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Part ii-october 2002.pdf

in a Family Practice Residency Training Program Adrienne Z. Ables, PharmD; Otis L. Baughman III, MD Background: According to a recent survey, 27% of 579 family practice residency programs in the UnitedStates employ a full-time clinical pharmacist. The majority of pharmacists’ time is spent teaching, usuallyat the point of care either on inpatient rounds or precepting in the outpatient clinic. This paper describesthe precepting activity of a full-time clinical pharmacist in a community-based family practice residencytraining program. Methods: A computer program written in Microsoft Access® captured the followingdata on each pharmacist-physician encounter: date, time, requestor, topic, therapeutic category, type ofquestion, summary of question and answer, resources used to answer the question, and time spent answer-ing the question. The database was updated daily to include all encounters. Results: Between February 1,1999, and January 31, 2001, we documented 2,260 precepting encounters. Almost half of the questionsrelated to general pharmacotherapeutic management of chronic or acute diseases. The most commontherapeutic categories encompassed cardiovascular, psychiatric, infectious disease, and neurologic dis-orders. Seventy-six percent of questions were answered using clinical knowledge and experience, while24% were based on published resources. Conclusions: Based on more than 2,000 precepting encountersbetween a faculty pharmacist and family practice residents, most encounters represented requests byresidents for information on general drug management of diseases. The pharmacist answered most ques-tions based on clinical knowledge and experience. Evaluations of the pharmacist by the residents indi-cated that she is an effective teacher and useful in helping take care of patients. With the increasing numbers of medications brought in 49% of the interventions, and there was an average to the US market every year and the publication of nu- cost avoidance of $154 per intervention. Mason and merous studies on those medications, attainment and Colley, in a study involving two general medicine clin- application of succinct pharmacotherapeutic informa- ics, showed that the number of potential drug problems tion is a challenge. Clinical pharmacists are in a unique identified per patient was significantly greater in a clinic position to complement physicians in the application without pharmacist intervention, while the number of of evidence-based pharmacotherapy and cost-effective beneficial interventions implemented was significantly greater in a pharmacist-staffed clinic.2 A cost savings The contribution of clinical pharmacists in ambula- of $185 per intervention was calculated. Finally, a ran- tory clinics has been described. Hatoum et al reported domized, controlled trial of elderly outpatients taking on 199 pharmacotherapeutic interventions made by four five or more chronic medications demonstrated that clinical pharmacists in 1 month.1 Types of recommen- inappropriate prescribing decreased significantly in dations included adding or changing a drug, changing patients whose regimens were reviewed by and inter- a dose, educating the prescriber, suggesting or discon- vened on by a clinical pharmacist, and the patients ex- tinuing laboratory orders, discontinuing a drug, clari- perienced fewer adverse drug events.3 In all three of fying or correcting a prescription, and changing a drug the aforementioned studies, physicians accepted the regimen. Positive patient outcomes were documented majority of the pharmacist’s recommendations. Indeed,in a study by Haxby et al, family physicians found 97%of pharmacist consultations useful, and 77% of the phy-sicians believed that the consultation enhanced the clini-cal outcome of their patients.4 Fro m t h e Sp art an b urg Fam i l y Med i ci n e Res i d en cy Pro g ram ,Spartanburg, SC.
