It’s a given that there are healthcare professionals out there with substance abuse problems. But, as we prepare to enter practice, many of us find it difficult to imagine that we’ll be working with affected individuals, or that we could become affected ourselves. Few professional programs ask students to consider what they would do if they suspected or knew that someone in their workplace was impaired. And, still fewer programs formally acquaint students with recovery resources.

No one really knows how widespread substance abuse is within the healthcare professions. With their livelihoods at stake, few people are going to admit to having a problem. Additionally, most health professionals are smart people who are relatively good at hiding their problems. A lecture given by Brian Fingerson, the president of the Kentucky Professionals Recovery Network, indicated that the figure is 12-16% for “pharmacists and some other healthcare professionals”¹.  Given that one out of every nine Americans over the age of twelve was found to have a problem with substance use or dependence in the 2007 National Survey on Drug Use and Health², the suggested range seems quite reasonable.

As healthcare professionals, we may be more likely to develop substance abuse problems than members of the general population due to high work-related stress, increased access to controlled substances, and our knowledge of drug effects. Those of us who do become addicted may be shielded from discovery by the trust of our patients and coworkers. Plus, we may work very hard to avoid discovery, fearing harsh professional, social, financial, and legal consequences.

By this point, it should be clear that you should expect to encounter impaired healthcare professionals during the course of your career. What is less clear is what role you will play in the situation and how you will feel about it.  When you aren’t sure about what is going on, it can be hard to take action. You may only suspect that a coworker is coming to work intoxicated. Maybe there are narcotics missing on a regular basis but you aren’t sure who is taking them. It is reasonable to have fears about accusing an innocent person. You may worry about losing rapport with your coworkers if your suspicions aren’t proven true. There are many other reasons that you may feel compelled not to act. Perhaps you are worried about feeling guilty about turning in a close friend, or taking a provider away from a family. Or, maybe you feel like it’s not your place to take action since others are already aware of the situation.

The bottom line is that an impaired colleague is a danger to both themselves and their patients and needs intervention. If you suspect that a coworker is impaired, you need to connect with someone who can investigate and assess the situation or refer you to resources to do so. This could be your employer, the state board, or a representative from a Professional Recovery Network (PRN) or Caduceus group. If you know that a coworker is impaired, they need to be relieved from duty immediately. But, in order to fully do the right thing, you should also make an effort to connect them the unique support, advocacy, treatment, and recovery resources available through a PRN program. It is may be best to shield yourself by giving the PRN their information and letting the program initiate contact. It is not necessary for the affected individual to know who made the referral.

With the advocacy and monitoring offered by PRN programs, many healthcare professionals are able to regain licensure and return to work while in recovery. These individuals are typically required to sign a contract with the PRN organization and are subject to practice restrictions such as not being allowed to work unsupervised or not being able to work more than a specified number of hours per week.³

While employers or partners must know whether or not a healthcare professional is in a PRN program, coworkers may not.³ They often choose not to identify themselves because they don’t want to deal with the stigma, have their work overly scrutinized, or be judged on a daily basis. If you do discover that a coworker is in a PRN program, I encourage you to be supportive. While there is potential for relapse, PRN programs are used because they work. One pharmacy PRN program coordinator at The Utah Conference on Alcoholism and Other Drug Abuses shared that the drug abuse rates in his state’s PRN program were lower than that of the general pharmacists population. So, with proper monitoring, it may be less risky to hire an individual in a PRN than it would be to hire the average applicant.

For students or professionals interested in learning more about substance abuse in the health professions, I recommend attending the University of Utah’s School on Alcoholism and Other Drug Dependencies, now in it’s 58^th year. This annual week-long event is designed to help students and professionals understand and cope with substance abuse and incorporates a mix of speakers, discussions, social events, and open meetings for recovering addicts and families. Exposure to and interaction with recovering health professionals is one of the most valuable aspects of the program. For students and professionals in recovery the school also offers a unique opportunity to connect with a supportive network of people who share similar experiences. The pharmacy section, which I attended this June, is the largest section of the group, with around 300 participants, mostly students. Other healthcare sections included physicians, dentistry, and nursing. Both college and continuing education credit and are available at a reasonable cost. For more information, please visit http://uuhsc.utah.edu/uas/

1) Fingerson, Brian. “Chemical Dependency Among Healthcare Professionals.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

2) http://www.drugabusestatistics.samhsa.gov/NSDUH/2k7NSDUH/2k7results.cfm#Ch7

3) Quigley, Michael. “Issues in Relapse Prevention and Monitoring.” Lecture. The University of Utah’s School on Alcoholism and Other Drug Dependencies. Salt Lake City, Utah. 23 June 2009.

by Tony Guerra, Pharm.D.

We have a hiring freeze. Call us in a couple of months. We have a position, but it’s in a small town. Do you need benefits? How much experience do you have? Did you do a residency?

These aren’t supposed to be answers to our interview questions as pharmacists. We’re supposed to be able to fog a mirror and get a job. We should get to negotiate for a higher salary with a nice sign on bonus where and when we want. What happened to the good old days? You know, last year.

