Bloom’s taxonomy has six tiers: Remember, Understand, Apply, Analyze, Evaluate, and, the highest level, Create. Nothing assesses the first five tiers quite like being tasked with combining what you learned from them to build something new.

Since starting pharmacy school, I knew I wanted to work in ambulatory care. During the first 3 years of my 4-year curriculum, I sought opportunities to learn more about this branch of pharmacy by networking with people who worked in this field, shadowing ambulatory care pharmacists, and volunteering at local clinics for the uninsured. During my fourth-year advanced pharmacy practice experiences (APPEs), I was able to spend at least part of four rotations in ambulatory care settings. After graduation, I was accepted to a PGY1 residency program that emphasized ambulatory care, allowing me to complete five additional rotations in these settings and a longitudinal rotation, where I spent 2 days a month in a primary care clinic throughout the year. These experiences taught me how to work well with patients, write SOAP (subjective, objective, assessment, plan) notes, build relationships with providers, and become proficient in evidence-based pharmacotherapy with specific emphases on diabetes, hypertension, and hyperlipidemia.

Since my PGY1 graduation 7 months ago, I have been a clinical innovations fellow at the University of Utah College of Pharmacy. My mentors and I created this fellowship to explore uncharted territory in Utah: (1) expanding ambulatory care pharmacy services into the sector of private, non–hospital-based clinics and (2) funding collaborations with a third-party payer for these services. This unique second-year experience has allowed me to build on my previous training and practice in Bloom’s sixth taxonomy level of “creating” through establishing pharmacy primary care services in a community clinic. I knew, of course, that I was no expert after just 1 year of postgraduate training, but implementing a new practice has provided me with valuable insight into what I truly understand – and still need to work on

Starting a practice, or even building on or strengthening one that’s already established, can be daunting, but here are some lessons I have learned and continue to think about each day.

What value do I provide?

As you start a practice, it’s important to plan and set up expectations for what you are there to do. Even when the practice is established, this question should be revisited regularly to help focus your efforts and brainstorm on innovative ways your role can be optimized to provide the most value to your team and patients. It’s also important to consider that you may need to demonstrate your value to multiple people or groups of people in different ways (e.g., patients, internal medicine physicians, family medicine physicians, a third-party payer, administration). If you find yourself stuck, consider starting a dialogue with the physicians regarding the unmet needs of their clinic and the potential activities within a pharmacist’s scope that could meet those needs, being careful to avoid high-cost, low-value activities.

What is not optimizing my potential?

As important as determining what to do is determining what not to do. Too often, when starting a new practice, pharmacists believe they must fill their time by taking on additional responsibilities that are not part of their job. As their practice grows, the less valuable responsibilities take up precious time that should be spent on more valuable activities. I had one mentor whose practice got so derailed by low-value activities (in this case, prior authorizations) that the clinic ended up removing the pharmacist from the practice altogether. The easiest way to avoid this is to catch these low-value activities early and help the administration, providers, or medical assistants create better procedures for providing and identifying ways to complete these tasks.

Who are my “champions”?

Now that you’ve identified what you are there to do and not do, find a champion – someone who “gets” it. Champions are interested in and appreciative of the clinical pharmacist’s contribution in improving patient outcomes. As you’re starting out, optimize your working relationship with this person to provide an example to others in the practice. They will get a glimpse into your role and see your value. However, continue to build relationships with all members of the team to avoid becoming “Dr. Smith’s pharmacist.”

Can I do this?

Transitioning from having a preceptor next to me (APPEs and PGY1) to having directors only on the other side of the city was a big wake-up call. I realized that even if my preceptors encouraged autonomy and tested me, they were still a security blanket of sorts. Eventually, we all have this transition, though, whether we’re starting a new position or a new practice. If you’re like me, you may feel inadequate at times. For example, some days, it seems like I have to research the answer to every question the physician asks, and I’m saying to myself, “I have had 5 years of school/training, so how do I not know the answer to any of these questions off the top of my head?” You may deal with some “imposter syndrome,” like I do, and worry that at any moment the people around you will discover that you’re not as good as they thought you were. But don’t worry, you can do this. You earned your position, you are qualified, and your best is absolutely enough. Here are some tips to help you combat the doubts:

• Become comfortable with saying something like “That’s a great question. I don’t know the answer off the top of my head, but I’ll look it up and get back to you.” No one expects you to know the answers to everything, and it’s far better to say you don’t know than to guess incorrectly and lose the physician’s trust or potentially cause harm to a patient. If you can’t address the question at that moment, provide a realistic time frame to the inquirer. If the physician needs an immediate answer, be honest about how confident you are in your answer, and provide a rationale for your decision.
• As you learn new things, document them; you’ll retain the information better, and you won’t need to duplicate your efforts if you forget.
• Take the time to recognize and appreciate your successes – don’t just attribute them to luck.

Establishing and strengthening a practice takes work and resiliency. This also provides a tremendous learning opportunity to identify your strengths and ways to improve. Even if you are in a clinic that’s had clinical pharmacists for years, always look for ways to innovate and improve because nothing provides quite the same enlightenment, teaching, fulfillment, and progress as creating.

About the Author: Shannon Gadd is a clinical innovations fellow at the University of Utah College of Pharmacy. She completed her PGY1 pharmacy training at University of Utah Health. Her professional interests include primary care, practice innovation, and cardiology.