Clinical Pharmacist

[tussionex]

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in regards to the ampho story...

i hope not too much happened to the pharmacist in question; yes, the patient died, but the onus should be placed upon the physician as well.

5.0 mg is a perfect example of why trailing zeroes are very, very bad.

of course, the pharmacist should have verified the dose as well...that's why we have double checks for the very young and the very old.

 

[AW88]

Dear sdn1977,

My wife going to graduated from Pharm D program at Southern CAL, and then she will move back to Bay Area with me. She definitely wants to be train for the residency program in North CAL area. My question is how can I find out the list of facility that provides the "residency" & Ambulatory program in North CAL?

Sincerely,

AW88

I'd have to agree with Priaprism that this gives a fairly good & consistent description with an academic environment in which the "clinical" (gosh I hate that term...) is separate from "staff". This does not exist in my environment - N CA...altho most of my work is in a community, moderate scale bed capacity hospital, I do work for friends in the local (well-known) medical university setting.

In my area, all the pharmacists are paid hourly - none, other than administrative (dop, asst dop) are salaried - primarily due to the labor laws of CA.

In my setting, I'm an intensive care/OR pharmacist...who has to occasionally take my turn in mhu & snf when needed. We do have an oncologist pharmacist, but among the whole staff, only two are residents & they are recent graduates - trained in the last 10 years.

After a certain number of years, residency is not as significant as experience. However, I will adamantly state, a general pharamcist cannot adequately shift between peds/NICU or oncology & adult medicine & be safe.

Since my institution is non-academic, there are no "rounds" as all you folks know them. The private practice physicians come when they have time - surgeons very early & very late.....IMs come at lunch, hospitalists are there all day & into the night. All our pharmacists (including those who work at the academic university setting) are required to dose antibiotics, start anticoagulation, start tpn - altho...that is totally unnecessary at night & provide input on pain management & blood pressure control options.

However, this is very location dependent. I have a colleague I speak with in NC who tells me hospitals won't even hire non-PharmD's, let alone residency trained PharmD's. In my view, this is short sighted. Fortunately, that is not the case in CA. Our jobs tend to be more globally responsibile for all the aspects which a generally trained resident should know.

However....the real question, I think here, is - should you do a residency or not????

My answer is - get the best education you can at the time you get it. If you want to pursue a specialty.....network with those in your area who are in that specialty. If I had to advise anyone....yes, consider a residency. I'm not sure a general residency is the best option, particularly if the site is not going to offer you something you don't already have.

No - I don't think you'll necessarily get paid more. However, many studies & many years in the business...at some point, your pay is not the primary reason why you go to work. I know thats hard to believe, but at a certain level of income....the reason you go is to keep your interest & desire to contribute.

For myself - I'm not a residency trained PharmD (for many reasons), but I've been a Pharm D for 30 years. The degree itself opened many doors - my experience opened the rest......

Good luck - keep an open mind, take advantage of every opportunity & think, think, think independently & with leadership!

 

[sdn1977]

Have your wife go to the Residency FAQ's on the top of this forum. She can see the geographic specific residencies & may answer most of her questions.

Good luck & congratulations to her!!!!

Dear sdn1977,

My wife going to graduated from Pharm D program at Southern CAL, and then she will move back to Bay Area with me. She definitely wants to be train for the residency program in North CAL area. My question is how can I find out the list of facility that provides the "residency" & Ambulatory program in North CAL?

Sincerely,

AW88

 

[MacGyver]

Pharmacists are completely different. The Pharmacists that have specialized training rarely set foot in the actual pharmacy, have offices on the floors where their patients reside, and have as much patient contact as some of the physicians.

I'm sorry but I have to call BS on that. I've been in 3 different hospitals, and I've never seen any clinical pharmD actually talk to a patient. I guess they could do diabetes teaching or coumadin teaching, but nurses usually do that already so its overkill to have a doctorate-trained person wasting time on this.