Supply and Demand

As the United States population has grown older and heavier, the demand for prescription medications has skyrocketed. Working to fill the need, chain pharmacies have gobbled up independents and kept their doors open later (many overnight), requiring greater levels of staff. As HMO’s, hospitals, clinics, universities, mail-order services, and the military all need pharmacists, they have been willing to pay handsomely for them.

At the same time, women have entered pharmacy in far greater numbers than ever before, many opting for part time positions or taking extended leaves to raise children. Complicating things further, when bachelor’s programs were phased out in favor of Pharm.D. programs, a year’s worth of graduates were lost.

All of this created an historic shortage of labor. State pharmacy schools could not keep up with demand, so the private schools started adding pharmacy programs at a rate of almost two per year (up from one every three years). In 1990, there were 74 pharmacy schools operating in the United States. Today, there are 103 with an additional nine in pre-candidate status. As salaries begin to stagnate or worse—drop, this may end up as a game of musical chairs, forcing a number of pharmacy programs to close their doors as quickly as they opened.

Tony Guerra, Pharm.D.

What does any of this have to do with finding a job you’re passionate about? To put it simply, you must work smarter to get it. If a PGY1 could have landed you a faculty spot before, then now you may need a PGY2 to get that same position. You may need to know a couple of people at the college or at the place you want to work. You may need to take a job that you don’t like as much so that you can build the skills and relationships to get exactly what you want.

But I want it now!

I understand. The truth is you can have it now, if you are willing to go outside the box.

I ask residents, “What are you going to do after your graduation or residency?” Nine times out of 10, the answer is, “I don’t know.”  Like being an Olympic athlete who has worked their entire life to win a gold medal, you will stand at the graduation platform thinking about the moment rather than what might satisfy you in the future. But there are actionable steps to arrive where you want to be.

Step One – Decide what you love to do on the most basic level.

Do you want to teach? Lead? Write? Advise? Manage? Whom do you love to help? Kids? Adults? Students? When you close your eyes, where do you see yourself smiling at work? By answering these questions, you can start moving in the right direction.

A pharmacist herself, my wife loves being the trusted advisor. Whether with family or patients, she loves to sit down and help people because she is a talented listener. With this in mind, she focused on becoming a diabetes expert through a program at Drake and in her practice. After showing a local free clinic how she could help them, they offered to create a 16-hour position due to the great work she had accomplished with diabetic patients. Because her passion was in line with her work, an opportunity was made.

Step Two – Volunteer.

Too many people ask for something then expect to get it, as if getting the career of your dreams is a one step process. The real order of service is to give, then ask, then receive. Since I wanted to teach and didn’t care if I got paid, I volunteered in a middle school math program. Later, I got paid to tutor, proctor, and teach test prep at Kaplan. It wasn’t a pharmacist’s salary, but their training program was great. After that, I volunteered to teach in pharmacy courses at the University of Iowa.

Each succeeding experience has made me more confident and more able. When the opportunity finally arose to teach a full-time course at a local community college, I was accepted right away. Yet, all of this began in a public school classroom with the willingness to give.

Step Three – Build your own practice.

The job you make for yourself is the job you’ll love. The day I left retail and started my own business, I was scared. But once I bought my own health insurance, I realized it wasn’t that bad and the freedom is amazing.

While I certainly had responsibilities to my customers, I could schedule them around other things in my life. I could coach in the afternoons, take trips with my family, and spend evenings at home. I was there for people when they needed me while building deep relationships one-on-one instead of trying to do the same through a plate glass drive-through window.

Building your own practice is life changing. It’s like going to a restaurant and ordering from the à la carte menu and getting exactly what you want.

Step Four – Start Now.

If you haven’t already, soon you will see the real impact of this economy. There are likely to be two kinds of responses. The first: you can cling to a job that you may not like out of fear of the unknown. The second: you can go forward, today, and start building a practice that you love. Involve the friends you missed while you were on that lonely pharmacy island.

Entrepreneurship is back in a big way. It can be your ticket to the work you love. Take the smallest step right now by writing down what you want. My own mission is to “build a service business so I can train in the mornings, teach during the day, coach in the afternoon, and be with my family and friends nights and weekends.” Write yours out, and it will become a reality.

Based on a series of polls conducted by the Student Doctor Network, students generally understand the current salaries they can expect to receive as a health professional.

The polls asked SDN users to select the salary range for an occupation “without Googling” to find the correct answer.  The results of the polls are available in the SDN poll archive.

Students were most likely to select the salary range into which the actual mean annual wage falls for all occupations except Dentists and Optometrists.  Actual wages used for comparison were determined by the Bureau of Labor Statistics and are accurate as of May 2007.

The range was underestimated for Optometrists and overestimated for Dentists.  In both cases the mean wage lay very close to a break point for the salary ranges available, and a majority of respondents selected either the correct range or the next closest range.

The table below details these wages:

 

For most occupations, while the answer most likely to be selected was the correct one, incorrect responses skewed higher than the actual wage.  For example, 61% of students overestimated the wage for Occupational Therapists (OTD), versus only 12% underestimating the wage.

