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CHAPTER

1 Introduction: The Practice


of Clinical Pharmacy

LEARNING OBJECTIVES
D efine pharmaceutical care and identify the four S tate the eligibility requirements for pharmacist board
outcomes that improve a patients quality of life. certification and identify the areas for which board
Define medication therapy management. certification is available.
List the three goals and five core elements of Define residency and fellowship and differentiate them
medication therapy management. with regard to length of training and mechanisms for
List the knowledge and skills needed for patient- credentialing.
focused pharmacy practice. Identify and differentiate among the various types of
State the requirements for pharmacy state licensure health care settings and environments.
and relicensure. Define health maintenance organization, point-of-
Differentiate between pharmacist board certification, service plans, and preferred provider organizations.
pharmacist-specific disease-specific credentialing, State the purpose of the medical team and identify the
multidisciplinary disease-specific credentialing, and roles and responsibilities of each team member.
pharmacy certificate programs in terms of eligibility and Identify and describe unresolved health care system
requirements. issues.

P harmacy practice is moving toward a model that


integrates patient-focused care (also known as patient-
centered care) and drug distribution services. To be success-
implies the integration of patient- and product-oriented
pharmacy practice.
Patient-focused pharmacists work closely with physi-
ful, pharmacists must understand and speak the language cians and other health care professionals to provide optimal
of the health care system and function in a system that patient care. Some pharmacists in traditional product-
to the uninitiated is foreign and excessively complex. centered practice settings use clinical pharmacy skills in a
The variety of providers, rapidly evolving types of health limited capacity, such as when they obtain a medication
care delivery systems, and complexities of relationships history or triage a patient to self-care with nonprescrip-
among the various heath care professionals working tion drugs. Some pharmacists have no traditional product-
within the health care system add to the confusion. This centered responsibilities and instead provide full-time
chapter describes patient-focused pharmacy practice and patient-focused care. Regardless of the setting and the degree
the clinical environment in which patient-focused phar- to which patient-focused skills are used, patient-focused care
macists function. is an integral part of the practice of pharmacy (Figure 1-1).
The term pharmaceutical care is used to describe the
broad-based, patient-focused responsibilities of pharma-
PATIENT-FOCUSED PHARMACY PRACTICE cists (see Figure 1-1). Hepler and Strand define pharma-
ceutical care as the responsible provision of drug therapy
The term clinical pharmacy historically described patient- for the purpose of achieving definite outcomes that
oriented rather than product-oriented pharmacy practice. improve a patients quality of life.1 The four outcomes
The term clinical pharmacist was used to describe a phar- identified include the following:
macist whose primary job was to interact with the health 1. Cure of disease
care team, interview and assess patients, make patient- 2. Elimination or reduction of symptoms
specific therapeutic recommendations, monitor patient 3. Arrest or slowing of a disease process
response to drug therapy, and provide drug information. 4. Prevention of disease or symptoms
Clinical pharmacists, working primarily in acute care set- Pharmaceutical care requires an expert knowledge of
tings, were viewed as drug experts; other pharmacists therapeutics; a good understanding of disease processes;
could occasionally use clinical skills, but they remained knowledge of drug products; strong communication
focused on product management. The pharmacy profes- skills; drug monitoring, drug information, and therapeu-
sion has evolved to the point that many pharmacists find tic planning skills; and the ability to assess and interpret
the term clinical pharmacy redundant; the term pharmacist physical assessment findings (Figure 1-2).

1
2 Clinical Skills for Pharmacists: A Patient-Focused Approach

Box 1-1Medication Therapy Management (MTM)


Core Elements
Provide a comprehensive or targeted medication
therapy review
Complete and update the patients personal
medication record (PMR)
Develop a medication-related patient-directed action
plan (MAP)
Intervene and/or refer when appropriate
Document all services and interventions, communicate
results of the MTM encounter, and provide appropriate
follow-up
Adapted from Bluml BM: Definition of medication therapy management: devel-
opment of profession wide consensus. J Am Pharm Assoc 45:566-572, 2005.