None ofthe clinical pharms Ive seen have order-entry privileges. They come to rounds, and if the doctor has a question about a drug he will ask them. Other than that, their interaction with doctors is to double check computer-entry orders to make sure its not a lethal dose, or to suggest alternative formulations. They never change doses on their own or change medications unless they ask the attending physician first.

 

[sdn1977]

I'm sorry but I have to call BS on that. I've been in 3 different hospitals, and I've never seen any clinical pharmD actually talk to a patient. I guess they could do diabetes teaching or coumadin teaching, but nurses usually do that already so its overkill to have a doctorate-trained person wasting time on this.

None ofthe clinical pharms Ive seen have order-entry privileges. They come to rounds, and if the doctor has a question about a drug he will ask them. Other than that, their interaction with doctors is to double check computer-entry orders to make sure its not a lethal dose, or to suggest alternative formulations. They never change doses on their own or change medications unless they ask the attending physician first.

Where you been MacGyver????? Its been awhile????

 

[Priapism321]

I'm sorry but I have to call BS on that. I've been in 3 different hospitals, and I've never seen any clinical pharmD actually talk to a patient. I guess they could do diabetes teaching or coumadin teaching, but nurses usually do that already so its overkill to have a doctorate-trained person wasting time on this.

None ofthe clinical pharms Ive seen have order-entry privileges. They come to rounds, and if the doctor has a question about a drug he will ask them. Other than that, their interaction with doctors is to double check computer-entry orders to make sure its not a lethal dose, or to suggest alternative formulations. They never change doses on their own or change medications unless they ask the attending physician first.

Well then, certainly you have not worked at a VAMC where pharmacists have prescriptive authority within their scope of practice. The Oncology Pharmacist I worked with was responsible, not able to, but responsible for writing orders/prescriptions for all supportive care medications for the outpatient infusion center (antiemetics, antidiarrheals, laxatives, topical antifungals, growth factors, appetite stimulants, etc). He also went in and talked to every patient admitted to the inpatient ward as they came in to the hospital. These are only a couple of the things he did, but are most relevant to the patient contact issue.

I have limited experience outside of academic medical centers (two centers really), and unless you have worked in either of these two, I don't know what to tell you. And after reading my initial statement, I actually don't like the way I worded it. However, I still do not think you can generalize your experience at three hospitals to every institution and every pharmacist in the country. Personally, I prefer to go about my day with minimal patient contact, but in certain areas where I have worked, that is absolutely not feasible. I guess I could come and work in these hospitals you speak of...

 

[dgroulx]

Well then, certainly you have not worked at a VAMC where pharmacists have prescriptive authority within their scope of practice. The Oncology Pharmacist I worked with was responsible, not able to, but responsible for writing orders/prescriptions for all supportive care medications for the outpatient infusion center (antiemetics, antidiarrheals, laxatives, topical antifungals, growth factors, appetite stimulants, etc). He also went in and talked to every patient admitted to the inpatient ward as they came in as well. These are only a couple of the things he did.

I have limited experience outside of academic medical centers (two centers really), and unless you have worked in either of these two, I don't know what to tell you. And after reading my initial statement, I actually don't like the way I worded it. However, I still do not think you can generalize your experience at three hospitals to every institution and every pharmacist in the country. Personally, I prefer to go about my day with minimal patient contact, but in certain areas where I have worked, that is absolutely not feasible. I guess I could come and work in these hospitals you speak of...

The difference is the VA. All hospitals that I was in on rotations are they way MacGyver wrote - except the VA.

 

[airtim00]

What is the VA ?

 

[sdn1977]

Veteran's Administration - they have their own hospitals known as "VA Hospitals" or Veteran's Administration Hospitals.

They're federal hospitals, therefore, you can work in any VA hospital in any state with any state license.

For example - you work at the Palo Alto VA Hospital in CA, but have a Nebraska license - you're ok - you don't need a CA license.

They don't follow state pharmacy laws - just federal.