Special Articles: Pharmacists in Family Practice Residency Programs In the early 1980s, involving clinical pharmacists in precepting in the residency program’s outpatient clinic, family practice residency programs was an innovative the Center for Family Medicine (CFM). Residents in trend.5 Pharmacists spent the majority of their time the CFM come to the pharmacist’s office during their teaching via formal lectures and providing drug infor- assigned clinic hours with questions regarding patient mation.6,7 They also provided direct patient care ser- management as it relates to drug therapy. Each resi- vices such as patient counseling, diabetic teaching, or dent makes the decision about whether to review cases patient monitoring. Since that time, clinical pharma- with or ask questions of the pharmacist, depending on cists have continued these roles with family practice whether the resident deems it beneficial to do so. The residency programs and now also develop comprehen- pharmacist’s office is located in the patient care area of sive pharmacotherapy curricula.8,9 According to a re- the CFM and is readily accessible to residents as they cent survey, however, only 27% of 579 family practice residency programs in the United States employ a full- In addition, the pharmacist provides drug informa- time clinical pharmacist.10 The typical pharmacist in a tion to the CFM faculty, residents, medical students, residency training program holds a doctor of pharmacy and nursing and laboratory staff; serves as a resource degree and has completed a clinical pharmacy residency for patient education; and is an intermediary for pro- program. The survey indicates that, on average, phar- fessional pharmaceutical sales representatives. She also macists spend 43% of their time teaching, 37% in pa- participates in scholarly activity and coordinates the tient care, and 12% in research activities. Point-of-care teaching takes place in the outpatient setting 59% of The pharmacist provides direct patient care by phy- the time and during inpatient rounds 38% of the time.
sician consultation only—ie, when specifically asked None of the aforementioned publications specifically describe the role of clinical pharmacists as preceptors.
This paper describes the precepting activity of a full- time clinical pharmacist in the ambulatory setting of a To document the precepting activity of the pharma- family practice residency training program.
cist, we collected data and entered it into a Microsoft munity-ba se d fa milypractice residency train- ing program, with 12 ap-proved positions in eachof the 3 postgra dua teyears. The full-time fam-ily medicine faculty con-sists of nine family phy-sicians, one clinical phar-mac ist (PharmD ), oneclinical psychologist, andone substa nc e a busecounselor.
pharmacist in our pro-gram is responsible forteaching family practiceresidents and medical stu-dents about rational andcost-effective drug ther-apy. This is accomplishedvia formal lectures, par-ticipation in daily teach- ing rounds on the inpa-tient service, small-group Note—The categories run clockwise on the pie chart, ie, cardiovascular 29%, psychiatry 14%, infectious disease Patient with NYHA IV heart failure and renal insufficiency with a SCr=3.9 mg/dl who presentswith major fluid overload and pulmonary edema. He also has hypertension and type 2 diabetesmellitus. Help with medication management.
How are formoterol (Foradil®) and salmeterol (Serevent®) different? What is the dose of oral acyclovir (Zovirax®) for oral herpes? Can valproic acid cause an increase in transaminase levels (LFTs)? Does grapefruit juice decrease amiodarone (Cordarone®) metabolism? Is there a generic enalapril/HCTZ combination? Is it true that Glucotrol XL® is the same price as generic glipizide? What is a white, round scored tablet with 5601 on one side and Dan on the other? I have a patient on bupropion (Wellbutrin SR®), fluoxetine (Prozac®), and valproic aci d (Depakote®).
She discovered that she is pregnant. Are any of these drugs teratogenic? Do you know who makes Premarin® and if they have a medication assistance program? After beginning warfarin therapy in a patient with atrial fibrillation, when should I check in INR? Please teach this patient how to use a metered dose inhaler.
Discussion of over-the-counter drugs for cold symptoms How much lidocaine should be used to dilute ceftriaxone (Rocephin®) for pediatric use? * Pharmacokinetics, toxicology, stabili ty/compatibili ty NYHA IV—New York Heart Association classification system (functional class IV)SCr—serum creatinineLFT—liver function testHCTZ—hydrochlorothiazideINR—international normalized ratio Access 97® computer file (Microsoft Corporation, The content of the precepting questions was docu- Redmond, Wash). Data included the following infor- mented by examining whether the pharmacist reviewed mation on each encounter between the pharmacist and the patient’s underlying conditions and current medi- health care providers: date and time, requestor name cations, made recommendations for medication addi- and type (eg, resident, faculty physician, nurse, etc), tions/deletions or adjustments, and discussed monitor- topic of the precepting encounter, therapeutic category, ing parameters. Information about pharmacotherapeu- type of question, summary of the question and its an- tic management that was not related to a specific pa- swer, resources used to answer the question, and time tient was categorized as a drug information question.