Figure 1-1 Patient-Focused Care in the Community


Pharmacy. Patient-focused care is an integral part of the practice Box 1-2Pharmacist Practice Areas
of pharmacy in all patient care settings. (Hopper T: Mosbys phar- Ambulatory care
macy technician: Principles and practice, ed 2, St Louis, Saunders,
Critical care
2007.)
Drug information
Geriatrics and long-term care
Internal medicine and subspecialties
Cardiology
Endocrinology
Gastroenterology
Infectious disease
Neurology
Nephrology
Obstetrics and gynecology
Pulmonary disease
Psychiatry
Rheumatology
Nuclear pharmacy
Nutrition
Pediatrics
Pharmacokinetics
Surgery

SITES AND TYPES OF PRACTICE


Figure 1-2 Patient Care. Patient care requires integration of
knowledge and skills. Patient-focused pharmacy practice is performed every-
where patients interact with the health care system, includ-
ing community pharmacies, outpatient clinics, teaching
and community hospitals, long-term care facilities, and
Medication therapy management (MTM) services pro- home health care. Pharmacists, like other health care pro-
vide pharmacists with new opportunities for direct patient fessionals, specialize in practice areas such as pediatrics,
care. The Medicare Prescription Drug, Improvement, and critical care, nutrition, and cardiology (Box 1-2). Some
Modernization Act of 2003 (also known as the Medicare practice areas (e.g., infectious disease, nutrition) parallel
Modernization Act) established Medicare Part D.2 Medicare and are similar to traditional medical specialty and sub-
Part D provides for prescription drug benefits for Medi- specialty areas. Other specialty practice areas (e.g., drug
care beneficiaries, including pharmacist-provided MTM information, pharmacokinetics) are unique to pharmacy.
services. MTM is defined as a distinct service or group
of services that optimize therapeutic outcomes for indi- REQUIREMENTS AND VOLUNTARY
vidual patients. Medication Therapy Services are indepen- CREDENTIALING AND CERTIFICATE
dent of, but can occur in conjunction with, the provision PROGRAMS
of a medication product.3 The goals of MTM services
include improved medication understanding, adherence Requirements
and detection of medication-related problems, includ- Licensure. To be eligible for licensure, pharmacists must
ing adverse drug reactions.4 MTM services include a wide be graduates of a college of pharmacy accredited by the
range of responsibilities and activities (Box 1-1). American Council on Pharmaceutical Education (ACPE)
Chapter 1 Introduction: The Practice of Clinical Pharmacy 3

