it becomes routine practice). Pharmacists can ensure they are doing what’s best for the patient by staying as up-to-date as possible on new clinical guidelines and recommendations. Being on the sharp edge of new information on medication use—and helping to disseminate that information to other members of the health care team—is critical to providing safe and effective treatment.

These types of interventions are not atypical, but I believe that they can be a great opportunity to educate fellow health care professionals about what pharmacists know and why we do what we do. It’s also important for new practitioners to develop confidence in discussing therapeutic changes with physicians. Interventions such as this one help to increase your rapport with practitioners, boost appreciation for a pharmacist’s role in patient care, and increase one’s own self-confidence in performing the critical duties of a pharmacist.

–By Bryan Pinckney White, Pharm.D., Staff Pharmacist, St. Francis Hospital, Columbus, GA

    1. Fijn R; Van den Bemt, P.M.L.A.; Chow, M.; De Blaey, C.J.; Jong‐Van den Berg, D.; & Brouwers, J.R.B.J. (2002). Hospital prescribing errors: Epidemiological assessment of predictors. British journal of clinical pharmacology, 53(3), 326-331.

 

  1. Dellinger, R.P.; Levy, M.; Rhodes, A.; Annane, D,; Gerlach, H.; Opal, S.M.;  Moreno, R. (2013). Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Intensive care medicine, 39(2), 165-228.

 

 

January 10, 2014

When Ripples Become Waves: Pharmacy as a Caring Profession

Filed under: Current Issue,Feature Stories,Residents,Students,Uncategorized,What Worked for Me — Kathy Biesecker @ 2:40 pm
Elva Angelique Van Devender, Ph.D., Pharm.D., BCPS

Elva Angelique Van Devender, Ph.D., Pharm.D., BCPS

PEOPLE OFTEN ASK ME about my most memorable intervention as a pharmacist. As an emergency department (ED) pharmacist, I am uniquely positioned on the front lines of patient care to make important life-saving pharmaceutical interventions for patients.

I have been fortunate to have had many meaningful interactions with patients as both an ICU and ED pharmacist. I have caught some serious drug interactions, put patients on life-saving medications, recommended cost-saving therapies to save patients money, and educated my patients about wellness and proper medication use. However, the experiences that stand out in my memory are not the pharmacologic interventions but the personal ones, such as holding a patient’s hand during a difficult diagnosis or hugging an elderly patient in terrible pain.

A Memorable Intervention

These interactions transform me as a practitioner as much as they do the lives of the patients for whom I care. My most memorable intervention happened during the first week of my first rotation as a fourth-year pharmacy student. Aside from igniting my lifelong interest in critical care and emergency medicine and cementing my desire to practice in this intense and challenging setting, this critical care rotation gave me the opportunity to assist in code situations.

At the end of my first week in the ICU, we had a code blue during rounds. The patient was 19 years old, and her mother was in the room when it happened. I was a student at the time, so what was I expected to do? I wasn’t able to administer medications… my preceptor was doing that. I felt useless in that room with so many expertly moving parts, and my preceptor didn’t need any help, so I looked at the patient’s mother.

Everyone was so focused on saving the patient that they didn’t notice that the girl’s mother was standing at the periphery of all of the action, crying. She was shaking, so I brought in a chair and wrapped some warm blankets around her.  Then I crouched down beside her and began explaining what the team was doing and what the telemetry meant, so she would not be so frantic about what was happening to her daughter. When it got to the point when I didn’t know what else to say or do, I just put my arm around her and prayed with her.

We couldn’t save her daughter. But the mother came up to me after the code and threw her arms around me, thanking me for my kindness. I just held her while she cried, not knowing what else I could say or do. We stood in the hallway for a long time like that, until the chaplain came.

The Ripple Effect of Small Actions

As a student with little experience and no real ability to intervene medically to save the patient, I had thought my contribution was trivial compared to the actions of the skilled doctors, nurses, and my preceptor who labored in the room that day.

What I didn’t realize was that my small actions had a ripple effect on those around me. In the weeks following that code, several people stopped me in the ICU to tell me that they remembered me from that code and what I had done for the patient’s mother. One of the nurses told me that I made her remember why she went into health care in the first place.

What I didn’t realize was that my small actions had a ripple effect on those around me.

That code became an important catalyst for my journey as a clinical practitioner because it taught me something very valuable: Every action has a ripple effect. Even when we feel invisible—and pharmacy can sometimes feel like an invisible hand guiding medication usage—actions matter. People matter.

Regardless of whether we are students or seasoned practitioners, I learned that we can never underestimate the power that our actions have on others. Waves can arise from the smallest of ripples. The tides we will experience tomorrow begin, in some small way, from the ripples we make today.