 

[Jeddevil]

The difference is the VA. All hospitals that I was in on rotations are they way MacGyver wrote - except the VA.

The four different hospitals I have been in while in school were also the way MacGycer wrote except for one thing. The last place, they didn't distinquish between clinical or staff pharmacist. All spent time out in the little closets, I mean offices that they had on the floor, and also spent time in the dungeon. Those on the floor also did order entry.

Other than that, clinical pharmacy has proven to be one of the largest jokes I have seen. Educators preach to you about the benefits of residency and working these 'clinical' jobs, yet they have students on rotations doing their jobs for them. What is so special, I just don't see it? It just isn't what they make it out to be.

Maybe it is in teaching facilities and the VA like Priap says. But there are not many positions available for that. It is a small minority of the available pharmacy jobs out there.

 

[sdn1977]

That's the idea - "clinical" is the way you approach pharmacy issues - not just get the order & fill it. You look at it differently (or NOT) each time you get an order.

It becomes the routine of pharmacy - just as the filling was the routine of pharmacy in the 50's.

It is a not a "position" you apply for - it is the way you do your job, no matter the position you occupy.

That is why this whole "clinical" designation should have gone away decades ago.....we've already gotten there!

You're all clinical - get it???

 

[sputnik25]

Great thread, very informative.

 

[Jeddevil]

You're all clinical - get it???

Yeah, I get it, and I appreciate you insights to that side. I just disagree with how academia portrays it, because they create something in your mind that just doesn't exist.

 

[tussionex]

Yeah, I get it, and I appreciate you insights to that side. I just disagree with how academia portrays it, because they create something in your mind that just doesn't exist.

i agree....academia does NOT get it at all...they are all too busy puffing up their egos about their "clinical" training.

example....we have a student at my hospital on rotation...he has little to no IV skills....yes, the college he attends is heavily into "clinical" pharmacist curriculum...but to become licensed in NY, you must pass a wet lab, a significant and troublesome portion of which is an IV preparation.

my point? it's great to teach to "clinical" positions, but if a students lacks the basic skills needed to get licensed, what's the point?

 

[airtim00]

You're all clinical - get it???

Im starting to get it.

but lets say you do a residency in oncology. or critical care.
would you find yourself dispensing?

 

[Priapism321]

Im starting to get it.

but lets say you do a residency in oncology. or critical care.
would you find yourself dispensing?

Once again, I can only speak for the institution that I work at; there are 3 or 4 intensive care pharmacists (surgical, medical, cardiac, pediatric), an oncololgy pharmacist, and 3 bone marrow transplant pharmacists. They have absolutely no dispensing role in the hospital.

However, I know of another academic medical center that I applied for residency at does not exactly operate this way. They actually have a distinction between what they call "clinical pharmacists" and "clinical pharmacy specialists" (the hospital's titles, not mine). While the "specialists" had no dispensing role (they had about 8 of these individuals), the clinical pharmacists were somewhere in between a staff pharmacist and a truly decentralized pharmacist. They actually would rotate between patient care areas and the pharmacy. Personally, I don't think it hurts to know what's going on in the actual pharmacy from time to time.

 

[sdn1977]

i agree....academia does NOT get it at all...they are all too busy puffing up their egos about their "clinical" training.

example....we have a student at my hospital on rotation...he has little to no IV skills....yes, the college he attends is heavily into "clinical" pharmacist curriculum...but to become licensed in NY, you must pass a wet lab, a significant and troublesome portion of which is an IV preparation.

my point? it's great to teach to "clinical" positions, but if a students lacks the basic skills needed to get licensed, what's the point?

Bingo! Academics is right on the edge of academic information, but behind on what is actually going on.

Just take Zpaks comment about the old fashioned tear-sheets for narcotics. We left those 20 years ago...some still have them..

It takes time for all "systems" to catch up to what is current, but professionally, the expectation is you all will have to do what is current, no matter the system by which you function.