“The internet makes it easy for students to identify what they can generally expect for a wage following completion of their degree,” said Michael Magatelli, an employment expert and executive coach with the Magatelli Leadership Group of Sacramento, California.  “No student should invest in a degree without understanding the value they are going to receive from it.”

To gain further insight into wages beyond the average salaries referenced above, Magatelli recommends students conduct four to six “informational” interviews.  These interviews will help illustrate any unique costs or required investments associated with setting up their desired practice model.

“Informational interviews, in addition to internet salary information, will provide a more complete picture of the costs of becoming a practicing health professional in your geographic area,” said Magatelli.

Nuclear pharmacy is a specialized practice area in pharmacy that involves compounding and dispensing radiopharmaceuticals to be used in various nuclear medicine procedures.  Unlike radiology, nuclear medicine is a fantastic tool for assessing physiology (function), as opposed to only structure and anatomy.

It is a unique niche within pharmacy and this article will provide an overview of the specialty area, including common radiopharmaceuticals and procedures used in nuclear medicine, as well as the role of a nuclear pharmacist on the healthcare team.

From a business perspective, the industry’s current standing includes nuclear pharmacies which are either institutional (and cater to a single medical center), or commercial.  Centralized commercial pharmacies are contracted by hospitals/clinics to provide radiopharmaceuticals.

Today, there are only a few major radiopharmacies: GE (formerly known as Amersham), Covidien (formerly known as Tyco or Mallinckrodt), and Cardinal Health (which bought out Syncor, among others), as well as a few smaller independents.

Tc-99m and Compounding Radiopharmaceuticals

Technetium (Tc-99m) is by far the predominant isotope used; it is an ideal diagnostic tracer and is used to compound the vast majority of radiopharmaceuticals.

To put it very simply, Tc-99m is obtained by eluting a molybdenum generator: a vial of saline is placed at the entry point of the generator, with an evacuated vial on the opposite end (encased by a heavy tungsten shield).  The negative pressure draws the saline through the generator, and a sodium pertechnetate eluate is produced.

Depending on the amount of activity needed for the run (and the number of doses the pharmacy will send out), several generators are hit throughout the course of the day.  This Tc-99m elution is then used to compound the majority of kits in the pharmacy. Since Tc-99m has a relatively short half-life (approximately six hours), logistical reasons require local preparation of the drugs.

In a laminar airflow workbench (LAFW) with an L-block for protection, multidose vials of the various radiopharmaceuticals (also placed into tungsten vial shields) are compounded using specific amounts of Tc eluate and saline.  Each drug kit has very particular compounding steps and procedures, which may include heating, venting, etc.

The pharmacist then hands the prepared multidose vials with corresponding prescription labels to technicians, who (in their own hoods) safely draw up unit doses into syringes with the help of a leaded glass syringe shield.  Due to the lead/lead glass composition, these are relatively heavy, and require dexterity and practice to use properly.

The technician draws the volume indicated on the prescription label, and then verifies the activity by placing the syringe into a dose calibrator.  The calibrator will indicate the current activity of the dose, as well as what it will read at the desired assay time indicated by the customer (i.e. 72 mCi now, and 30 mCi at 08:00).

Each unit dose (syringe) is placed into a lead-shielded “pig”, labeled, capped, and placed into a case to be shipped out to the hospital or clinic.  When the dose arrives to the customer, a nuclear medicine technician/physician will verify the activity in their own calibrator, and administer the dose to the patient.  After a set amount of time, the patient is scanned and the images are interpreted.

In addition, prior to doses leaving the pharmacy, quality control by chromatography is performed on each and every kit that is prepared to ensure the drug is sufficiently bound to the isotope, there are no impurities, etc.  USP sets certain percentage requirements for each drug to pass QC, and each company may set even more stringent internal requirements (i.e. 95% purity or above to pass).

Radiopharmacology and the Common Procedures in Nuclear Medicine

Relatively speaking, there are really only a small number of radiopharmaceuticals and nuclear isotopes available.  This permits nuclear pharmacists to become true experts in their practice.  Approximately 80% of radiopharmacy is diagnostic; however, there are some fascinating and effective therapeutic drugs that we compound as well.

The following list does not include every radiopharmaceutical available, but will give you a good taste of what is available.

• Cardiology: this is the bread and butter of nuclear medicine. The major agents used are Thallium-201, Tc-99m Sestamibi (Cardiolite®) and Tc-99m Tetrofosmin (Myoview^TM). They are useful in myocardial perfusion imaging (i.e. comparing a ‘rest’ and ‘stress’ image to identify ischemia/infarction), avid infarct imaging (to detect damaged myocardial tissue post-MI) and cardiac function studies (to determine how well the heart is pumping via LVEF). These studies are a great tool for guiding a patient’s course of therapy; helping to determine whether they may need open heart surgery, catheterization, or strictly risk management with lipid control, and so on.
  