spent answering the question. Data on topics of Simpler questions on a side effect or drug interaction precepting encounters were usually classified as a drug were documented separately. The summary of the ques- (listed by generic name), a drug class, or a disease tion and its answer were entered into the database us- state. Therapeutic categories were classified as shown ing a free-text format. Resources used to answer the in Figure 1. Questions not falling into one of these questions were categorized as books, journal articles, categories were labeled as “miscellaneous.” Question types were summarized and classified in one of 16types (Table 1).
Special Articles: Pharmacists in Family Practice Residency Programs An evaluation of all family medicine faculty mem- The most commonly used resource used by the phar- bers, including the clinical pharmacist, was distributed macist to answer questions was personal clinical knowl- to the residents for completion on a quarterly basis. All edge and experience. Seventy-six percent of encoun- evaluations were anonymous. Residents gave their com- ters relied on such personal knowledge. Micromedex® pleted evaluations to a faculty secretary, who entered Healthcare Series (MICROMEDEX, Greenwood Vil- the scores into a computer file. The cumulative report lage, Colo) and Drug Facts and Comparisons (Burnham did not have any resident identifiers. Residents scored TH, Noval KK, Schweain SL, eds) were the next most the pharmacist on four characteristics (Table 2). The common information sources, used in 13% of encoun- ters, primarily for questions dealing with side effects or drug interactions. The National Library of Medicine Data analysis was performed via queries within the was used 4% of the time for questions requiring litera- Access program to document activity and look for ture searches. Various other resources were used to trends. Descriptive statistics are reported.
answer the remaining questions (7%).
Of a possible 288 evaluations, 33% were completed Between February 1, 1999, and January 31, 2001, during the study period. Residents’ evaluations of the 2,260 precepting encounters were documented. Close clinical pharmacist, conducted every 3 months, yielded to one third of questions asked by residents fell into the a total average score of 28.75 out of a possible 30 points cardiovascular therapeutic category (Figure 1). The most common question type was about pharmacothera-peutic management (Table 1).
Family practice residents asked 84% of the 2,260 This paper describes the precepting role of a clinical questions. Faculty physicians, registered nurses, and pharmacist in a family practice residency program. The students asked 11%, 3%, and 1% of questions, respec- pharmacist serves as an on-site, evidence-based knowl- tively. Licensed practical nurses and employees made edge advisor to guide the residents in making decisions up the remainder of the requestors. The proportion of about drug therapy. Based on 2,260 encounters over questions asked by residents increased in a linear fash- 2 years, the majority of advice related to pharmaco- ion with postgraduate year, with first-, second-, and therapeutic management (ie, how to manage medica- third-year residents asking 14%, 34%, and 52% of the tions in patients with multiple disease states, taking into questions, respectively. The busiest times of the day account effectiveness, safety, and cost). This finding for the pharmacist were between 11 am–12 pm and 4– points to the residents’ need for learning the practical application of pharmacology on a daily basis. Cardio- The average length of time spent per encounter was va sc ula r thera pe utic s domina ted the re side nts’ 7 minutes (range 5–90 minutes). Questions asked by precepting encounters. This is not surprising, since es- residents that took the pharmacist ≥ 30 minutes to an- sential hypertension and heart disease are among the swer were typically those categorized as pharmaco- top 20 reasons for visits to physician offices in the therapeutic management or drug information. The phar- United States,11 and heart disease is the leading cause macist spent between 30 and 90 seconds entering each of death in patients >45 years of age.12 Other promi- encounter into the database or about 10–15 minutes per nent therapeutic categories of questions in this study, including psychiatry, infectious disease, neurology, andendocrinology, are also among patients’ most impor-tant reasons for ambulatory care visits.11 The analysis of the data also showed an increased number of questions as the residents matured into thethird year of training. The higher number of patient Residents’ Evaluation* of the Clinical Pharmacist contacts in the PGY-III year explains part of this in- crease. The increase in encounters may also, however, suggest the development of professional relationships between the resident physician and the clinical phar- macist or a greater awareness of the need for pharma- The clinical experience and personal knowledge of * n = 94** A higher number indicates a more desirable performance.