or from a pharmacy school approved by the state board


of pharmacy. Pharmacists who graduated from foreign
pharmacy schools are eligible for licensure if they have
earned the Foreign Pharmacy Graduate Examination
Committee (FPGEC) certification or follow other state-
specific requirements. All states except California require
successful completion of the North American Pharmacist
Licensure Examination (NAPLEX). (California admin-
isters its own licensing examination.) All states require
that licensure candidates complete a specified number
of internship hours, typically around 1500 hours, prior
to seeking licensure. Some states allow the internship
hours to be earned prior to graduation from pharmacy
school; some states require that some or all of the hours
be earned after graduation. Many states also require suc-
cessful completion of the Multi-State Pharmacy Juris-
prudence Examination (MPJE). Some states still require
successful completion of a laboratory (wet lab) exami-
nation. Licensure for authorization to administer inject-
able medications (e.g., immunizations) is a separate but
parallel licensing process.
Relicensure. Most licensing boards require that pharma-
cists earn continuing education units (CEUs) for relicen-
sure. The CEUs are earned by successful participation in Figure 1-3 Pharmacist Credentials. Pharmacists are eligible for
ACPE-accredited continuing education programs (e.g., a variety of voluntary credentials. (Jupiter Images)
live programs and continuing education articles in pro-
fessional journals). Some states require that pharmacists
earn some of the CEUs by participating in specific types Table 1-1Board of Pharmacy Specialties (BPS)
of continuing education programs (e.g., live programs). Recognized Pharmacy Specialties
Some states require specific content (e.g., human immu-
Initial
nodeficiency virus [HIV] or immunization continuing Specialty Acronym Recognition
education).
Nuclear Pharmacy BCNP 1978
Voluntary Credentialing and Certificate Programs Pharmacotherapy BCPS 1988
Postlicensure credentialing. Postlicensure credential- Nutrition Support Pharmacy BCNSP 1988
ing is voluntary and is available at the specialist or dis- Psychiatric Pharmacy BCPP 1992
ease level. Postlicensure credentials indicate that the
Oncology Pharmacy BCOP 1996
pharmacist has additional expertise above and beyond
what is required for licensure (Figure 1-3). The Council BCNP, Board Certified Nuclear Pharmacist; BCNSP, Board Certified
on Credentialing in Pharmacy (CCP) defines certifica- Nutrition Support Pharmacist; BCOP, Board Certified Oncology Pharmacist;
tion as a voluntary process through which a nongov- BCPP, Board Certified Psychiatric Pharmacist; BCPS, Board Certified
ernmental agency or an association grants recognition Pharmacotherapy Specialist.
to an individual who has met certain predetermined
qualifications specified by that organization. This formal
recognition is granted to designate to the public that this the BPS6 (Table 1-1). Requirements vary by board. For
individual has attained the requisite level of knowledge, example, BPS board certification requires an entry-level
skill, and/or experience in a well-defined, often special- pharmacy degree (bachelor of science in pharmacy or doc-
ized, area of the total discipline.5 The term certification tor of pharmacy), an active pharmacy license, additional
should not be confused with the term certificate, which experience and/or training (residency or fellowship) in
is the document given to a person upon completion of the specialty area, and passage of a specialty-specific writ-
a program. ten examination. Recertification is required every 7 years.
Specialist credentialing. Board certification (official The BPS also recognizes additional expertise within a sub-
recognition of specific knowledge and skills) is achieved specialty area by the designation Added Qualifications
in addition to state and federal professional licensure. (AQ) (e.g., Board Certified with Added Qualifications).
Some employers require board certification for specific Added Qualifications in infectious diseases pharmaco-
jobs, whereas other employers reward pharmacists who therapy and cardiology pharmacotherapy are currently
become board certified with additional career advance- available within the pharmacotherapy specialty practice
ment opportunities and salary differentials. The Board area. The Added Qualifications designation is earned by
of Pharmacy Specialties (BPS), created in 1976 by the demonstrating the additional expertise through a portfo-
American Pharmacists Association (APhA), is responsible lio process (Box 1-3).
for setting standards for certification and recertification Multidisciplinary disease-specific credentialing: A
and for administering the certification and recertification variety of health care professionals, including pharma-
processes. Five specialty practice areas are recognized by cists, are eligible for certification in select disease-specific
4 Clinical Skills for Pharmacists: A Patient-Focused Approach

