In my first ACCP Report column last fall, I introduced my theme of the year and its related terminology. The theme is “Advancing a comprehensive and consistent direct patient care practice for clinical pharmacists—the future is now.” Each of my subsequent columns has addressed some aspect of this theme and its prodigious significance to the future of clinical pharmacy practice.
Recently, during the late evening hours after an enjoyable day of sailing, I was relaxing in the cockpit as a light rain bounced off the canvas overhead. As I held a chilled glass of white wine in my left hand, I found myself reflecting on the content for this final column. It occurred to me that there are potentially interesting parallels between one of my favorite pastimes and my profession. However, there are also important differences.
Sailing requires knowledge, training, and experience best gained by many hours on the water (and making a few mistakes along the way). Sailors have a unique terminology and language that is foreign to the average landlubber. For control and trim of the sails, we have halyards, sheets (jib or genoa), mainsheet, traveler, Cunningham, outhaul, boom vang, reefing lines, downhaul, uphaul, and genoa cars, to name a few. When sailing, we may tack or jibe, luff up or bear away, and we set our sails for various points of sail—everything from “close hauled” when pinching upwind to a “run” downwind—including everyone’s favorite, a “beam reach.” There are also many rules that should be followed for the safety of the crew. For example, a sailboat on a starboard tack has the right-of-way (stand-on vessel) over a boat on a port tack (give-way vessel). The captain of the vessel takes full responsibility for the safety and well-being of the entire crew and must operate within his or her skills, remain aware of potential dangers (weather and sea conditions), and know when to reduce sail, return to port, or seek shelter. This is especially important given that recreational sailors often have guests aboard who know nothing (or very little) about sailing.
Novice sailors, or individuals with underdeveloped skills, are often competent to captain a sailboat under calm conditions of wind and sea, but they can be a menacing danger under more challenging or complex conditions. Last season, one of my heartier sailing companions and I were heading out to have some “fun” in a 25-knot wind and 5- to 7-foot seas. When bashing our way out of port, we observed a 26-foot sloop that had sailed headlong into the seawall with full sails still aloft and sheeted in close. The bow was repeatedly bashing into the rocks and quickly disintegrating while the captain was running around on deck trying to get the pitch off; the clearly novice and terrified crew members were huddled in the cockpit as the boat repeatedly broached to about 60–70 degrees. Nobody had yet thought to release the sheets and depower the sails! The Coast Guard was scrambling to assist the distressed vessel and crew. How one sails into a seawall under daylight conditions with full sail up in a 25-knot wind is incomprehensible, but clearly, the captain was incompetent to handle the conditions with which he was faced and likely panicked—imperiling the crew, the vessel, and those called to assist.
The parallels between clinical pharmacy practice and sailing are hopefully evident. Both require knowledge, skills, and attitudes. Like sailors, clinical pharmacists have a professional vocabulary and language that, although often shared with other health care professionals, is often foreign to the lay public. The sailor is responsible for safeguarding the crew; the clinical pharmacist is responsible for the patient. Both have important rules and expectations that must be considered. The sailor must maintain situational awareness, monitor environmental conditions, and sail within his or her capabilities, whereas the clinical pharmacist must closely monitor the patient, adjust treatment accordingly, be aware of the limitations of his or her knowledge and skills, and know when to seek help to ensure safe and effective patient care. Both the sailor and the clinical pharmacist should pursue additional education and training to address gaps in their knowledge and skills (continuing professional development, in the case of clinical pharmacy). Similar to any sailor, a pharmacist of any ilk may be competent to handle most uncomplicated issues. However, much as the competent sailor needs knowledge, skills, and experience in complex and challenging conditions, the competent clinical pharmacist needs advanced training and experience to care for complex patients with more challenging pharmacotherapeutic problems.
At the end of the day, however, sailing is a pastime, hobby, or leisure activity for most sailors. I normally tie up in the same slip I left from and therefore accomplish little of real societal value (as my wife is quick to point out) beyond my own relaxation, enjoyment, and occasional catecholamine-induced tachycardia. In fact, the non-sailor often does not understand the appeal of sailing around in circles for a few hours and then coming back to dock at one’s starting point.
Clinical pharmacy is our profession and the source of our livelihood. More importantly, it serves a high purpose of improving the health outcomes of our patients. That is clearly the key differentiator from our pastimes and leisure activities. However, I have heard some very learned and respected colleagues state that one of the failures of clinical pharmacists during the past 40–50 years is that we often appear to be more hobbyists than we are professional practitioners. As a clinical pharmacist who has invested a great amount of time and effort in this profession, I assume that you find this as offensive and insulting as I do. But is there some truth to this intentional and provocative insult? Should we pay attention to this argument and reflect on what changes may be needed to more clearly meet the definition of a professional practitioner? Is this not essential to achieve the long-sought-after “provider status” for clinical pharmacists?
