Problem with PGY2's?

[Dred Pirate]

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Our hospital recently hired a bunch of PGY2's with little to no work post residency - I am curious as to if anyone else has a similar experience. It seems like many of them are constantly unhappy and complaining that they aren't instantly promoted to a clin spec job, and even constantly badmouth those that have been (I used to be a clinc spec)- especially if they have less credentials (albeit much more real world experience). I am trying to figure out if it is a generational thing (millennials vs Gen x) - but I don't see it in our hires that are of similar age, but have a PGY1 or PGY0. What annoys me the most is a couple of them (before they get to know me) think they have to explain simple items to me- I usually bite my tongue, but lately I usually respond by taking it the next step and replying with an experience or situation where I know they don't know the right answer to- it is passive aggressive, but don't talk down to me- 15 years of experience trumps your 2 years where almost everything you did had oversight to it.

rant over.

 

[confettiflyer]

Sounds like poor hiring procedures.

 

[Rockinacoustic]

Are you a community hospital? Many PGY2 (especially ones from academic places) are out of touch with what clinical pharmacy is in 95% of hospitals.

 

[Deja]

and yet you guys keep hiring them? lol so who's really at fault here

 

[297point1]

Ignore them...they are salty that they didn't land the PGY3 they were hoping for.

 

[StockPharmD2020]

Lolz

 

[StockPharmD2020]

Sir, this is the stock subforum.

 

[lord999]

I would actually play happily dumb in front of them and goad them into publicly embarrassing themselves. That helps with egos. Also, you don't hire for character it seems. This is a management conversation. Finally, we had those issues too but the market was much more in our favor.

If they seem to be character deficient, you're aren't government, fire them for a little humility.

 

[Dred Pirate]

well- I am not mgmt - so I didn't hire them 🙂

 

[Amicable Angora]

Sounds like they need to make themselves feel better by bullying other people in attempt to justify their PGY2, sad.

 

[gwarm01]

I saw this with any PGY1 or PGY2 pharmacist hired back when I was a real pharmacist. We specifically hired them for evening jobs and it would take about a week before they felt entitled to specialist position with good hours and more "prestige." I just assumed it was poorly socialized people who never held a job and spent their formative years in school. They seem to think that you "graduate" PGY2 into a specialist position, kind of how you moved from high school, to college, to pharmacy school, to residency.

I agree with the idea of public humiliation to knock some sense into them. Maybe explain that jobs aren't created because you want them, they are created when they are needed. You have to need a clinical pharmacy specialist a whole hell of a lot to justify the costs.

 

[Dred Pirate]

I saw this with any PGY1 or PGY2 pharmacist hired back when I was a real pharmacist. We specifically hired them for evening jobs and it would take about a week before they felt entitled to specialist position with good hours and more "prestige." I just assumed it was poorly socialized people who never held a job and spent their formative years in school. They seem to think that you "graduate" PGY2 into a specialist position, kind of how you moved from high school, to college, to pharmacy school, to residency.

I agree with the idea of public humiliation to knock some sense into them. Maybe explain that jobs aren't created because you want them, they are created when they are needed. You have to need a clinical pharmacy specialist a whole hell of a lot to justify the costs.

we have had to do some subtle public shaming - them being turned down for jobs, making an effort to staff them in less desirable shifts/areas until they put in their sweat equity. The biggest problem is that for every unicorn job these people think they are entitled to, there are about 250 people wanting them. I think we had 75 pgy2 apply for our one staffing position a year ago.

 

[Sine Cura]

Sometimes people need a (metaphorical) punch to the face to wake up

 

[StockPharmD2020]

we have had to do some subtle public shaming - them being turned down for jobs, making an effort to staff them in less desirable shifts/areas until they put in their sweat equity. The biggest problem is that for every unicorn job these people think they are entitled to, there are about 250 people wanting them. I think we had 75 pgy2 apply for our one staffing position a year ago.

Are you at a super prestigious hospital they are hoping to transition to a clinical specialist job at? That's a lotmof applications for a staff job they don't want

 

[gwarm01]

Are you at a super prestigious hospital they are hoping to transition to a clinical specialist job at? That's a lotmof applications for a staff job they don't want

Imagine when they get the specialist job and realize it still kind of sucks.