multidisciplinary certification programs (Table 1-2). program. Certificate programs are voluntary and do not
Requirements are different for each program. For exam- require any additional training or experience beyond
ple, the 2010 requirements for application for the Certi- that required for pharmacy licensure. ACPE certificate
fied Diabetic Educator (CDE) program include a minimum programs provide at least 15 hours of programming that
of 2 years of professional practice, completion of a mini- must include practice experiences to demonstrate the
mum of 1000 hours of diabetes self-management edu- given professional competency. Participants are evalu-
cation (DSME), completion of a minimum of 15 hours ated by a summative evaluation process. Completion of
of relevant continuing education activities within the 2 a certificate program provides evidence of achievement
years prior to application, and status as either a licensed of professional competencies beyond those required for
clinical psychologist, registered nurse, occupational ther- pharmacy licensure.
apist, optometrist, pharmacist, physical therapist, physi- Postlicensure residency and fellowship training pro-
cian (MD or DO), or podiatrist, or as a registered dietitian, grams. Pharmacy graduates obtain additional experi-
physician assistant, exercise physiologist, or other health ence, knowledge, and skills by completing a variety of
care professional with a minimum of a masters degree.7 residency and fellowship postgraduate training certifi-
Certificate programs. In 2000, the ACPE assumed cate programs. Most residency and fellowship programs
responsibility for voluntary pharmacy certificate pro- require candidates to have either entry-level or postbac-
grams based on specific professional competencies (Phar- calaureate doctor of pharmacy degrees. The American
macy-Based Immunization Delivery, Pharmaceutical Society of Health-System Pharmacists (ASHP) publishes
Care for Patients with Diabetes, Pharmacy-Based Lipid a directory of ASHP-accredited residency programs. The
Management, OTC Advisor: Advancing Patient Self- American College of Clinical Pharmacy (ACCP) publishes
Care, and Delivering Medication Therapy Management a directory of residency and fellowship programs offered
Services in the Community). Pharmacists who success- by members of the ACCP. The APhA provides a searchable
fully complete a postgraduate certificate program receive on-line community pharmacy residency locator directory.
a certificate documenting successful completion of the A residency is defined as an organized, directed, post-
graduate training program in a defined area of pharmacy
practice8 (Table 1-3). Residencies provide pharmacists
Box 1-3Portfolio Requirements for Added with 1 to 2 years of supervised experience in practice
Qualifications in Cardiology and management activities. Postgraduate year 1 (PGY-
1) residency programs train generalists; postgraduate
Letter requesting portfolio review
year 2 (PGY-2) residency programs train pharmacists in
Detailed summary of each of the following elements:
a specialty patient care area. Residents generally gain
Specific and current professional responsibilities
experience by providing a variety of inpatient and out-
Bibliography of professional publications
patient pharmacy services under the supervision of
Past (within last 7 years) and present research and other
one or more preceptors. Most residencies are based in
scholarly activities
hospitals; however, increased interest in community
Past (within last 7 years) and current activities in
pharmacy and ambulatory care residencies has resulted
didactic or clerkship, residency, or fellowship
in the creation of an increasing number of community
education of health care professionals in
pharmacy and ambulatory care residency programs. The
cardiovascular pharmacotherapy
ASHP accredits residency programs, but there are many
Current memberships in professional organization
nonaccredited residency programs.
related to cardiology
A fellowship is a highly individualized program
Special or unique training or professional development
designed to prepare the pharmacist to become an inde-
programs
pendent researcher.8 Fellows spend approximately 80%
Professional awards, honors, or special achievements
of their time in research-related activities. Currently no
related to cardiovascular pharmacotherapy
mechanism for accreditation of fellowship programs is
Current curriculum vitae
available. However, the ACCP Fellowship Review Com-
From Board of Pharmacy Specialties: Current Specialties. Available at: http:// mittee conducts a voluntary peer review of fellowship
www.bpsweb.org/specialties/specialties.cfm. Accessed October 12, 2009. programs. As of 2009, 17 fellowship programs were

Table 1-2 Examples of Multidisciplinary Credentials


Specialty Credentialing Organization Title Acronym
Anticoagulation National Certification Board for Anticoagulation Certified Anticoagulation Care CACP
roviders
P Provider
Asthma National Asthma Educator Certification Board Certified Asthma Educator AE-C
Diabetes National Certification Board for Diabetic Educators Certified Diabetic Educator CDE
Lipidology Accreditation Council for Lipidology Clinical Lipid Specialist CLS
Pain American Academy of Pain Management Credentialed Pain Practitioner CPP
Toxicology American Board of Applied Toxicology Diplomate of the American Board of DABAT
Applied Toxicology
Chapter 1 Introduction: The Practice of Clinical Pharmacy 5

