How valuable are pharmacists?

[ChasingMyDreams]

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Retail pharmacist here. There has been a lot of discussion in pharmacy about "team-based healthcare". Just wondering how valuable pharmacists are to you MDs/DOs out there? From a retail perspective I don't really get to talk to you all much and I'm just wondering if you guys feel any value is added by having us check the RXs you write or if it seems largely unnecessary? Just looking for general thoughts on where/if a pharmacist should be/is integrated into today's healthcare model?

For example, there's a big push in retail pharmacy towards MTM, do you guys see this as a valuable service or just another source of annoying phone calls/faxes?

 

[Raryn]

Retail pharmacists I don't know about, but a good clinical pharmacist in the inpatient setting is worth his weight in gold. Especially when they have the time/opportunity to round with us and just go over the meds, bring up some stuff that we didn't consider, etc. Frequently some of the best learning we have.

 

[db1210]

I think it is easy to take pharmacists (among other things) for granted here.
I have spoken to a few MDs that are working with NGOs and there is a need for pharmacists abroad. The need is not just for clinical pharmacists, but for ones to run pharmacies altogether along with helping the MDs optimize treatment.

My point is I don't want to see what it would be like without pharmacists here. You are very important to the healthcare system.

 

[SouthernSurgeon]

Retail pharmacists I don't know about, but a good clinical pharmacist in the inpatient setting is worth his weight in gold. Especially when they have the time/opportunity to round with us and just go over the meds, bring up some stuff that we didn't consider, etc. Frequently some of the best learning we have.

Yup. Our clinical pharmacist on transplant is a lifesaver. Manages all the immunosuppression for us and just sends the orders to us to cosign.

 

[evilbooyaa]

Clinical pharmacists who round with the team are critical. They routinely pick up on possible interactions that the residents didn't notice. The people who verify orders for the hospital are important too, because they are the last line of defense from someone giving a patient 400mg of morphine IV.

 

[Beargryllz]

The people who verify orders for the hospital are important too, because they are the last line of defense from someone giving a patient 400mg of morphine IV.

You're thinking of nurses, not pharmacists

 

[artenjoyall]

My point is I don't want to see what it would be like without pharmacists here. You are very important to the healthcare system

 

[Packman2003]

Clinical pharmacists routinely provide valuable information to the team and are up to date on pharmaceutical treatment guidelines - very nice to have.

Retail pharmacists have an especially important role in (usually older) patients where polypharmacy is an issue. It is a frequent problem that doesn't get enough attention. Too often I see patients who are seeing multiple prescribing specialists who lack proper communication and can have a tendency to mostly only pay attention to "their" meds.

Both are also important when it comes to dosing, especially for older patients, renal dosing, etc. Improper dosing for certain populations lands people in the hospital.

 

[SouthernSurgeon]

You're thinking of nurses, not pharmacists

No, he's thinking of pharmacists.

All orders go through a pharmacist who double checks and verifies dosing before dispensing the medication. We frequently get calls from pharmacists saying "Hey did you really mean to give this patient 200 mEq of potassium or did you mean 20?".

Or was your point just to nitpick that nurses, not pharmacists, are the literal last person in the chain of drug delivery to a patient?

 

[evilbooyaa]

You're thinking of nurses, not pharmacists

Considering that I don't have faith that EVERY SINGLE nurse (although I'm sure 99% at least) in the hospital would know that 400mg of morphine is too much to give to a patient, I consider pharmacy review to be the last line of defense in the cake. If nursing catches something, that's a cherry on top.

 

[Raryn]

Considering that I don't have faith that EVERY SINGLE nurse (although I'm sure 99% at least) in the hospital would know that 400mg of morphine is too much to give to a patient, I consider pharmacy review to be the last line of defense in the cake. If nursing catches something, that's a cherry on top.

Given that the nursing concerns are 99 times out of a 100 totally ridiculous and require us to spend valuable time explaining why in fact I do want whatever med given, and the pharmacy reviews usually provide valuable insight (and not infrequently save my ass), I totally agree. Outside of the ICU that is. I actually trust ICU nurses and other than them, I'd love if the rest would just enact orders as written and stop calling us.

The difference in education between an RN and a PharmD when it comes to medications is humongous.

