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The Mindset of a Clinical Pharmacist

By Joseph Muench, PharmD, BCPS aka “Pharmacy Joe”


Pharmacy Joe is the author of “A Pharmacist’s Guide to Inpatient Medical Emergencies,” host of The Elective Rotation - a critical care pharmacy podcast, and creator of an online Critical Care Pharmacy Academy found at pharmacyjoe.com.

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When it comes to improving the lives of patients, how a pharmacist thinks can be as important as their knowledge base. This article is a collection of mindset techniques that I have found useful in my practice as a clinical pharmacist.
 
Know what you don’t know


Develop a robust self-awareness of what you don’t know, and a determination to close that knowledge gap before giving a recommendation to another clinician. It is daunting to admit when you don’t know the answer to a question. But your credibility will be permanently damaged if another clinician thinks you made up an answer to avoid saying “I don’t know.”  Once you recognize that you don’t know an answer to a question, call upon resources - other clinicians, reference material, etc… - to close your knowledge gap.



What to memorize and what to rely on a reference for

Experienced clinicians seem to have a natural ability to apply their knowledge to any patient scenario, no matter how complex. This is actually a skill that can be practiced and developed. The key is to focus on connecting the mechanism of action of medications to the pathophysiology of diseases. By learning in this manner, you will develop the ability to:

  1. Anticipate indications and contraindications for new medications.

  2. Correctly apply pharmacotherapy principles to any patient case, even if you have never encountered a particular combination of disease states before.
  3. Remember what you have learned and apply it to the next patient without having to look it up every time.

Here is an example of this in action:

You encounter a patient who took an overdose of the sulfonylurea glyburide. They continue to have episodes of profound hypoglycemia despite treatment with IV dextrose. The hypoglycemia is due to the excess release of insulin from the pancreas that glyburide causes. You recall that one of octreotide’s mechanism of action is to inhibit release of insulin from the pancreas. Connecting these dots leads you to the information that octreotide can be used as an antidote to sulfonylurea toxicity. You give a single subcutaneous dose of octreotide and the patient’s blood glucose normalizes.

To make this connection, one only has to understand the pathophysiology of sulfonylurea overdose and the mechanism of action of octreotide. This is much easier than memorizing lists of facts!  

How to prioritize your day

I prioritize my day by the formula “One minute before 9 am = 2 minutes after noon.”   This means completing necessary work early to free up time later in the day to spend on unexpected events or important follow-up care.

For example, I have pre-rounding, monitoring, and report reviewing to do in the morning.

I begin work on these tasks before answering emails, updating policies or protocols, completing a medication use evaluation, or conversing with colleagues.

If you use this formula to guide the start to your day, expect 4 important things to happen:

  1. Your day will become more efficient. Early in the morning, charts and patients tend to be on the unit for easy access rather than off the unit for a test or procedure. You will spend less time hunting down charts or returning to the unit to interview a patient because they were off the unit the first time you checked.

  2. Much work-related stress will disappear. Because essential tasks are out of the way before the day is halfway done, you will rarely need to scramble at the end of the day to finish that last patient consult or follow-up.

  3. Opportunities will open up for you to expand your knowledge base and learn from other clinicians. With the essential tasks out of the way you can say ‘yes’ to questions like “Do you want to watch this autopsy?” or “Do you want to see this bronchoscopy?” You can respond to every rapid response or code blue call without leaving an essential task undone. You will have the time to learn something new from a consultant, such as a cardiologist or infectious disease doctor.

  4. Unexpected events are less of a problem. Surprise meeting with the boss? No problem, your pre-rounding is already done. A resident needs time to be mentored? No problem, your consults are already done. Three patients have back-to-back-to-back code blues? No problem, you've got the time to help.

 


Where to spend your time


Try to spend as much of your day as possible on the nursing unit, elbow-to-elbow with patients and the care team. Use your time off the unit for activities that require a quiet space to work such as creating an in-service / presentation, or drafting a policy / procedure.

When you spend most of your time on the unit, 3 things tend to happen:

  1. You become more efficient by observing / interacting with the patient:
    If you are trying to determine whether venous thromboembolism prophylaxis is appropriate, it is much faster and accurate to see the sequential compression devices (SCDs) on the patient’s legs than it is to search the medical record for documentation.