 

[StockPharmD2020]

Imagine when they get the specialist job and realize it still kind of sucks.

As a former specialist, agree

 

[TranslationalRPh]

As a former specialist, agree

Explain?

 

[rph3664]

I saw this with any PGY1 or PGY2 pharmacist hired back when I was a real pharmacist. We specifically hired them for evening jobs and it would take about a week before they felt entitled to specialist position with good hours and more "prestige." I just assumed it was poorly socialized people who never held a job and spent their formative years in school. They seem to think that you "graduate" PGY2 into a specialist position, kind of how you moved from high school, to college, to pharmacy school, to residency.

I agree with the idea of public humiliation to knock some sense into them. Maybe explain that jobs aren't created because you want them, they are created when they are needed. You have to need a clinical pharmacy specialist a whole hell of a lot to justify the costs.

Almost 20 years ago, when I worked at the big hospital, we hired a newly graduated Pharm.D. who tried to tell our oldest pharmacist, who graduated in 1966, that he didn't know what he was talking about because he didn't have a Pharm.D. Mr. 1966, who was normally a really laid-back guy, totally let him have it. Sometimes, you just have to do that.

 

[Dred Pirate]

Are you at a super prestigious hospital they are hoping to transition to a clinical specialist job at? That's a lotmof applications for a staff job they don't want

I don't work at a "national name" hospital by any means - we are considered one of the better places to work, and a highly rated hospital. We really don't have the academic medical center model of clin specs who don't work - bascially clin specs still staff, but have to do a lot more teaching, and policy development for 5% more - IMO not worth it (been there done that)

 

[StockPharmD2020]

I don't work at a "national name" hospital by any means - we are considered one of the better places to work, and a highly rated hospital. We really don't have the academic medical center model of clin specs who don't work - bascially clin specs still staff, but have to do a lot more teaching, and policy development for 5% more - IMO not worth it (been there done that)

Staff >>>>> clinical or manager.

Some of the micromanagement of staffing sucks but worth it.

 

[BenJammin]

Just another consequence of the residency disaster. This is why hospitals should hire their own instead of relying on random residency trained pharmacists, a majority of them being incapable of competent practice at a high level.

 

[Dred Pirate]

Staff >>>>> clinical or manager.

Some of the micromanagement of staffing sucks but worth it.

since I started nights I dread the thought of going back to days - literally so much autonomy - I have only seen my manager once in the past 15 months, It is awesome.

 

[StockPharmD2020]

since I started nights I dread the thought of going back to days - literally so much autonomy - I have only seen my manager once in the past 15 months, It is awesome.

I love nights. Just feel like ****

 

[njac]

Explain?

I am a specialist in a very busy urban ED (all of our ED pharmacists are specialists for reference. We all have pgy2 in EM or fellowship in tox) academic medical center.

We have 1-3 learners on rotation with us all but one 5 week block of the year this year. Our rotation is popular - some of us (not me) are much better preceptors than others (me).

Central pharmacy has somehow come to the conclusion that because there is a pharmacist present in the ED 20hr/say they don’t have to help with our orders (100% prospective verification with a robust override list). Management claims to be on our side but we’re making very little headway with anyone is welcome to please verify anything >10 min old.

This means I can be at two cardiac arrests with a head bleed coming in and central is forwarding calls from one of my RNs to me because they need their IM Ceftriaxone verified. Meanwhile I’m trying to keep the clueless pgy1 to not let them start dexmedetomidine on the bradycardic ROSC patient “because they’re hypotensive”. Oh and I have to spoon feed the Med rec techs which patients to talk to because they’re incompetent because they don’t have enough oversight.

Mix in meetings of variable usefulness (Med shortages >>> everything)

Then the residents give us feedback we don’t do enough topic discussions. (With what time, chile?) and you go home at night to read
And edit said residents’ grand rounds slides, research proposals, and nevermind work on your own SCCM presentation you were invited to give. Oh and now it’s interview season so I’m reviewing 60 pgy1 apps 20 pgy2 plus giving our own residents CV review and general career mentoring/emotional support.

I love my job but it’s a lot. We all rotate through a week of nights every month and I look forward to it - I do the least work at home
That week because I can actually get things done at work and mostly just take care of patients.