the pharmacist were the source of information for thelargest number of precepting encounters. While this may make the pharmacist appear to be a non-evidence-based Special thanks to James C. Ables, PharmD, for his expertise in database source of information, reading and analyzing original research articles, evidence-based clinical practice guide- Corresponding Author: Address correspondence to Dr Ables, Spartanburg lines, and systematic reviews and attending continuing Family Medicine Residency Program, 853 N. Church Street, Suite 510, education seminars continually enhance personal Spart anb urg , SC 29 30 3. 8 64 -5 60 -15 07 . Fax : 8 6 4-5 60 -05 04 .
knowledge. This is likely similar to faculty physicianswho rely on their accumulated knowledge and practiceexperience when supervising and teaching family prac- 1. Hatoum HT, Witte KW, Hutchinson RA. Patient care contributions of clinical pharmacists in four amb ulatory care clinics. Hosp Pharm 2. Mason JD, Colley CA. Effectiveness of an ambulatory care clinical This study has limitations. Although every attempt pharmacist: a controlled trial. Ann Pharmacother 1993;27:555-9.
was made to document each encounter, it is possible 3. Hanlon JT, Weinberger M, Samsa GP, et al. A randomized, controlled that not all were entered into the database. In addition, trial of a clinical pharmacist intervention to improve inappropriate pre-scri bi ng i n el derl y o ut pat i ent s wi t h pol yph arm acy. Am J Med the results in our program may not predict results in another residency program. Lastly, not all residents 4. Haxby DG, Weart CW, Goodman BW Jr. Family practice physicians’ completed evaluations of the pharmacist every quarter, perceptions of the usefulness of drug therapy recommendations fromclinical pharmacists. Am J Hosp Pharm 1988;45:824-7.
which may have affected the cumulative score.
5. Geyman J P. Cli ni cal pharm acy in fami ly practice. J Fam Pract 6. Love DW, Hodge NA, Foley WA. The clinical pharmacist in a family practice residency program. J Fam Pract 1980;10:67-72.
Based on more than 2,000 precepting encounters 7. Johnston TS, Heffron WA. Clinical pharmacy in family practice resi- between a faculty pharmacist and family practice resi- dency programs. J Fam Pract 1981;13:91-4.
dents, most encounters represented requests by resi- 8. Shaughnessy AF, Hume AL. Clinical pharmacists in family practice residency programs. J Fam Pract 1990;31:305-9.
dents for information on general pharmacotherapeutic 9. Bucci KK, Frey KA. A description of a pharmacotherapy curriculum in management of diseases. The pharmacist answered a universi ty-b ased famil y m edicine prog ram. Ann Pharmacoth er most questions based on clinical knowledge and expe- 10. Dickerson LM, Denham AM, Lynch T. The state of clinical pharmacy rience. Evaluations by the residents indicated that a practice in fami ly practice residency p rograms. Fam M ed 200 2; pharmacist can be an effective teacher and useful in 11. Cherry DK, Burt CW, Woodwell DA. National ambulatory medical care survey: 1999 summary. Advance data from Vital and Health Statistics,no. 322. Hyattsville, Md: National Center for Health Statisti cs, 2001.
Acknowledgment: This paper was presented at the Society of Teachers of 12. Communi ty health status report. Spartanburg County, SC: US Depart- Family Medicine 2001 Annual Spring Conference in Denver.
ment of Health and Human Services, July 2000.


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