–By Elva Angelique Van Devender, Ph.D., Pharm.D., BCPS, Clinical Pharmacist, Legacy Good Samaritan Medical Center, Portland, Oregon

 

July 15, 2013

West Penn Clinic Successfully Treating Underserved Patients

Filed under: Current Issue,Feature Stories,Innovation,Managers,Provider Status,What Worked for Me — Tags: , , , , , , , , , , , , — Kathy Biesecker @ 12:24 pm

Pharmacists at West Penn are a key part of the transition-of-care team as indigent patients move from inpatient care to care at the Health and Wellness Clinic.

PITTSBURGH KNOWS A THING OR TWO about comebacks. The Rust Belt capital suffered big losses when the steel industry collapsed in the 1980s, but returned to prosperity with a diversified economy. The West Penn Hospital also faced its own budgetary crisis a few years ago, after peaking in patient volume in 2008.

In 2010, we were forced to significantly downsize and reduce patient care services due to the financial difficulties of our parent organization. After an acquisition and two years of rebuilding and revitalization, we have turned things around with the reopening of a transformed emergency department, an increase in patient beds, technology upgrades, and the biggest transformation yet: the opening of a “new concept” health and wellness clinic in downtown Pittsburgh.

The West Penn Hospital Health and Wellness Clinic, which opened in February 2013, helped us to re-establish our reputation as a cornerstone of medical care in Pittsburgh and the surrounding Bloomfield-Garfield community. Funded 100 percent by proceeds from the hospital’s 340B drug discount program, the clinic provides critical medical services to underinsured and otherwise underserved patients.

Jennifer Davis, Pharm.D.

Jennifer Davis, Pharm.D.

Since its inception, the pharmacy services department has been a driving force behind West Penn’s 340B program.  As the system director for outpatient pharmacy services, I’ve taken the lead in the overall operations of the new clinic. We run the clinic as efficiently as possible, saving time and resources by using existing space and personnel, including on-staff physicians. The funds generated by our 340B program pay for medications that patients might not otherwise be able to afford and for the cost of staffing the clinic.

As a 340B-covered entity, West Penn Hospital contracts with local pharmacies to fill prescriptions using inventory purchased by the hospital at the 340B price. Through this contract pharmacy network, we provide discounted medications to uninsured patients and generate much-needed supplemental revenue from prescriptions covered by insurance.  The revenue, in turn, is used to cover the cost of the downtown Health and Wellness Clinic as well as costs associated with other uncompensated care.

Clinic Grows, Hospital Readmission Shrinks

Physicians at the clinic see uninsured and underserved patients weekly, and we expect to see more patients as word spreads. With funding generated by the 340B program, we help patients offset the costs of their medications. They literally benefit twice from the same 340B savings—patients now have increased access to care and their prescription costs are lower.

As with most hospitals today, readmission is a hot topic at West Penn. Pharmacists at the clinic help keep patients from using the hospital’s emergency department by providing disease management, medicine adjustments, and lab monitoring services. In addition, we receive prescription compliance data from our 340B program administrator to help clinicians monitor the patients who use the program. In February alone, the clinic saw 52 patients. We were also able to hire a full-time receptionist. By year’s end, the clinic hopes to see 800 patients.

Transitioning to Better Care

At the clinic, we are strong advocates for the “transition of care” program, which helps patients use the wellness clinic and Allegheny General Hospital (AGH) Apothecary (one of the hospital’s 340B contract pharmacies) and other local contract pharmacies. This program helps to ensure the coordination and continuity of care as patients transfer between different locations or different levels of care within the same location.

Another service we offer at the clinic is bedside medication counseling at discharge and seeing these patients at the clinic for medication management. AGH Apothecary fills prescriptions as needed. Pharmacists also provide post- hospitalization follow-up for patients who are unable to see their regular doctor.

Key Partners in Setting up the Clinic

With the health and wellness clinic, we have made the best possible use of the hospital’s 340B savings. Starting the clinic, however, took planning, resourcefulness, hard work, and a partnership with a contact pharmacy administrator, Wellpartner, to manage the program.

Wellpartner has expertise in creating custom 340B retail pharmacy networks that include both chains and independents.  Our network is well balanced with the right geographical coverage, which helps increase 340B program utilization.

The hospital first implemented its 340B contract pharmacy program in 2011, after a local pharmacist noted that uninsured and underinsured patients from the hospital’s Joslin Diabetes Center could no longer pay for their medications. Currently, West Penn’s 340B program uses 29 contract pharmacies, filling more than 8,800 prescriptions in 2012.

I also credit the hospital’s C-suite for helping to get the clinic started. They were huge champions for us, and I believe that with strong C-suite support any hospital can implement such a program.

The economy has caused plenty of setbacks for us and for people in need throughout our service area.  But the West Penn Hospital Health and Wellness Clinic proves that with hard work and ingenuity, positive results are possible, even in the worst of times.

–By Jennifer Davis, Pharm.D., Director of Outpatient Pharmacy Services, West Penn Health System, Pittsburgh

 

 

 

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