• Brain imaging: Tc-99m Exametazime (Ceretec^TM) and Tc-99m Bicisate (Neurolite®) are agents used to screen for tumors, detect metastases, detect intracranial injury, identify seizure foci, and even aid in determining legally defined ‘brain death’.
  

• Skeletal imaging: Tc-99m Medronate (MDP) and Tc-99m Oxidronate (HDP); are radiotracers with a bisphosphonate structure used to assess bone trauma (i.e. fracture imaging), distinguish osteomyelitis from cellulitis, evaluate bone cancer/multiple myeloma, paget’s disease, and so on.

• Treatment of pain due to bone metastasis: This is a good example of where nuclear medicine is used in treatment rather than strictly for diagnosis. Sr-89 Chloride (Metastron®) and Sm-153 Lexidronam (Quadramet®) can be far more effective than traditional therapy in helping cancer patients suffering from excruciating pain resulting from bone mets.

• Liver/Spleen imaging: Tc-99m Sulfur Colloid is essentially a radioactive particle that is phagocytized by the RES. It is used to image for hepatitis/cirrhosis, high LFT’s, liver tumor, trauma, abscesses, etc., where ‘cold spots’ (dark areas) in the image indicate an abnormality.
  

• Lymphoscintigraphy: small doses of filtered Tc-99m Sulfur Colloid are injected during surgery to locate lymphatic drainage patterns, guide oncological surgeons, and to identify the location of a sentinel node. The sentinel node (first node downstream from the tumor) can then be sent for biopsy to determine whether the cancer has metastasized>

• Hepatobiliary imaging: Tc-99m Mebrofenin (Choletec®) is used for gallbladder imaging to differentiate between acute (oftentimes caused by gallstones) and chronic cholecystitis. In acute cholecystitis, the gallbladder will light up in the scan, but does not for chronic disease.

• Renal imaging: Tc-99m Pentetate (DTPA) and Tc-99m Mertiatide (MAG-3) are two radiopharmaceuticals used for renal function imaging (i.e. quantifying GFR or tubular secretion), whereas Tc-99m Succimer (DMSA) is used to assess structure/anatomy of the kidney. These agents are useful in patients with renal obstruction, renal HTN, tumor, trauma, and so on.
  

• Pulmonary imaging: VQ scans are done to differentiate between a pulmonary embolism (lung clot) and chronic obstructive pulmonary disease (COPD). A perfusion test (using Tc-99m MAA) is generally done first. If the results are abnormal, the ventilation portion of the study (using radioactive Xe-133 gas or aerosolized Tc-99m DTPA) is performed. Normal ventilation will then indicate that the patient has a high probability of having a PE, whereas abnormal ventilation points to COPD.
  

• Thyroid imaging and treatment: since the thyroid gland naturally takes up iodine in order to produce thyroid hormones, administering radioactive iodine is a logical step in order to assess function (uptake) of the thyroid, as well as image or treat thyroid cancer. Thyroid uptake/function studies are performed by administering I-123 or I-131 NaI, which are useful in the diagnosis of hypo-/hyperthyroidism. Thyroid imaging can also be performed to assess ‘hot’ or ‘cold’ nodules on the thyroid; as well as whole body imaging, to look for metastatic tumors during follow-up of thyroid cancer. Thyroid therapy is a classic example of how nuclear medicine is used for treatment purposes. I-131 NaI is administered in higher activities to treat hyperthyroidism, as well as ablate the gland after surgery to mop up any remaining cells.
  

• Infection imaging: Ga-67, which is similar to iron, is passively localized to a site of infection and is an excellent choice for chronic infection imaging. Radiolabeled white blood cells can be an effective option in patients with an acute infection, inflammatory bowel disease, fever of unknown origin, osteomyelitis, soft tissue abscess, skin graft infection or diabetic foot ulcer. A hospital will send us a syringe containing a sample of the patient’s blood. In the pharmacy’s blood room (a completely segregated area from the remainder of the pharmacy), a needless procedure is used to extract the patient’s white blood cells. The leukocytes are then tagged with radioactive In-111 or Tc-99m Exametazime (Ceretec^TM). The patient’s own radio-labeled WBC’s are then sent back to the hospital where they are re-injected into the patient, and scanned to localize the site of infection.
  

• Monoclonal antibody imaging/therapy: this could quite possibly be the future for nuclear medicine, as there are so many possible applications for monoclonals. There are a only a handful of agents available now: In-111 Capromab Pendetide (ProstaScint®) to image prostate cancer, and In-111/Y-90 Ibritumomab Tiuxetan (Zevalin^TM) or I-131 Tositumomab (Bexxar®); however many more are in production. Zevalin^TM and Bexxar® are effective treatment options for patients with non-Hodgkin’s lymphoma.

• PET: is another fascinating area of nuclear medicine. F-18 FDG (”radioactive glucose”) is produced at a facility with a cyclotron, and is used to detect areas of the body undergoing high metabolism (i.e. epilepsy, cancer) relative to normal tissue. Since PET looks at the disease on a chemical level, you can identify the disease much sooner than when using other imaging modalities.
  