 

[SouthernSurgeon]

Given that the nursing concerns are 99 times out of a 100 totally ridiculous and require us to spend valuable time explaining why in fact I do want whatever med given, and the pharmacy reviews usually provide valuable insight (and not infrequently save my ass), I totally agree. Outside of the ICU that is. I actually trust ICU nurses and other than them, I'd love if the rest would just enact orders as written and stop calling us.

The difference in education between an RN and a PharmD when it comes to medications is humongous.

Eh I don't think that's fair. I had a patient saved by an RN who noticed that the pharmacist had mixed a bag of insulin at 100x the intended concentration 😱

I just meant its ridiculously nitpicky to obsess over the use of the phrase "last line"

 

[DermViser]

No, he's thinking of pharmacists.

All orders go through a pharmacist who double checks and verifies dosing before dispensing the medication. We frequently get calls from pharmacists saying "Hey did you really mean to give this patient 200 mEq of potassium or did you mean 20?".

Or was your point just to nitpick that nurses, not pharmacists, are the literal last person in the chain of drug delivery to a patient?

I figured it was the bolded. Quite unnecessary, IMHO.

 

[DermViser]

You're thinking of nurses, not pharmacists

Yeah, pharmacists have no role. Have you had a pharmacist on rounds with you? They are crucial.

 

[Siggy]

Clinical pharmacists who round with the team are critical. They routinely pick up on possible interactions that the residents didn't notice. The people who verify orders for the hospital are important too, because they are the last line of defense from someone giving a patient 400mg of morphine IV.

Wait, you mean putting a patient on norco 5/325 q4 ATC while forgetting to D/C the Norco 20/650 q4 PRN order is a bad thing for the patient's liver? Umm... yea... give me a second to log in and I'll adjust that order...

I will admit, though, that I die a little every time I get paged to the inpatient pharmacy number. "Hi, this is Dr. Siggy... what did I screw up this time?"

 

[Siggy]

Considering that I don't have faith that EVERY SINGLE nurse (although I'm sure 99% at least) in the hospital would know that 400mg of morphine is too much to give to a patient, I consider pharmacy review to be the last line of defense in the cake. If nursing catches something, that's a cherry on top.

400mg Morphine DOCTOR? That too much. 53mg dilaudid? Sure thing doctor.

(replace 400 with 10mg morphine and 53 mg dilaudid with 1.5 mg and you'll see a real conversation that I witnessed as a student).

 

[Beargryllz]

Yeah, pharmacists have no role. Have you had a pharmacist on rounds with you? They are crucial.

In all my time on the floor, I have never (and I truly have to emphasize the word NEVER) seen a pharmacist double check any dose of anything before administration. It is always an RN, every time.

I truly will believe you if you try to tell me that a pharmacist looks over the dose as well, they just have no role in actually checking and administering the dose to a patient. At least not in any healthcare setting I'm familiar with. Maybe they do it different down in wherever you're from.

Definitely check what you're commenting on, because I'm not trying to downplay the job of a pharmacist. I merely have to point out the reality of drug administration.

 

[DermViser]

In all my time on the floor, I have never (and I truly have to emphasize the word NEVER) seen a pharmacist double check any dose of anything before administration. It is always an RN, every time.

I truly will believe you if you try to tell me that a pharmacist looks over the dose as well, they just have no role in actually checking and administering the dose to a patient. At least not in any healthcare setting I'm familiar with. Maybe they do it different down in wherever you're from.

We're talking about active work rounds, where the PharmD rounds with the team looking over meds and labs.

 

[Siggy]

In all my time on the floor, I have never (and I truly have to emphasize the word NEVER) seen a pharmacist double check any dose of anything before administration. It is always an RN, every time.

I truly will believe you if you try to tell me that a pharmacist looks over the dose as well, they just have no role in actually checking and administering the dose to a patient. At least not in any healthcare setting I'm familiar with. Maybe they do it different down in wherever you're from.

Definitely check what you're commenting on, because I'm not trying to downplay the job of a pharmacist. I merely have to point out the reality of drug administration.

At my hospital, all computer orders go through the pharmacist first before popping up on the RN's screen. Stat medications are often charted through Pyxis override.

 

[Raryn]

In all my time on the floor, I have never (and I truly have to emphasize the word NEVER) seen a pharmacist double check any dose of anything before administration. It is always an RN, every time.

I truly will believe you if you try to tell me that a pharmacist looks over the dose as well, they just have no role in actually checking and administering the dose to a patient. At least not in any healthcare setting I'm familiar with. Maybe they do it different down in wherever you're from.