In my first ACCP Report column, I noted that a professional practice is defined as having three required elements: (1) a philosophy of practice; (2) a specific, well-defined process of care; and (3) a practice management system. The philosophy of practice is a foundational requirement of one’s practice that includes the guiding professional principles of ethical values, fiduciary responsibility to patients, patient-centeredness, and accountability for patient outcomes. I believe that most clinical pharmacists adhere to an appropriate philosophy of practice; however, the societal expectation related to this philosophy is limited at best. For the past 2 years, much discussion has ensued within ACCP concerning the importance of a well-defined, consistent process of care for clinical pharmacy that is applicable across all practice environments. This discussion has led me to conclude that we neither currently meet this requirement nor consistently teach a defined process of care to our students and residents. Finally, the practice management system supports the clinical pharmacist’s delivery and documentation of patient care activities; scheduling of patient visits and patient care activities; communication with patients and health care professionals; measurement of patient outcomes; and submission of charges, claims, or bills, as appropriate. Although there are exceptions, the lack of recognition of clinical pharmacists as patient care providers by most payers has often resulted in the underdevelopment or absence of practice management systems to support clinical pharmacists. If we accept the defining elements of a professional practice, clinical pharmacy has some important gaps to fill in order to fulfill this obligation. If we fail to meet this definition of a professional practice, do we run the risk of being regarded as “hobbyists”?
At many of our practice sites, we provide clinical pharmacy services. A clinical service is defined as the application of the professional practice to a specific patient care setting or clinical area. The resulting nature and delivery of the clinical service may vary in different patient care settings. Do many of the “clinical services” provided by clinical pharmacists meet the definition of a professional practice? As described in my previous column, there are many recognized barriers to realizing the desired state of practice, including limited resources, an inadequate number of properly trained and credentialed clinical pharmacists, the political and regulatory environment, misaligned reimbursement and reward models, predominantly mercantile business models in the community pharmacy setting, traditional well-entrenched “practices,” and societal expectations of pharmacists, to name a few. Despite these limitations, we should avoid providing clinical pharmacy services that fall far short of meeting the definition of a professional practice because this may do more harm than good for both patients and the advancement of clinical pharmacy. In my opening remarks at the 2012 Annual Meeting, I used the term drive-by pharmacy, which provoked many comments, both positive and negative, from members. An intensivist colleague and I began using this term many years ago to describe the phenomenon of well-meaning pharmacists who provide recommendations (“interventions”) related to drug therapy with inadequate knowledge of the patient and the clinical intent of his or her treatment—and often with no expectation of taking ongoing responsibility for the monitoring and outcomes of the patient (e.g., one-time “renal-dosing” recommendations). This creates a lot of irritation on the part of my intensivist colleague, who is a strong advocate for clinical pharmacists as members of the ICU patient care team (practitioners) but who has no patience for “drive-bys” (hobbyists). The analogy he uses is “drive-by shootings,” which are sometimes effective at hitting the target but also have the potential to cause a lot of collateral damage. He views such pharmacist drive-bys as an irresponsible way of getting a job done.
I was recently asked to review a case for a potential liability defense. Without sharing any confidential details, a relatively young patient with a serious infection was ordered a pharmacy consultation to manage her drug regimen. At the outset of therapy, the “clinical” pharmacist ordered an appropriate dose under the circumstances; however, the pharmacist devised no monitoring plan and failed to follow the patient beyond the initial consultation. After about a week, the drug concentration was markedly elevated, and the patient had sustained significant harm, which very likely was caused by drug toxicity. The pharmacist’s defense was that the recommendation was appropriate at the time and that it was the pharmacist’s fault, but rather, the fault of the clinical team for failing to adequately monitor the patient! My major criticisms were that the pharmacist (1) lacked a philosophy of practice that established the pharmacist’s responsibility to the patient and her outcome and (2) failed to adhere to a comprehensive process of care. I consider this a classic case of “drive-by pharmacy,” resulting in more collateral damage than benefit.
The major and single most important policy initiative of ACCP is the pursuit of changes to Medicare and the Social Security Act to recognize direct patient care by qualified clinical pharmacists as a covered benefit under Medicare Part B, characterized by some as a quest to achieve provider status for clinical pharmacists. Central to this initiative is the “what” of clinical pharmacy practice, which ACCP has defined as the pharmacist’s provision of direct patient care through comprehensive medication management (CMM) as a formal member of an interprofessional patient care team. This delivery of CMM is based on a specific relationship with, and knowledge of, the patient. In addition, it requires a clinical pharmacist to take responsibility for the patient’s medication-related needs and outcomes. To be successful, the patient care provided under this proposed benefit needs to meet the three criteria of a professional practice. CMM, as described by the Patient-Centered Primary Care Collaborative, incorporates both a philosophy of care and a consistent process of care. As an extension of its Medicare benefit initiative, ACCP will be developing guidance and tools to assist members with implementing and navigating practice management systems and business practice models for clinical pharmacists. Practice management systems for team-based care are complicated in this era of emerging health care reform and evolving payment models, but such systems remain an essential component of a professional practice that must be understood and used by clinical pharmacists.
The ultimate goal is to improve patient outcomes by “getting the medications right,” and ACCP firmly believes that the incorporation of a qualified clinical pharmacist as part of the health care team is vital to achieving this goal, especially in the care of complex patients with multiple problems. Having specialized knowledge, advanced training, well-developed clinical skills, and a willingness to influence patient care decisions does not necessarily establish one as an essential health care practitioner. Clinical pharmacists are dedicated to improving medication-related outcomes; moreover, they (1) take responsibility for their patients, (2) provide for continuity of care in their absence, (3) effectively function in an interprofessional team environment, (4) are aware of and sensitive to the patient’s needs and preferences, and (5) have otherwise established that the required elements of a clinical pharmacy practice will be indispensable in a reformed health care system. And they will never be accused of being hobbyists! It is incumbent on clinical pharmacy’s leadership to remain true to these critical elements when establishing comprehensive clinical pharmacy services in a practice environment of any type and to avoid the temptation of going only partway because of real or perceived barriers. Now is the time for us to realize the clinical pharmacist’s full potential in contributing to team-based patient care.