 

[TranslationalRPh]

I am a specialist in a very busy urban ED (all of our ED pharmacists are specialists for reference. We all have pgy2 in EM or fellowship in tox) academic medical center.

We have 1-3 learners on rotation with us all but one 5 block of the year this year. Our rotation is popular - some of us (not me) are much better preceptors than others (me).

Central pharmacy has somehow come to the conclusion that because there is a pharmacist present in the ED 20hr/say they don’t have to help with our orders (100% prospective verification with a robust override list). Management claims to be on our side but we’re making very little headway with anyone is welcome to please verify anything >10 min old.

This means I can be at two cardiac arrests with a head bleed coming in and central is forwarding calls from one of my RNs to me because they need their IM Ceftriaxone verified. Meanwhile I’m trying to keep the clueless pgy1 to not let them start dexmedetomidine on the bradycardic ROSC patient “because they’re hypotensive”. Oh and I have to spoon feed the Med rec techs which patients to talk to because they’re incompetent because they don’t have enough oversight.

Mix in meetings of variable usefulness (Med shortages >>> everything)

Then the residents give us feedback we don’t do enough topic discussions. (With what time, chile?) and you go home at night to read
And edit said residents’ grand rounds slides, research proposals, and nevermind work on your own SCCM presentation you were invited to give. Oh and now it’s interview season so I’m reviewing 60 pgy1 apps 20 pgy2 plus giving our own residents CV review and general career mentoring/emotional support.

I love my job but it’s a lot. We all rotate through a week of nights every month and I look forward to it - I do the least work at home
That week because I can actually get things done at work and mostly just take care of patients.

So helpful!!! Thanks.

 

[PharmDBro2017]

With the way schools are pushing PGY1/PGY2 on students... they come out of these residency thinking they have authority/special powers vs. the rest of hospital staff. You need to take them down a notch (or two/three).

 

[lord999]

I am a specialist in a very busy urban ED (all of our ED pharmacists are specialists for reference. We all have pgy2 in EM or fellowship in tox) academic medical center.

We have 1-3 learners on rotation with us all but one 5 week block of the year this year. Our rotation is popular - some of us (not me) are much better preceptors than others (me).

Central pharmacy has somehow come to the conclusion that because there is a pharmacist present in the ED 20hr/say they don’t have to help with our orders (100% prospective verification with a robust override list). Management claims to be on our side but we’re making very little headway with anyone is welcome to please verify anything >10 min old.

This means I can be at two cardiac arrests with a head bleed coming in and central is forwarding calls from one of my RNs to me because they need their IM Ceftriaxone verified. Meanwhile I’m trying to keep the clueless pgy1 to not let them start dexmedetomidine on the bradycardic ROSC patient “because they’re hypotensive”. Oh and I have to spoon feed the Med rec techs which patients to talk to because they’re incompetent because they don’t have enough oversight.

Mix in meetings of variable usefulness (Med shortages >>> everything)

Then the residents give us feedback we don’t do enough topic discussions. (With what time, chile?) and you go home at night to read
And edit said residents’ grand rounds slides, research proposals, and nevermind work on your own SCCM presentation you were invited to give. Oh and now it’s interview season so I’m reviewing 60 pgy1 apps 20 pgy2 plus giving our own residents CV review and general career mentoring/emotional support.

I love my job but it’s a lot. We all rotate through a week of nights every month and I look forward to it - I do the least work at home
That week because I can actually get things done at work and mostly just take care of patients.

The reward for hard work is more work. But the terms also include choosing what hard work. To some degree, I do understand the new. If you think about it, most of us had scut work for the career start. On the other hand, the shortage gave us the ability to get into the upper divisions much more quickly and easily. But what the young don't understand, is the pay cut and the worse work circumstances that we came in with. It's that lack of appreciation from the young that somewhat drives this. On the other hand, the young drive innovation because they don't know that things aren't possible, so they do make things possible.

Every generation has its problems. Pay and work conditions are not hospital problems at present, but they were when we started. On the other hand, qualifications were not a problem then, but they are now that pay and work conditions are arguably equitable or superior to retail now.

I feel no sympathy for all the retail workers who cashed it in at the start. They made their money, and I hope they are happy with it. Those who took the time to invest in alternate work when it wasn't especially rewarding, are basically rewarded right now.