 

[njac]

Yeah, I get it, and I appreciate you insights to that side. I just disagree with how academia portrays it, because they create something in your mind that just doesn't exist.

I absolutely agree. Obviously at this point Ionly know the ins and outs of how my current hospital handles the various positions but I do feel that UNM is doing us a slight disservice by so heavily pimping the pharmacist clinician. UNM's goal is to keep us here in New Mexico, yet by so heavily pushing the clinical side of things in such a poor and rural state - there are ridiculously few of these positions available. By building up expectations, how many of the students are going to be incredibly disappointed when they graduate, can't leave NM for whatever reason, and can't find this mythical job where you get to see your patients one on one and diagnose and prescribe etc.

I know it would need more faculty and money and whatnot but I wish there were seperate tracks within a curriculum or more electives available. I know I've sought out more difficult electives because they were more interesting (ie: Clinical Toxicology) but I don't know that schools have the resources to provide the extra exposure for every possible interest in the student body.

 

[sdn1977]

Once again, I can only speak for the institution that I work at; there are 3 or 4 intensive care pharmacists (surgical, medical, cardiac, pediatric), an oncololgy pharmacist, and 3 bone marrow transplant pharmacists. They have absolutely no dispensing role in the hospital.

However, I know of another academic medical center that I applied for residency at does not exactly operate this way. They actually have a distinction between what they call "clinical pharmacists" and "clinical pharmacy specialists" (the hospital's titles, not mine). While the "specialists" had no dispensing role (they had about 8 of these individuals), the clinical pharmacists were somewhere in between a staff pharmacist and a truly decentralized pharmacist. They actually would rotate between patient care areas and the pharmacy. Personally, I don't think it hurts to know what's going on in the actual pharmacy from time to time.

Again - a discrepancy between geography & institutions (perhaps academic, altho the "big" academic center in the area close to me is more like what I'll describe). These differences don't make one better or worse than another - just different. It is the difference you need to appreciate!

The pharmacists are assigned to "units" - ICU, OR, oncology, transplant, peds (a whole separate hospital), adult med, neurosurg, etc....

Each of them has complete responsibility for all that goes on during their shift - that means - if there are rounds which go on (this is a medical teaching institution - not a pharmacy teaching institution) & they are part - then they are part of them. All orders are entered by these pharmacists & first doses, if expected within 30 minutes are dispensed by these pharmacists. Any technician assigned to that particular unit is supervised & the work is checked by that pharmacist (think OR & cardioplegia solutions). ICU & OR IV's are ususally done by a tech in this decentralized pharmacy & checked by this pharmacist, however, tpns are done centrally.

Now - the community hospital down the road...each pharmacist is assigned a certain number of units - logically. ICU, step down or transitional care, final cardiac care prior to discharge, OB-L&D is with nursery (this is not a tertiary NICU), Inpt acute med, mental health unit, snf, etc....

Again,, during the day, all pharmacy functions are done by that pharmacist - order entry, dosage adjustment, meetings with family/patients, etc.. as well as dispensing first doses.

All pyxis fills are done centrally as well as IV's.

There are as many permutations & combinations of each situation and circumstance as there are hospital pharmacies.

The idea - be flexible, be willing to do ANYTHING - because you will someday have to do EVERYTHING (I've worked 2 strikes), be encouraging and enthusiastic & try to find a way to find a solution rather than find the fault which might exist within the system.

Finally, remember - who your ultimate user is of your knowledge is. It could be the prescriber - you have to be available, accessible, be understandable, be willing to listen & try to accomplish what the prescriber is trying to do. If your user is the pt - understand he/she is overwhelmed! You may need to get close to that pt & try more than once to educate him or his family. He/she may not remember you were there yesterday - patience, consistency, compromise & understanding go a long way. Finally, if your user is the nursing staff - try to remember we are an unwitting thorn in their side often. We don't mean to be - it sometimes just happens. We don't realize that we've ordered a blood draw at the most inopportune time possible for them or they absolutely NEED to give this medication because they know the pt is going down for a study & will be gone for hours, which is something we were never informed of. We just got their frustration, which on the surface just appears to be a b*tchy nurse, but they've had lots of long hours with pts in and out constantly.