Definitely check what you're commenting on, because I'm not trying to downplay the job of a pharmacist. I merely have to point out the reality of drug administration.

In any hospital with an EMR, the nurse cannot administer any medications without them being A) Ordered by an MD and B) The order being approved by a pharmacist. There's a few rare exceptions to this, primarily situations like codes and rapid responses.

Pay attention to your residents and I 100% guarantee that you will see them paged by the pharmacy to discuss an order at some point. Frequently it's things like we forgot to adjust a medication for the patient's renal status, truly making a difference in patient care. Sometimes they aren't sure exactly why we're ordering a med and just wanted to clarify, because for some indications they might suggest a dosing or interval change. 100% valuable.

 

[SouthernSurgeon]

In all my time on the floor, I have never (and I truly have to emphasize the word NEVER) seen a pharmacist double check any dose of anything before administration. It is always an RN, every time.

I truly will believe you if you try to tell me that a pharmacist looks over the dose as well, they just have no role in actually checking and administering the dose to a patient. At least not in any healthcare setting I'm familiar with. Maybe they do it different down in wherever you're from.

Definitely check what you're commenting on, because I'm not trying to downplay the job of a pharmacist. I merely have to point out the reality of drug administration.

As others have said...at every hospital I've worked at the workflow is this (EMR or paper):

MD orders med. Order goes to inpatient pharmacy. Pharmacist reviews and verifies order and dispenses med, or pages MD with question about order accuracy. Med gets dispensed and sent to the floor (or pulled from the on-floor stocks) where it is administered by nurse. Nurses of course should and do verify as well.

If you don't think the pharmacists are verifying orders, you just aren't aware of what's happening. Every single med order placed in our hospital, from simethicone to chemotherapy to cough drops, runs through a pharmacist.

 

[Beargryllz]

At my hospital, all computer orders go through the pharmacist first before popping up on the RN's screen. Stat medications are often charted through Pyxis override.

So why even entertain the notion that pharmacists are some kind of "last resort" to medication administration?

 

[Siggy]

So why even entertain the notion that pharmacists are some kind of "last resort" to medication administration?

...because I'm going to put more trust that the pharmacist is going to catch a mistake than the RN.

 

[tdram]

Yes pharmacist's knowledge of meds >>>> any RN.

 

[SouthernSurgeon]

So why even entertain the notion that pharmacists are some kind of "last resort" to medication administration?

So you're still just being ridiculously nitpicky about the use of the word last and got your feathers ruffled that in a thread about the usefulness of pharmacists no one gave the floor RN proper deference as the "last resort?"

Here is the thing...no, I don't expect a floor RN to push 400 of morphine. Because that's a **** ton of morphine and they know better. But if my patients creatinine is trending up do I expect the floor nurse to know how to adjust the vanco dosing? No - because they aren't a freaking pharmacist

 

[styphon]

I found hospitalist pharmacist a great help. We had one assigned to our inpatient team, helped find interactions, incorrect dosing, overuse of meds, etc...

In the ICU they had one pharmacist per ICU team - they are also great for interactions, how to titrate down or up certain meds, other options when things have failed.

 

[evilbooyaa]

So you're still just being ridiculously nitpicky about the use of the word last and got your feathers ruffled that in a thread about the usefulness of pharmacists no one gave the floor RN proper deference as the "last resort?"

Here is the thing...no, I don't expect a floor RN to push 400 of morphine. Because that's a **** ton of morphine and they know better. But if my patients creatinine is trending up do I expect the floor nurse to know how to adjust the vanco dosing? No - because they aren't a freaking pharmacist

I'll admit that 400mg of morphine was an exaggerated comparison.

Let's call it 20mg of dilaudid instead (when I actually wanted to give 2mg of dilaudid). Pharmacist would likely call about that, not 100% sure if nurses would.

Nurses are technically the last line of defense, but they are not as good at catching errors in medication ORDERS (not talking about what pharmacy mixes on the spot and sends up to the floor) done by physicians as pharmacists are.

 

[fancymylotus]

Hospital pharmacists are great, retail pharmacists drive me motherfcking CRAYZEE

But my opinion might be useless, I'm not MD/DO. I do work in private practice and in a hospital though.