But this all is cyclical. I expect hospital cutbacks to resemble the early 80s again and all will be right with the world (pharmacists are overworked, underpaid, underappreciated, but lack significant direct responsibility and have decent job withdrawal after hours).

Many of those people in about 10 years will be pharmacy administration at some point. Be kind to them on their way up (although some humility is in order), because you'll be seeing them someday as your bosses.

 

[confettiflyer]

Just another consequence of the residency disaster. This is why hospitals should hire their own instead of relying on random residency trained pharmacists, a majority of them being incapable of competent practice at a high level.

We hire our own residents when it’s the right fit, it’s a great training/trial program with no expectations at the end of the year.

Much better than playing the guessing game at an interview and praying you find their quirks within 90 days...or good luck to you following your hospital’s preestablished termination pathway (gahhh).

 

[Sparda29]

I am a specialist in a very busy urban ED (all of our ED pharmacists are specialists for reference. We all have pgy2 in EM or fellowship in tox) academic medical center.

We have 1-3 learners on rotation with us all but one 5 week block of the year this year. Our rotation is popular - some of us (not me) are much better preceptors than others (me).

Central pharmacy has somehow come to the conclusion that because there is a pharmacist present in the ED 20hr/say they don’t have to help with our orders (100% prospective verification with a robust override list). Management claims to be on our side but we’re making very little headway with anyone is welcome to please verify anything >10 min old.

This means I can be at two cardiac arrests with a head bleed coming in and central is forwarding calls from one of my RNs to me because they need their IM Ceftriaxone verified. Meanwhile I’m trying to keep the clueless pgy1 to not let them start dexmedetomidine on the bradycardic ROSC patient “because they’re hypotensive”. Oh and I have to spoon feed the Med rec techs which patients to talk to because they’re incompetent because they don’t have enough oversight.

Mix in meetings of variable usefulness (Med shortages >>> everything)

Then the residents give us feedback we don’t do enough topic discussions. (With what time, chile?) and you go home at night to read
And edit said residents’ grand rounds slides, research proposals, and nevermind work on your own SCCM presentation you were invited to give. Oh and now it’s interview season so I’m reviewing 60 pgy1 apps 20 pgy2 plus giving our own residents CV review and general career mentoring/emotional support.

I love my job but it’s a lot. We all rotate through a week of nights every month and I look forward to it - I do the least work at home
That week because I can actually get things done at work and mostly just take care of patients.

Let me ask you something. I've been trying to convince our pharmacy manager to designate one staff pharmacist per shift as the ED pharmacist. Manager thinks that this would require hiring residency trained people or extensive training/adjustments.

Would my proposal of simply throwing one staff pharmacist every shift into the ED without any additional training work?

 

[njac]

Let me ask you something. I've been trying to convince our pharmacy manager to designate one staff pharmacist per shift as the ED pharmacist. Manager thinks that this would require hiring residency trained people or extensive training/adjustments.

Would my proposal of simply throwing one staff pharmacist every shift into the ED without any additional training work?

Depends how busy your ED is. You would have to know what you don’t know. We really struggle with central “helping” when they verify overtly wrong things. So we looks like jerks when we call and say “hey could you not” and they say “well I’ll just stay out of your orders then ”

Are there times it would be great? Sure, but only a few hours out of the day. In all honesty the queue spoon feeds us interventions and highlights patients who we may have missed when there are 100+ in the department.

 

[Sparda29]

Depends how busy your ED is. You would have to know what you don’t know. We really struggle with central “helping” when they verify overtly wrong things. So we looks like jerks when we call and say “hey could you not” and they say “well I’ll just stay out of your orders then ”

Are there times it would be great? Sure, but only a few hours out of the day. In all honesty the queue spoon feeds us interventions and highlights patients who we may have missed when there are 100+ in the department.

Here is the problem, currently, the ED doctors here have the ability to enter orders without pharmacy verification, and ER nurses can override the pyxis and pull meds that have not been verified. They constantly make mistakes about regular vs ER tablets, they consistently underdose vancomycin.

The ER enters about 1500-2000 orders on a daily basis that aren't verified by us.

 

[njac]

Here is the problem, currently, the ED doctors here have the ability to enter orders without pharmacy verification, and ER nurses can override the pyxis and pull meds that have not been verified. They constantly make mistakes about regular vs ER tablets, they consistently underdose vancomycin.