So...be patient. Dispensing is not a bad thing. It gets you to know the nurses, the resp therapists, the house staff - if you're willing to go out of your way...when they know you're carrying the beeper that day - they'll go easy. It is always harder to be angry with someone who you know by name & face than with some faceless stranger at the other end of the phone.

 

[Old Timer]

That's the idea - "clinical" is the way you approach pharmacy issues - not just get the order & fill it. You look at it differently (or NOT) each time you get an order.

It becomes the routine of pharmacy - just as the filling was the routine of pharmacy in the 50's.

It is a not a "position" you apply for - it is the way you do your job, no matter the position you occupy.

That is why this whole "clinical" designation should have gone away decades ago.....we've already gotten there!

You're all clinical - get it???

This is 10000000% correct. All pharmacists are clinical pharmacists, if they want to be. I have been in retail all of my life, almost 25 years. I have been there since the typewriter days. I have been in pharmacies that filled 600 prescriptions per week and pharmacies that have filled 4000 prescriptions per week. I speak to patients every day and NOT just to get some milk while they are at the drive through.

I am from the day when Dr's ordered and pharmacists filled. NO QUESTIONS. Those days are over. I counsel my patient's all the time. I confer with physicians about their therapy. And if mom has a sick child in the car, I am glad to run into the store to pick up something when she comes to pick up the Augmentin prescription for the toddler's otitis media.

 

[airtim00]

so..
has anyone on here completed a residency?

 

[sdn1977]

so..
has anyone on here completed a residency?

Nope - not me.....I had few options in 1977 & none of them suited me at the time.

I think Tussionex is starting one though......

 

[tussionex]

Nope - not me.....I had few options in 1977 & none of them suited me at the time.

I think Tussionex is starting one though......

that's comedy gold, sdn!

no residency for me...why would i want to be paid half the money for twice the work!

i'm a very happy night schmuck!

 

[Omegadramon]

This topic is a gold mine of information. I'm going to read these comments (especially sdn's) over and over again. Then if I get an interview in 6 months, I'll sound like a genius.

 

[konkan]

that's comedy gold, sdn!

no residency for me...why would i want to be paid half the money for twice the work!

i'm a very happy night schmuck!

Agreed. If smth is being heavily advertised - most likely it is a bull. Since students are being pushed for pharm. residency so much, most likely it is not that good. Have u ever seen pushing for medical residencies (coz one can work after a med. school without a residency) or ads for harvard med school, or for a ceo of a big company or even a lexus (ok I saw a couple of lexus', but not too many).

 

[Priapism321]

Agreed. If smth is being heavily advertised - most likely it is a bull. Since students are being pushed for pharm. residency so much, most likely it is not that good. Have u ever seen pushing for medical residencies (coz one can work after a med. school without a residency) or ads for harvard med school, or for a ceo of a big company or even a lexus (ok I saw a couple of lexus', but not too many).

Wow, this may actually be the worst bit of reasoning I have ever read. I am not sure if I even care to elaborate. But shortly, if you think that educators in medical school don't advocate their students getting into the best residency programs, you are dizzy. And, you have only seen a couple of advertisements for Lexus?? Are we talking about the same thing, the car??

I can go further, we'll see if it is necessary.

 

[konkan]

Wow, this may actually be the worst bit of reasoning I have ever read. I am not sure if I even care to elaborate. But shortly, if you think that educators in medical school don't advocate their students getting into the best residency programs, you are dizzy. And, you have only seen a couple of advertisements for Lexus?? Are we talking about the same thing, the car??

I can go further, we'll see if it is necessary.