    When assessing whether medications can be changed from the IV to enteral route on the nursing unit, you can see the NG tube hooked up to the tube feeding, or the patient eating their breakfast and know they will tolerate enteral medications.

    When evaluating cross-allergenicity of a medication order, being able to step in a patient’s room and ask them questions about their allergy history is far more effective than scouring old progress notes or reading in the record that the patient has “hives to penicillin.”

  2. You have more Interaction with the care team:

    When the care team knows they can count on you being on the unit, they are more likely to seek out your assistance. Your consistent presence turns into more IV compatibility questions, more pain consults, more drug fever or thrombocytopenia evaluations, more antibiotic stewardship opportunities, etc…

    Being available in-person for spontaneous questions provides an invaluable service to members of the care team. You will find many questions you can answer off the top of your head without further research – this saves you and the nurse or physician a significant amount of time.

    When you interact face-to-face with the care team you begin to learn how each discipline thinks and what their priorities are – this will allow you to more effectively communicate recommendations / interventions to those team members in the future.

  3. You will have more learning opportunities:

    The number of learning opportunities you will be exposed to by maximizing your time on the nursing unit is tremendous. No one is going to hold off starting a procedure for the pharmacist to walk up from the basement to the nursing unit. But if you are already there, you will get to see bronchoscopies, endoscopies, echocardiograms, central lines, joint reductions, intubations, tracheotomies, autopsies and countless other procedures. By viewing procedures, you will gain a better understanding of how medications are used to facilitate them.

    There is no shortage of experts readily available to learn from when you spend most of your day on the nursing unit. Want to know the best way to calculate the QTc when the rate is irregular? Find a cardiologist and ask them. Want to know why the infectious disease physician didn’t double-cover legionella? Be on the unit to ask them before they see the patient for the day. Want to know exactly how phentolamine is used in extravasation? Ask the IV therapy nurse next time you see him or her.

    Occasionally you will find someone who is too busy or stressed at the moment to share their expertise with you – but this is the exception, not the rule. Nearly always, people are happy to take a moment to share their expertise or answer questions.


How to communicate with physicians


When you approach a physician with a recommendation, they are usually occupied with another task. To have the best chance for acceptance of your recommendation, you need to focus the physician’s attention on your patient. To do this, present your recommendation in the same manner they are used to thinking about patients - like a case study. Plan ahead of time to succinctly phrase and communicate the recommendation. Use a structured tool, such as ISBAR:

    Introduction (if they don’t know you already)
   Situation
   Background
   Assessment
   Recommendation

Presenting your thoughts using this format allows the physician to follow your decision making process so that you can agree on a plan of action.


Here is an example:

Introduction
Hello Dr. Jones, I am Joe a pharmacist.

Situation
I would like to talk to you about your patient Joe Doe, the 63 year old male you just admitted with a community acquired pneumonia and are treating with levofloxacin 250 mg IV daily. I am concerned that his dose of levofloxacin is too low given his kidney function.

Background
I was looking at his labs and saw his serum creatinine is 0.8.

Assessment
I estimate his creatinine clearance to be 90 mL/min.

Recommendation
I would like to increase his levofloxacin dose to 750 mg IV daily as this is the recommended dose for CAP at his level of renal function.



How to quickly and easily develop relationships with physicians and nurses

It is essential to deliberately cultivate relationships with physicians and nurses. This can be done by following up with them on patients that you have cared for together. Asking “How is Mrs. Smith doing with her new gabapentin dose?” or “Did that patient’s tremor stop that we discussed last week?” lets the physician or nurse know that you are there to help them take care of the patient.

The relationships that you develop can be leveraged to help you better care for patients, learn new information and skills, and improve your future interactions with physicians and nurses.


Conclusion
I hope that implementing these mindset techniques will help you improve your ability to care for patients!

For more examples of connecting pathophysiology to mechanism of action, and for an ISBAR tool to use when structuring your recommendations to physicians go to pharmacyjoe.com/globalrph

-Pharmacy Joe


Disclaimer
The authors make no claims of the accuracy of the information contained herein; and these suggested doses are not a substitute for clinical judgment. Neither GlobalRPh Inc. nor any other party involved in the preparation of this program shall be liable for any special, consequential, or exemplary damages resulting in whole or part from any user's use of or reliance upon this material.  PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. BY ACCESSING OR USING THIS SITE, YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER.


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