 

[Kaustikos]

Here's my take:
I've worked at six different hospitals and I can say clinical pharmacists are amazing for the most part (99%).
They do, in fact, manage dosing. The right pharmacist pre rounds on patients just like medicine. They look at meds and dosing. They then tell us in several ways. Some hospitals have pharmacists as part of your team that rounds and will tell you what they think in terms of meds during rounds/before. They'll let you know if a drug is better or not. They'll tell you if the pca pump can have a better rate. This is so awesome because when you're a med student, you really need this help. I can't tell you how much Ive learned about pca dosing and such. They make your life better this way. This also comes in handy when you're dosing for someone with renal impairment.
They are also the best person for antibiotic/viral/fungal treatment recs. Yes, you can consult ID. But why when you have the pharmacist right there? Even if they aren't, there's always been a pager number for one if I needed it. Most of the ones I work with have the sensitivity **** in their heads and can tell you which is best.
In the right place and persons, pharmacists make things move way more smoothly.
Having done nephrology and heme/onc, I can say Ive learned so much not just from medicine, but also pharmacists.

I don't know how other places do things, but Ive always had a pharmacist nearby/with us to work with and it's been amazing. Have there been bad ones? Absolutely. But that's been rare in the hospital.

 

[DoctwoB]

Agree with the above sentiments. Clinical pharmacists are a key part of the patient care team and will save your a** repeatedly. I have no idea what retail pharmacists do.

 

[tdram]

OP can you give us an idea of what retail pharmacists do?

 

[RxMonkey]

Agree with the above sentiments. Clinical pharmacists are a key part of the patient care team and will save your a** repeatedly. I have no idea what retail pharmacists do.

Generally, retail pharmacists act in much the same way. That is, they provide an extra layer of protection between the prescriber and the patient... Watching for interactions/contraindications, patient education/consultation, etc.

 

[aldolase]

Let's say that there is a question about drug therapy in cardiology. Wouldn't it be better to consult a cardiologist who have specialized knowledge about drugs in their filed than a pharmacist (who has a broader yet not as specialized set of drug knowledge) ? Additionally, the specialist physician would understand the entire clinical picture due their specialized training and make better recommendation ? Same for any other speciality. What do you guys think ? or is this a cost saving measure or anything else ?

 

[DermViser]

Let's say that there is a question about drug therapy in cardiology. Wouldn't it be better to consult a cardiologist who have specialized knowledge about drugs in their filed than a pharmacist (who has a broader yet not as specialized set of drug knowledge) ? Additionally, the specialist physician would understand the entire clinical picture due their specialized training and make better recommendation ? Same for any other speciality. What do you guys think ? or is this a cost saving measure or anything else ?

A pharmacist knows the pharmacokinetics and pharmacodynamics of a drug than a cardiologist. They work with each other, not against each other.

 

[joker2400]

Let's say that there is a question about drug therapy in cardiology. Wouldn't it be better to consult a cardiologist who have specialized knowledge about drugs in their filed than a pharmacist (who has a broader yet not as specialized set of drug knowledge) ? Additionally, the specialist physician would understand the entire clinical picture due their specialized training and make better recommendation ? Same for any other speciality. What do you guys think ? or is this a cost saving measure or anything else ?

Also a clinical pharmacist will have undergone residency training and possibly a fellowship in a specific area. Some specialties can be found here: http://www.pharmacy.umaryland.edu/residentsfellows/programs/index.html

 

[aldolase]

A pharmacist knows the pharmacokinetics and pharmacodynamics of a drug than a cardiologist. They work with each other, not against each other.

That's surprising. I thought that a cardiologist would know the intricacies of the cardio drugs very well.

 

[DermViser]

That's surprising. I thought that a cardiologist would know the intricacies of the cardio drugs very well.

Just bc a pharmacist knows things doesn't mean the doctor doesn't. They both have their strengths.

 

[aldolase]

Just bc a pharmacist knows things doesn't mean the doctor doesn't. They both have their strengths.

Can you give some concrete, real life examples to illustrate the point. Thanks

 

[pharmnrp804]

That's surprising. I thought that a cardiologist would know the intricacies of the cardio drugs very well.