I meant med. residencies in general. Nobody is pushing med. students for A medical residency coz everybody knows that without it one doesn't really become a real physician. And as we all know 99.9% of med. schools grads enter a residency. In pharmacy, students are being pushed for A residency so much and the number of students actually entering is so small, that I naturally think it's a bs. The idea is that a good stuff sells by itself. Next time read carefully before scrambling smth back. As of lexus, I see way more commercials for American cars than for Japanese.

 

[Priapism321]

I meant med. residencies in general. Nobody is pushing med. students for A medical residency coz everybody knows that without it one doesn't really become a real physician. And as we all know 99.9% of med. schools grads enter a residency. In pharmacy, students are being pushed for A residency so much and the number of students actually entering is so small, that I naturally think it's a bs. The idea is that a good stuff sells by itself. Next time read carefully before scrambling smth back. As of lexus, I see way more commercials for American cars than for Japanese.

So, by this logic, in your opinion, American cars are "a bs"? I think that I naturally assume someone doesn't know what they are talking about when they are unable to form a coherent string of sentences in the English language.

 

[Priapism321]

I really do not understand some of the negative opinions regarding post graduate residency training. If professors are "selling" this concept throughout pharmacy school, one reason may be because at least two of the three large national associations representing Pharmacists are very pro-residency (not sure where APha stands on the matter). So, to me, they are being responsible and attempting to prepare students for where the future of Pharmacy appears to be heading.

The American College of Clinical Pharmacy has recently stated that in the future, all Pharmacy Practitioners in direct patient care roles should be residency trained. It is also their position that all Clinical Pharmacy Practicioners should be Board Certified:

http://www.accp.com/report/rpt0507/art07.php
http://www.accp.com/position/wp_phco200612.pdf

Just this month, the American Society of Health-system Pharmacists published a "vision" for the future of Health-systems Pharmacy. One of the core elements of this involves Pharmacists completing residency training.

http://www.ashp.org/s_ashp/article_press.asp?CID=168&DID=2037&id=20681

This is what is known as professional credentialing. I think it makes sense that the Pharmacist with two years of residency training with Board Certification in Pharmacotherapy should have more privileges than the Pharmacist with 2 years of undergraduate training and a Pharm.D. from a three year program.

If Pharmacists want this profession to continue to evolve as it has over the past two decades, the resistance to things such as post-doctoral training needs to go away in a hurry, in my humble opinion.

 

[Priapism321]

Agreed. If smth is being heavily advertised - most likely it is a bull. Since students are being pushed for pharm. residency so much, most likely it is not that good. Have u ever seen pushing for medical residencies (coz one can work after a med. school without a residency) or ads for harvard med school, or for a ceo of a big company or even a lexus (ok I saw a couple of lexus', but not too many).

Just an FYI, I am currently watching the U.S Open, which is professional golf's national championship. The primary sponsor of this event's television coverage: Lexus, and there is a Lexus commercial every 12 minutes or so during the 6 hours of broadcast.

 

[konkan]

Just an FYI, I am currently watching the U.S Open, which is professional golf's national championship. The primary sponsor of this event's television coverage: Lexus, and there is a Lexus commercial every 12 minutes or so during the 6 hours of broadcast.

I am currently watching outside my window and I see an 80 y/o woman with a black dog. Does that mean that all my neighbors are 80 y/o women with black dogs? Your logic kills me

 

[pharmboy30]

sdn, you are my new best friend! your posts are always informative, but thanks for giving props to the "off-shifts"....there sometimes is the misconception that we are just the flunkies who do nothing all night. the reality is, sometime we are the ONLY pharmacists in house...so we have to be "staff", "clinical" "residency-trained" all rolled into one

your post made me smile!👍

yup...it's 4 am right now 🙁
tonight I actually am doing nothing....it's pretty slow.

I agree though, most people at the pharmacy I work at think we do nothing all night. they don't realize how many questions we answer, mistakes we catch (extremely frustrating), iv's compounded, etc... no respect.

the good thing is I can turn my music up loud and don't have to deal with the drama of day shift!