Authorized Nuclear Pharmacist (ANP) Training

As can be expected, the training necessary to become a nuclear pharmacist is very extensive.  About 200 hours of didactic training, and 500 hours of hands-on experience are required to practice under a pharmacy’s RAM license.

There are a few ways to go about getting this and becoming an “ANP”: 1) Attend a pharmacy school that has a nuclear program, which is completed during the PharmD curriculum (i.e. Universities of Arkansas, Oklahoma, New Mexico, Tennessee ).  Option 2) Once already a pharmacist, privately pay for training (i.e. through NEO).  Option 3) Pursue a nuclear specialized residency (i.e. SUNY or Walter Reed) or Option 4) and this is probably what most people do; begin working for a nuclear pharmacy company.  They will generally pay pharmacist salary while you do your training, and provide the training as well.

Typical Day at a Nuclear Pharmacy

Most pharmacies will typically have between 1 – 3 set “runs”.  A typical day at my pharmacy begins at around midnight when the night pharmacist arrives; they will then begin to hit the generators and start compounding the first run.  Technicians and drivers will begin to trickle in; doses are drawn (including FDG brought in from a cyclotron) and packed up.  First run is out the door and on its way to customers between 04:00 – 05:00.

The pharmacist and technicians then have some down time to clean up, log all of the kits prepared during the run into the computer, grab a bite to eat, etc.  Second run then starts at around 06:00; a second pharmacist arrives at around 07:00 as this is when the phones start to pick up with same day add-ons from the customers.  Second run is out the door by 08:00.  A third and fourth pharmacist arrive at 08:30.  One of them will generally be designated to work on the bloods; another will help answer the phone, take orders, deal with customer service issues, etc.

Third run compounding (which is usually pretty light), begins at 10:00 and is out the door by 11:30.  I-131 capsules will need to be compounded at some point during the day as well.  Throughout the morning and afternoon, we’ll field phone calls ranging from STAT add-ons to clinical questions (i.e. pediatric dosing, altered biodistribution, questions about drug selection, and so on).  The rest of the day is generally spent setting up for the next night: order entry, drawing any doses (i.e. Thallium, which has a long half-life) that can be drawn the day prior.  Prescription labels are printed, double-checked and any products needed for the next day are ordered.  So, as you can see, the daytime hours are generally spent getting ready for the following night.

The closing pharmacist locks up sometime around 17:00 and is on call for the remainder of the night.

Radiation Safety

Radiation safety and proper handling of all RAM is at the forefront of the training we receive.  Employees are required to wear ring badges (to monitor extremity exposure) as well as a body badge at collar/thyroid level (to monitor whole body exposure).  Rings are monitored weekly, and badges monthly, to assess each employee’s radiation exposure.

The US government has set limits (i.e. 5 REM/year for whole body exposure, 50 REM/year for extremities).  In addition, companies will oftentimes have even stricter limits than these, and will assess each individual as necessary if their exposure approaches action levels.  Most of the times, this will entail adjusting ones compounding techniques to ensure practice of “ALARA” principles.  Each pharmacy will also have a “Radiation safety officer” (who may or may not be a pharmacist), and they are responsible for overall safety at the pharmacy: monitoring air concentrations, training personnel, and keeping employees under all federal/company radiation guidelines.  Pregnant women can officially declare their pregnancy to the company as well, and will receive an additional fetal badge to be worn near the belly.  She will have even stricter limitations to restrict the amount of radiation exposed to the child.

Advantages of Becoming a Nuclear Pharmacist

As mentioned earlier, this is a very specialized field and there is a general appreciation for the training/education a nuclear pharmacist has received.  As you read in the description of a typical day in the pharmacy, (barring any problems), the pace is generally pretty relaxed with some lag time, especially at night.  You become very close with your staff (technicians, drivers, administrators) and get to know your customers very well.  You are treated as a professional and they value your input and services.  After you’ve gotten enough hours under your belt, you’re also able to become board certified (BCNP) if you so desire; nuclear pharmacy was the first specialty area established by the BPS.  There’s definitely opportunity for job growth through management.  Nuclear pharmacy is a neat balance between clinical pharmacy, physics, chemistry, math, management, business/sales, customer service, current issues like the application of USP <797> across the industry; there is a little bit of everything for everyone.

Disadvantages of Becoming a Nuclear Pharmacist

The reality is, we deal with radiation and biohazardous material on a daily basis.  We are however, provided with the training on how to deal with this properly, and it is in your own interest to do things by the book.  Over-night hours are another stickler for some people.  A fully staffed pharmacy though, will permit pharmacists to rotate their shifts.  It may be possible that you will only have to work the opening shift one week out of every four to six.

Specializing in this field also requires us to keep up with “regular” pharmacy.  Many times, hospital/retail pharmacists will not know what Cardiolite® is, but nuclear pharmacists rarely talk about the new factor Xa inhibitor anticoagulant either.

Many people ask me whether it’s difficult to find a job as a nuclear pharmacist. The answer is: no.  It’s not hard to find “a” job; there will always be a demand for a well-trained specialist, however, unlike retail pharmacies, you’re not exactly going to find a nuclear pharmacy on every corner.  As a result, it may take a little longer to find “the” opening you want, in the specific city/state you’re interested in.