The ER enters about 1500-2000 orders on a daily basis that aren't verified by us.

Sounds like you need an ED pharmacist.

But you all could route the orders to pharmacy and put the Pyxis on profile-mode. Obviously with a pretty robust override list.

What would be the most helpful would be someone to handle the admission orders. (Again, will depend how your ED is configured. Some places don’t release admit orders until they get to the floor)

 

[njac]

Here is the problem, currently, the ED doctors here have the ability to enter orders without pharmacy verification, and ER nurses can override the pyxis and pull meds that have not been verified. They constantly make mistakes about regular vs ER tablets, they consistently underdose vancomycin.

The ER enters about 1500-2000 orders on a daily basis that aren't verified by us.

Also sounds like BCMA would improve the IR vs ER issue.

 

[Sparda29]

Sounds like you need an ED pharmacist.

But you all could route the orders to pharmacy and put the Pyxis on profile-mode. Obviously with a pretty robust override list.

What would be the most helpful would be someone to handle the admission orders. (Again, will depend how your ED is configured. Some places don’t release admit orders until they get to the floor)

Admission orders have to be verified by us, those are released as soon as they are entered.

 

[confettiflyer]

Also sounds like BCMA would improve the IR vs ER issue.

BCMA and ED are like oil and water (at first), and even that presupposes there’s an accurate/verified order to barcode against...which doesn’t seem to be the case at Sparda’s hospital.

I have many thoughts on Sparda’s hospital, but time to sleep, I’ll post later.

 

[WVUPharm2007]

This is why I work at CVS.

 

[Rockinacoustic]

Here is the problem, currently, the ED doctors here have the ability to enter orders without pharmacy verification, and ER nurses can override the pyxis and pull meds that have not been verified. They constantly make mistakes about regular vs ER tablets, they consistently underdose vancomycin.

The ER enters about 1500-2000 orders on a daily basis that aren't verified by us.

I prefer residency-trained people in the ED - that being said, your place sounds like it would benefit from anyone being present for the sake of medication safety. But even if they do end up hiring an external candidate, someone will need to cover their PTO.

 

[njac]

BCMA and ED are like oil and water (at first), and even that presupposes there’s an accurate/verified order to barcode against...which doesn’t seem to be the case at Sparda’s hospital.

I have many thoughts on Sparda’s hospital, but time to sleep, I’ll post later.

Agree - my mind was blown the first time I worked somewhere with BCMA.

But it honestly has more utility when the ADCs aren’t profiled - IF your RNs actually listen when it won’t scan.

It’s a struggle finding the perfect balance between scan %s and reasonable scan overrides. They’ve been militant about it at my current (and last) institution to a fault.

 

[lane one]

I am a specialist in a very busy urban ED (all of our ED pharmacists are specialists for reference. We all have pgy2 in EM or fellowship in tox) academic medical center.

We have 1-3 learners on rotation with us all but one 5 week block of the year this year. Our rotation is popular - some of us (not me) are much better preceptors than others (me).

Central pharmacy has somehow come to the conclusion that because there is a pharmacist present in the ED 20hr/say they don’t have to help with our orders (100% prospective verification with a robust override list). Management claims to be on our side but we’re making very little headway with anyone is welcome to please verify anything >10 min old.

This means I can be at two cardiac arrests with a head bleed coming in and central is forwarding calls from one of my RNs to me because they need their IM Ceftriaxone verified. Meanwhile I’m trying to keep the clueless pgy1 to not let them start dexmedetomidine on the bradycardic ROSC patient “because they’re hypotensive”. Oh and I have to spoon feed the Med rec techs which patients to talk to because they’re incompetent because they don’t have enough oversight.

Mix in meetings of variable usefulness (Med shortages >>> everything)

Then the residents give us feedback we don’t do enough topic discussions. (With what time, chile?) and you go home at night to read
And edit said residents’ grand rounds slides, research proposals, and nevermind work on your own SCCM presentation you were invited to give. Oh and now it’s interview season so I’m reviewing 60 pgy1 apps 20 pgy2 plus giving our own residents CV review and general career mentoring/emotional support.