Can you give some concrete, real life examples to illustrate the point. Thanks

Really? Cardiologists know their drugs to a point. A cardiology-trained pharmacist knows slightly different things about those drugs. Things such as metabolism and drug clearance in patients who have recently undergone procedures and/or may have existing co-morbidities. Or how multiple drug therapies work with or against each other based on availability of specific liver enzymes and synergism in a target tissue (such as the heart). Interactions and metabolism are huge components of drug therapy. If you give someone a drug, such as verapamil (calcium channel blocker), that is used to treat high blood pressure, how is that going to affect the metabolism of another drug that the patient may also be prescribed? People who have high blood pressure usually have other disease processes, such as high cholesterol. However, if you give someone a statin (cholesterol-lowering agent), its metabolism may be impaired by the presence of the calcium channel blocker. Therefore, doses may need to be adjusted. This is where the pharmacist comes in. I'm not saying that physicians don't know this stuff, but it's much less commonly known. As DermViser said, we work with each other, not against each other.

 

[Promethean]

A good pharmacist can save your ***, your license, and maybe your patient's life. I've seen them catch dosing and other medication errors that could have killed the patient had they not been diligent and attentive. And they are a priceless resource to avoid making such errors in the first place. There is a reason that they don't just replace pharmacies with vending machines. We don't think twice about consulting specialist physicians when the patient's condition calls for it. The pharmacist is the specialist who is consulted every time you write a script.

 

[Psai]

Also a clinical pharmacist will have undergone residency training and possibly a fellowship in a specific area. Some specialties can be found here: http://www.pharmacy.umaryland.edu/residentsfellows/programs/index.html

You can call it a residency and a fellowship if you want but it's not the same thing as our system. It isn't even close

 

[Promethean]

I'll admit that 400mg of morphine was an exaggerated comparison.

Let's call it 20mg of dilaudid instead (when I actually wanted to give 2mg of dilaudid). Pharmacist would likely call about that, not 100% sure if nurses would.

Nurses are technically the last line of defense, but they are not as good at catching errors in medication ORDERS (not talking about what pharmacy mixes on the spot and sends up to the floor) done by physicians as pharmacists are.

Woah! 20mg of Dilaudid? Nurses may not catch med errors with rarely used drugs. Maybe if you were talking about 500 of demerol instead of 50, since that is much less used these days. But give us credit when it comes to our most popular menu items. We are used to doses of dilaudid written for .2 IV, or 2mg PO. Even a novice's eyes would bug out at a dose of 20mg Dilaudid.

Still, I'd expect the pharmacist to beat me to that catch.

 

[DarknightX]

Yup. Our clinical pharmacist on transplant is a lifesaver. Manages all the immunosuppression for us and just sends the orders to us to cosign.

Totally agree. Can't tell you how many times the transplant pharmacist has saved my ass.

 

[pacman2018]

You can call it a residency and a fellowship if you want but it's not the same thing as our system. It isn't even close

I will agree with you as far as the time spent in residency goes. It will also depend a great deal on where they are doing their residency... Some programs are pretty tough and others not so much. Where I went to pharm school, the residents guessed they averaged around 90 hrs/wk. If you wanted to do something like cardiology (since it was given in the example) you have 2 years of residency after school and then fellowship if you choose to do that. Also where I went to school, the pharm residents had a lot more projects/extra crap to work on compared to the medical residents that I worked with. I will definitely say they don't have to put in the time that cardiologists have to (not even close) but I would consider it a residency/fellowship training since it can take as long as it does for some physicians (ie FM or IM)

 

[MEN2C]

LIFESAVERS!


Just did my subi and talking to the interns - it sooo nice that we have pharmacy that'll put a hold on the order if it's something ludicrous and likely to harm the patient. Especially true for interns (but also happens to senior residents and attendings) where most of the time they are prescribing a med for the first time and may get the dosages wrong. Doubly true because this is pediatrics and everything is weight based and it's easier to make mistakes.

I've only done gen peds so far so pharmacists rounding with us usually doesn't have much to say - because the medicines usually aren't particularly complex and also because if something was wrong, they've already paged us prior to rounds to let us know 😛.

In the ICU, they are even more critical. I have to admit, I didn't know much about what pharmacists did or knew prior to med school (having seen them only in retail) but they are absolutely vital in the hospital.

 

[MEN2C]

That's surprising. I thought that a cardiologist would know the intricacies of the cardio drugs very well.

He might. But it's rare a patient is on those drugs and nothing else. People might be on 25 different drugs from six different specialties. How much would a cardiologist know about his drugs interacting with the rheumatological or neurology drugs?

 

[aldolase]

He might. But it's rare a patient is on those drugs and nothing else. People might be on 25 different drugs from six different specialties. How much would a cardiologist know about his drugs interacting with the rheumatological or neurology drugs?

Right. That's a good point.