Thank you for your interest in this topic; hopefully this article will spur further discussion of nuclear pharmacy and nuclear medicine on the SDN Forums.  It’s a fascinating specialty practice that allows pharmacists to excel and provide valuable diagnostic and therapeutic options for our patients.

I encourage all students who are interested in the field to take an elective at your school if one’s offered, sign up for a nuclear rotation, or even contact a nearby pharmacy to shadow a pharmacist for a day.

Since October is National Pharmacists Month, now is an excellent time to examine the evolving role of pharmacists in the modern health care system. The profession of pharmacy is going through a period of vast development and change. Instead of being tied solely to the product of medications and dispensing, it is diligently recreating its image into an increasingly cognitive practice.

Pharmacists have become such an integral part of the health care team because they have the unique advantage of being among the most accessible health care professionals. As patients come in once a month to refill a prescription, the pharmacist tends to be the professional that they see the most regularly.

Unfortunately, due to the mandates of insurance companies, physician visits are growing shorter and shorter these days.

If a patient presents for an acute condition during a physician visit and that condition is addressed and cared for, there is generally little time left for the management and care of any chronic conditions. It is in the management of such chronic conditions that the cognitive services offered by pharmacists can be useful.

Chronic medical conditions are not uncommon across the country. Focusing on the Medicaid program alone, approximately 30 percent of recipients have a diagnosed chronic medical condition . Not only are these chronic conditions physically taxing for the afflicted individuals, but they also have significant financial impacts for the Medicaid system. Approximately 83 percent of spending for Medicaid is dedicated to people with multiple chronic conditions . As a result, new strategies have to be developed to deal with this sizable issue. In the state of Iowa for example, one strategy to combat chronic conditions is through a program called Pharmaceutical Case Management (PCM). A collaboration between physician and pharmacist, a patient is identified as being at high risk for potential drug interactions and/or adverse drug reactions based on the disease states and number of medications being taken. Through an interview and consultation process, pharmacists can thus help manage the long-term care of chronic conditions in an effective way.

Begun in 2000, the Iowa Medicaid PCM program has allowed pharmacy to take on a new role for patients. By looking at the pharmacy dispensing system and refill history, a patient is identified for eligibility. In order to qualify for the Iowa PCM program, patients must have one of 12 different chronic disease states and also be on four or more chronic medications. Additionally, they must not reside in a long-term care facility. When a patient is identified, eligibility for the program is verified by Iowa Medicaid which will pay for the services provided. After this step, the patient is contacted to come into the pharmacy for an interview. To enable the pharmacist to get a better understanding of the patient, a simple patient history form is filled out discussing disease states, hospitalizations, and common background questions. The interview then proceeds by reviewing the background paper, the medications, and the refill history of the patient. The goal of a PCM interview is to identify drug therapy problems such as:

1. dose too high
2. dose too low
3. wrong drug
4. untreated condition
5. drug therapy for unidentified condition
6. drug interactions with other drugs/food/labs
7. adverse drug reaction and/or inappropriate compliance

Following this interview, a SOAP note is sent to the physician involved in the care of the problem. There is variety in how SOAP notes can be written. Some pharmacists like to focus on one patient problem at a time, while other pharmacists identify all the problems in one SOAP note. The SOAP note is documentation of the interview and also enables the pharmacist to communicate with the primary care physician and relay information from the interview to the physician.

The most intriguing portion of the Iowa Medicaid PCM program is that is based in a community pharmacy setting. Traditionally, community pharmacy has been driven by dispensing functions. However, as pharmacy continues to grow and expand services (especially cognitive services), PCM is going to be an increasingly important program. As mentioned earlier, community pharmacists are the most accessible health care providers for some patients. By providing this service in the outpatient and community settings, the focus can remain on the management of the chronic condition rather than being involved in the patient’s immediate hospital care needs.

With this new program comes special considerations for the practitioner as well. In order to provide PCM services to Medicaid patients, pharmacists must have completed one of two training modules. Either they must be a Doctor of Pharmacy graduate, or they must complete a training program through Iowa Center for Pharmaceutical Care (ICPC). The pharmacist then has to complete an application and submit five patient care SOAP notes completed in the past six months.

The Iowa Medicaid PCM program reimburses pharmacies for providing not only the initial interview but also any necessary follow-ups. Initial interviews are reimbursed at $75 with preventative problem follow-up assessments reimbursed at $25. The preventative problem follow-ups can be done once every six months. If a problem is identified, problem follow-up assessments can be completed and reimbursed at $40 per occurrence, up to four times in a 12-month period. If a new problem is identified, this can be reimbursed two times per year. In this way, the program is designed to provide long term follow-up and maintenance for the patient while truly managing the patient’s chronic condition.

As PCM is a new service provided to patients enrolled in Iowa Medicaid, the program has been evaluated with significant results having come out of the review. During the study period, pharmacists identified 2.6 drug related problems per patient. The most common recommendation of pharmacists was the addition of another medication, such as a beta-blocker or aspirin for a heart attack patient. While Iowa Medicaid paid a total of $94,170 for PCM services,there was no net increase in the health care utilization costs or charges for patients who received PCM services versus those patients who did not receive them.