I love my job but it’s a lot. We all rotate through a week of nights every month and I look forward to it - I do the least work at home
That week because I can actually get things done at work and mostly just take care of patients.

Oh my, I think we work together 🙂.

Not trying to pick a fight here, but I know we've experienced a significant reduction in inpatient staffing due to covid and still have a full house. Is it possible that your central pharmacy is overwhelmed with critically ill inpatients and is therefore prioritizing "their" patients instead of "your" patients? I really don't think it's anything territorial, just the reality of the current staffing situation.

You have to admit, from the outside looking in (your central pharmacy), it does seem counter-intuitive to have 20hr ED coverage...and still need another pharmacist to verify orders.

 

[TheBlaah]

Oh my, I think we work together 🙂.

Not trying to pick a fight here, but I know we've experienced a significant reduction in inpatient staffing due to covid and still have a full house. Is it possible that your central pharmacy is overwhelmed with critically ill inpatients and is therefore prioritizing "their" patients instead of "your" patients? I really don't think it's anything territorial, just the reality of the current staffing situation.

You have to admit, from the outside looking in (your central pharmacy), it does seem counter-intuitive to have 20hr ED coverage...and still need another pharmacist to verify orders.

It actually does seem like the ED pharmacists in their hospital does a lot of projects outside of ED coverage.

Why they do it is beyond me though.

At my hospital, 99% of orders from the ED are auto-verified unless the product comes from central pharmacy or they're loading doses of vanc/aminoglycosides which are pretty simple to calculate. While admission orders populate while the patient is in ED, the ED pharmacist doesn't verify them.

Which means very few orders for the ED pharmacist. A report would show that a central pharmacist does 5-10x more orders in about half the time on a regular basis.

They have no additional projects or responsibilities outside of codes.

And somehow we're still asked to help with orders.

 

[gwarm01]

It actually does seem like the ED pharmacists in their hospital does a lot of projects outside of ED coverage.

Why they do it is beyond me though.

At my hospital, 99% of orders from the ED are auto-verified unless the product comes from central pharmacy or they're loading doses of vanc/aminoglycosides which are pretty simple to calculate. While admission orders populate while the patient is in ED, the ED pharmacist doesn't verify them.

Which means very few orders for the ED pharmacist. A report would show that a central pharmacist does 5-10x more orders in about half the time on a regular basis.

They have no additional projects or responsibilities outside of codes.

And somehow we're still asked to help with orders.

Ah, you see, you aren't doing anything important up in central pharmacy. You might as well help the real pharmacists out on the floors. Everyone knows central pharmacy is just where the grunt work is done anyway. (A real quote by an ICU specialist to one of our technicians while he was "slumming it" in central over the weekend)

 

[confettiflyer]

It actually does seem like the ED pharmacists in their hospital does a lot of projects outside of ED coverage.

Why they do it is beyond me though.

At my hospital, 99% of orders from the ED are auto-verified unless the product comes from central pharmacy or they're loading doses of vanc/aminoglycosides which are pretty simple to calculate. While admission orders populate while the patient is in ED, the ED pharmacist doesn't verify them.

Which means very few orders for the ED pharmacist. A report would show that a central pharmacist does 5-10x more orders in about half the time on a regular basis.

They have no additional projects or responsibilities outside of codes.

And somehow we're still asked to help with orders.

# orders verified is an appropriate metric to measure ED Rph impact?

Sounds like poor rx management and resource utilization to me if all they do is go to codes.

 

[confettiflyer]

Ah, you see, you aren't doing anything important up in central pharmacy. You might as well help the real pharmacists out on the floors. Everyone knows central pharmacy is just where the grunt work is done anyway. (A real quote by an ICU specialist to one of our technicians while he was "slumming it" in central over the weekend)

“Slumming it in central” is probably the greatest phrase to have come from SDN these last few years. Glad to see it pop up annually.

 

[Rockinacoustic]

Oh my, I think we work together 🙂.

Not trying to pick a fight here, but I know we've experienced a significant reduction in inpatient staffing due to covid and still have a full house. Is it possible that your central pharmacy is overwhelmed with critically ill inpatients and is therefore prioritizing "their" patients instead of "your" patients? I really don't think it's anything territorial, just the reality of the current staffing situation.