By helping to manage the chronic conditions of eligible patients, the Pharmaceutical Case Management program has great potential to positively affect the Medicaid population. As health care continues to evolve and become more team oriented, pharmacists are going to be asked to take on more responsibility in the care for patients. Pharmacists in the community setting are poised to help manage patients at great risk to adverse events due to their medications. By demonstrating their success to both insurance companies and the greater medical community, hopefully services such as PCM will continue to grow.

1. Agency for Healthcare Research and Quality. Accessed Sept. 20, 2008. Available at http://www.ahrq.gov/qual/medicaidmgmt/medicaidmgmtint.htm
2. Agency for Healthcare Research and Quality. Accessed Sept. 20, 2008. Available at http://www.ahrq.gov/qual/medicaidmgmt/medicaidmgmtint.htm
3. Iowa Medicaid Pharmaceutical Case Management Program Final Report December 2002. Accessed Sept. 20, 2008. Available at http://www.iarx.org/Documents/PCM%20Final%20Report.pdf.

Through her three companies (Creative Educational Concepts, ConvenePro and PromoGistics) she interacts regularly with health care professionals in a variety of medical specialties.

She earned her PharmD from the University of Tennessee and was previously employed in as a Clinical Pharmacist in the Continuing Education department at University of Kentucky’s Chandler Medical Center and as a Clinical Pharmacist in the areas of geriatrics and psychiatry with the Department of Veteran’s Affairs.

Tell us about your companies.

PromoGistics is a full service professional marketing and communications company with a diverse clientele. ConvenePro, LLC is a full service healthcare communications company specializing in market research, resource development, and event management for the pharmaceutical industry. We work primarily with consumer healthcare and pharmaceutical companies whose target audiences include specialists, primary care, consumers, patients, pharmacists and allied healthcare workers. Finally, Creative Educational Concepts, Inc. (CEC) is a nationally accredited provider of continuing education for physicians and pharmacists. CEC is dedicated to lifelong learning.

What do you like best about your current position? What do you like least?

I have a lot of variety in my daily activities and the work is mentally challenging. My position is flexible and I enjoy the family-like atmosphere of my work team. Some of the stresses include the pressure of being a business owner, human resource challenges and the constantly changing legal and regulatory environment in which we work.

Besides your pharmacy degree, what type of training is required or helpful for a position such as yours?

Training in marketing, accounting, finance, management and supervision would be big assets to someone considering a position like mine. Additionally, competence in legal and regulatory affairs, training in strategic planning and excellent communications skills are essential.

Do you engage in any outside consulting or other professional activities?

I was a founding member of the CPNP (College of Psychiatric and Neurologic Pharmacists) and I remain active on committees as well as with BCPP recertification. I’m also involved with the American Lung Association at the state, regional and national level and with anti-smoking advocacy efforts.

Do you participate in research, conferences or other professional activities?

Yes, in addition to conducting hundreds of meetings through our companies every year, I attend national meetings in all medical specialties (asthma/allergy, cardiology, psychiatry, epilepsy, etc.) in order to stay abreast of clinical issues. I also attend conferences targeted to medical education providers and conduct workshops on accreditation regulatory compliance.

In what direction do you think the field of pharmacy and your area of focus are headed?

There will always be a need for lifelong learning and demonstration of sustained competence for health professionals. My industry faces particular challenges with regard to the evolving regulatory environment.

What advice do you have for students interested in or currently pursuing a career in pharmacy?

It is an incredible profession that provides training far beyond the conventional practice sites that most Americans see. There are a number of challenging, innovative opportunities available for those willing to explore them.

Is there anything else you’d like students to know about your career or the profession of pharmacy?

“If you can dream it, you can do it.” (Walt Disney)

Dale Whitby, PharmD, BCPS works for Gold Standard Inc, an Elsevier Company. Gold Standard provides drug information products such as Clinical Pharmacology, eMPOWERx and Pharmacy Solutions to the health care community.

Dr. Whitby earned his PharmD from Virginia Commonwealth University/Medical College of Virginia and completed residencies in Pharmacy Practice and Pediatric Pharmacy at the University of Kentucky. Prior to joining Gold Standard, he was a Pediatric Critical Care Clinical Pharmacy Specialist at Shands Hospital at the University of Florida.

What do you like best about your current position? What do you like least?

I enjoy the constant challenge of keeping up with current literature and being able to summarize it in a useful manner for other practitioners. I also appreciate that my work

schedule is flexible. One drawback is the limited opportunity I have to serve as a mentor. I would like to have more contact with student pharmacists and residents.

Besides your pharmacy degree, what type of training is required or helpful for a position such as yours?

Residency training and several years of clinical practice are huge assets. Because of the time I spent with patients and other practitioners, I am better able to determine the relevance of information before adding it to our database. Additional training in medical writing or drug information would be helpful for a student considering a position like mine.