You have to admit, from the outside looking in (your central pharmacy), it does seem counter-intuitive to have 20hr ED coverage...and still need another pharmacist to verify orders.

I have worked on both ends- where the ED pharmacist does all order verification, and where central verifies all ED orders. The best model is a compromise. Am I the best one to verify the morphine order while mixing alteplase bedside for a stroke? No. Am I the best one to dose the Vanco for the septic patient? Yes. Does it make sense for me to stop answering provider questions, changing discharge antibiotics, or interviewing patients for their medication history in order to verify admission orders? I don't think so.

Don't get me wrong, there truly are clipboard pharmacist out there who attend rounds, write notes that no one reads, and think they're above help expedite that stat order from central. I find my ED colleagues to be less like this.

 

[StockPharmD2020]

Depends how busy your ED is. You would have to know what you don’t know. We really struggle with central “helping” when they verify overtly wrong things. So we looks like jerks when we call and say “hey could you not” and they say “well I’ll just stay out of your orders then ”

Are there times it would be great? Sure, but only a few hours out of the day. In all honesty the queue spoon feeds us interventions and highlights patients who we may have missed when there are 100+ in the department.

We have a policy/rule for when to verify clinical covered orders.

5 min for Stat, 30 min for routine -- includes next day orders which is dumb.

I'd suggest getting something like that.

An to add.... if you call and say "could you not" to me one time, I'll never go out of my way to be helpful to you again. If you come up and have a conversation about the order and educate me or explain where it was suboptimal I'll be much more receptive.

As a former clinical specialist, I'm over clinical specialist telling me I'm wrong because they would have made a different decision. If you want vanc dosed exactly the way you want to, do the consults 24/7. It's different if there was something terribly wrong with what I verified but a lot of times it is from info they gained on rounds, provider discussion, something not in the chart, something they knew from rounding on same patient last admission, etc.

 

[njac]

Oh my, I think we work together 🙂.

Not trying to pick a fight here, but I know we've experienced a significant reduction in inpatient staffing due to covid and still have a full house. Is it possible that your central pharmacy is overwhelmed with critically ill inpatients and is therefore prioritizing "their" patients instead of "your" patients? I really don't think it's anything territorial, just the reality of the current staffing situation.

You have to admit, from the outside looking in (your central pharmacy), it does seem counter-intuitive to have 20hr ED coverage...and still need another pharmacist to verify orders.

Ooh, maybe we do! And maybe we don’t because it’s a pretty universal staffing model and pain point. Unfortunately I don’t know that anyone has found the perfect balance. But we keep trying!

I don’t think your picking a fight at all - even pre-COVID everyone’s job has it’s own challenges, and they’ve just been magnified by social distancing staff. I don’t know that the staffing model at my institution has changed much due to covid other than many of the clinical pharmacy staff working from home during the peak. But I could
Also be removed from some of the decisions that are happening in central.

I think everyone is guilty of some degree of prioritization and queue filtering. But if there are stat orders in the queue >30min anywhere in the hospital maybe it means that primary pharmacist is slammed and could use some help? It’s incredibly inconsistent whether anyone sees that and helps or not. When I run into that scenario I usually open up the queue for the whole hospital and if everywhere is that behind I just start from the top and help clean things up from everywhere, not just the ED. But if the whole house queue is completely empty except for 20+ ED orders it’s pretty obvious when they’re being blatantly avoided.

I have zero issues with verifying orders for my patients. I have some philosophical differences with those who feel their practice is “too clinical” to be bothered with it. It practically spoon feeds interventions to me (a metric we are graded against more than # orders verified) and also can alert me to what might be going on a patient who has snuck under the radar when we have 150+ in the department. But being the only specialists in the department who are expected to be 100% primary in the queue and have to practically beg for assistance (when most of our orders are once and intended to be given asap) is tough. In our model the inpatient specialists are only formally expected to be primary on their own orders until 12 or 1pm. That leaves nearly half of their shift to do the teaching and projects and meetings and all of the other things that are expected of us in addition to direct patient care. It’s unfortunate that it is seen as redundant to get some support on orders from central because I’ve absolutely made Med errors (and written myself up for them) because I was multitasking between a resident topic discussion and trying to stay up
On the queue. It’s also not fair to the resident and their learning when I have to get up every 5 minutes to go get something fixed. Their opportunity cost for taking this extra year of training and learning factors in - maybe not as overtly as the APPE students paying tuition to be on rotation.

Anyway. We’re eventually going to start with some auto-verify and I hope that helps a bit. If we can remove some wheat from
The chaff that should make what does come through a little more relevant.

Swing by and say hi sometime!

 

[njac]

We have a policy/rule for when to verify clinical covered orders.

5 min for Stat, 30 min for routine -- includes next day orders which is dumb.

I'd suggest getting something like that.

An to add.... if you call and say "could you not" to me one time, I'll never go out of my way to be helpful to you again. If you come up and have a conversation about the order and educate me or explain where it was suboptimal I'll be much more receptive.

As a former clinical specialist, I'm over clinical specialist telling me I'm wrong because they would have made a different decision. If you want vanc dosed exactly the way you want to, do the consults 24/7. It's different if there was something terribly wrong with what I verified but a lot of times it is from info they gained on rounds, provider discussion, something not in the chart, something they knew from rounding on same patient last admission, etc.

I do not use the “could you not” for this very exact reason - it’s nothing but condescending and counter-productive ! There are times I understand the sentiment but that doesn’t make it appropriate or productive. And unfortunately it does happen.

I pretty regularly send out articles to the department when we’ve had a practice change (looking at you, ceftriaxone 500mg for gonorrhea) because I know a lot doesn’t trickle down from the units like it could.

 

[njac]

Ah, you see, you aren't doing anything important up in central pharmacy. You might as well help the real pharmacists out on the floors. Everyone knows central pharmacy is just where the grunt work is done anyway. (A real quote by an ICU specialist to one of our technicians while he was "slumming it" in central over the weekend)

That’s wild.

One of the downsides of my current position is the lack of cross-training. My first job out of residency, despite being hired as a specialist, I was trained to do every single pharmacist shift before I even stepped foot in the ED. It was a much smaller hospital but I liked that I could do everything and was scheduled 1-2 shifts/month in central. This was really great for team dynamics and fostering relationships with everyone - most importantly the techs.

Everyone’s job is important and hard in its own right. It’s honestly harder to answer questions without a lot of the context you get from the doc walking up to you with the question or just walking to the patients bedside yourself.

 

[gwarm01]

As a former clinical specialist, I'm over clinical specialist telling me I'm wrong because they would have made a different decision. If you want vanc dosed exactly the way you want to, do the consults 24/7. It's different if there was something terribly wrong with what I verified but a lot of times it is from info they gained on rounds, provider discussion, something not in the chart, something they knew from rounding on same patient last admission, etc.

I'm right there with you on this one. I once had a confrontation with a pharmacist who was angry that I dosed vancomycin "too high" on a patient, even though the the trough came back at exactly 15. I guess he had some sort of arbitrary max dose in his mind that we weren't supposed to cross. He tried to dress me down in front of half the staff, but I think I put him in his place. I even got him to admit I made the right call this time, but that I shouldn't do it again. I guess the right call can only be made by specific people.

I always think back to one of my professors, who also happened to be head of the antimicrobial stewardship program at the hospital where I was an intern, who shared a story about a patient on vancomycin. They were admitted to a community hospital and were septic. It was a pediatric patient, and you know they like to clear things fast, so they were having trouble getting the trough where it needed to be. When the providers tried to order a dose greater than 15 mg/kg, the pharmacists absolutely refused to allow it. Not a single one would verify that order, because 15 mg/kg is the MAX dose per Lexicomp or something like that. They had to air lift the patient to our hospital, where we probably bumped them up to something like 17 mg/kg q8h, and the patient was taken care of in short order.

Anyway, that was sort of a rambling way to say medicine is an art and sometimes you aren't going to find the exact answer in a book. That's why I can't stand these know it all pharmacists who have no flexibility in their practice.

 

[owlegrad]

I once had a confrontation with a pharmacist who was angry that I dosed vancomycin "too high" on a patient, ...

I relate to this. It was an initial source of friction where I work at that I was being “too aggressive” with my vanco dosing.

Never mind that most of the staff are so ridiculously under aggressive that we have people who complete therapy without ever getting to goal, obviously the real problem is me and actually wanting to get to goal before the end of therapy.