Do you participate in research, conferences or other professional activities?

I typically give one presentation per year at a regional or national meeting. I have co-authored three book chapters in the last three years (one pharmacy textbook and 2 medical textbook chapters). I also provide lectures for pharmacy students.

In what direction do you think the field of pharmacy and your area of focus are headed?

Because of the constantly increasing numbers of drug approvals and demands on health care professionals’ time, there is an increasing need for electronic medical information that is current and concise. I only see this field growing over the next decade.

What advice do you have for students interested in or currently pursuing a career in pharmacy?

Keep an open mind. The possibilities are endless, but keep in mind that sometimes the shortest route to a goal is not necessarily the best route in the long run. In many cases, the skills that you learn during a year or two of post-graduate training are key to opening up new possibilities for you in the future.

Is there anything else you’d like students to know about your career or the profession of pharmacy?

This is an exciting time for pharmacists. We have numerous possibilities in addition to the traditional pharmacist roles. Explore your options and choose the best fit for you.

By Juliet Farmer
Staff Writer

Nicholas Blanchard, PharmD, MEd, is Assistant Dean for Student Affairs and Advocacy at Wegmans School of Pharmacy, St. John Fisher College in Rochester, New York.

Dr. Blanchard has nearly 20 years of practice and academic experience in pharmacy. Prior to coming to Fisher in early 2006, he held the positions of Assistant Dean of Student Affairs at Wingate University School of Pharmacy, Associate Dean of Experiential Education at Texas Tech University School of Pharmacy, and Associate Professor of Pharmacy Practice at Washington State University College of Pharmacy.

He also held positions in the pharmaceutical industry and in practice.

Dr. Blanchard received his B.S. in Pharmacy from University of North Carolina, his Doctor of Pharmacy degree from the University of Washington, and his Master’s in Education from Campbell University.

Describe a typical day at work.
My days are quite variable. I teach both a Top 200 Medications course and a course in AIDS therapy. I also coordinate the Diversity for Pharmacy Students course. On any given day, I can be found talking with students or in attendance at a variety of meetings. As the Assistant Dean for Student Affairs and Advocacy, I take the job and title very seriously. I spend much time meeting with students to resolve any issues.

Why did you select academics over private practice?
Of the last 20 years since I graduated, I have been in academia for all but three of those. I worked for a while in industry with the company GlaxoSmithKline. It was a wonderful experience. But my true heart was in academia – so I returned to it.

What mix of clinical/research/teaching work do you do? How much power do you have to change that mix?
As an administrator, I am no longer in clinical practice. I worked for several years as a clinical pediatric pharmacist and staffed a pharmacist-run Asthma Clinic.

What are the advantages to academic pharmacy?
Being in academia, you have an opportunity to be on the front line and to observe new and cutting edge medicine.

If you had it to do all over again, would you still become a Pharmacist? (Why or why not? What would you have done instead?)
Yes I would. I would not have changed anything.

Why did you choose your specialty?
I always wanted to be in pharmacy and in pediatrics – hence my career path.

Did you plan to enter your current specialty prior to pharmacy school?
Yes – I always aimed for it.

Now that you’re in your specialty, do you find that it met your expectations?
Absolutely.

Are you satisfied with your income?
I am very blessed to have the income that I do. However, I do wish that education paid as well as community or hospital practice.

What do you like most and least about your specialty?
I wish that there were more hours in a day.

If you took out educational loans, is paying them back a financial strain?
I had all of my loans paid back within two years.

On average: How many hours a week do you work? How many hours do you sleep each night? How many weeks of vacation do you take?
I work a lot of hours – as do many in healthcare. I work a minimum of 60 hours per week – usually more. I sleep on average six to seven hours per night. I take four weeks of vacation per year. I try to live by the motto, “Work hard and play hard.”

Do you have a family and do you have enough time to spend with them?
I am single – but I do have a 12-year-old black English Cocker Spaniel named Jefferson. I am very fortunate to work in a setting where I can bring him to work daily. In fact, Jefferson has been adopted by my department.

In your position now, knowing what you do – what would you say to yourself 10 years ago?
To remember that perception is reality. Treat everyone as fairly as possible and you will go far.

What information/advice do you wish you had known when you were a pre-pharmacy student? (What mistakes or experiences have you encountered that you wished you had known about ahead of time so you could have avoided them?)
I wish that I would have taken the time to take a few more fun courses. It’s hard to go back now and to take a course – so I think I would have taken a couple of semesters of Italian for myself.

From your perspective, what is the biggest problem in health care today?
That’s a hard one to answer. At one time, I would have said that it was insurance. However, today I feel that it is illegal immigration and the health care system. There are too many people using the system and not enough tax dollars going into it.

From your perspective, what is the biggest problem within your own specialty?
There are too few people going into Pharmacy Education. Many are looking to practice because of the significant difference in salaries.

What types of outreach/volunteer work do you do, if any? Any international work?
I volunteer one to two days a month at AIDS Rochester delivering meals to patients who are homebound.

Favorite TV Show?
Dexter on Showtime