Table 1-3 Residencies and Fellowships


Postgraduate Year 1 Residency Postgraduate Year 2 Residency
Feature Programs (PGY-1) Programs (PGY-2) Fellowship Programs
Credential earned Certificate Certificate Certificate
Program accreditation ASHP ASHP No official accreditation body
(ACCP provides specific guidelines)
Duration 1 year 1 year Minimum of 2 years
Prerequisites Graduate of an ACPE-accredited PGY-1 residency program Residency or equivalent experience
pharmacy program
Focus Medication use management Knowledge, skills, attitudes, and Research-related activities, teaching
s ystems; medication therapy abilities in a selected area of and clinical practice in a selected
outcomes for a wide variety of patient care* area of research
patients and diseases

ACCP, American College of Clinical Pharmacy; ACPE, American Council on Pharmaceutical Education; ASHP, American Society of Health-System Pharmacists.
*ASHP-accredited PGY-2 residency areas include ambulatory care, cardiology, critical care, drug information, emergency medicine, geriatrics, health systems

pharmacy administration, infectious diseases, human immunodeficiency virus, informatics, internal medicine, managed care pharmacy systems, medica-
tion use safety, nuclear pharmacy, nutrition support, oncology, pain and palliative care, pediatrics, pharmacotherapy, psychiatry, and solid organ transplant.
ACCP-recognized fellowship programs include those with the following areas of emphasis: ambulatory care, cardiology, clinical pharmacology, critical care,

drug metabolism, infectious disease, oncology, pediatrics, pharmacodynamics, pharmacoeconomics, pharmacoepidemiology, and pharmacokinetics.

recognized as meeting the ACCP Guidelines for Research


Box 1-4Health Care Settings
Fellowship Training Programs. Nonaccredited fellowship
programs are available.
OUTPATIENT
Clinics
Day surgery units
THE CLINICAL ENVIRONMENT Emergency departments
Home health care
Health care is provided in many different settings (Box
Private offices
1-4). Examples of outpatient (ambulatory) settings
include private offices, outpatient clinics, day surgery
INPATIENT
units (also known as short procedure units), and emer-
Hospitals
gency departments. Acute care hospitals provide inpa-
tient care. Patients are hospitalized for major surgery,
LONG-TERM CARE FACILITIES
treatment of acute disorders, and diagnostic evaluations
Rehabilitation centers
and procedures. Long-term care facilities, such as nursing
Skilled nursing homes
homes and rehabilitation centers, provide health care for
patients who require skilled management of chronic dis-
orders. Home health care services are available for chroni-
cally ill and disabled patents. Table 1-4 Basic Health Care Plans
Inpatient and outpatient health care services are pro-
Health Care Plan Acronym Characteristics
vided to patients through individual or group practices.
Group practices consist of health care professionals with Fee for service FFS Patients may select any
similar practices (e.g., family medicine, obstetrics) or doctor, hospital, or labora-
with multiple specialties (e.g., internal medicine, family tory without permission
medicine, and obstetrics and gynecology). Health care of primary care physician
professional practices changed dramatically in response (PCP). Patients pay up front
to the 1990s evolution of heath care delivery from tradi- then submit the bill for
tional fee-for-service (FFS) indemnity insurance plans in reimbursement.
which patients were free to select any physician, hospi- Health mainte- HMO Patients must choose a
tal, or laboratory they wanted to managed care insurance nance organization PCP and are restricted
plans such as health maintenance organizations (HMOs), to in-network doctors.
point-of-service (POS) plans, and preferred provider orga- Referrals are made through
nizations in which care is coordinated through a primary the PCP.
care provider and patients have less freedom of choice Point of service POS Similar to HMO but with
(Table 1-4). fewer restrictions.
Many different alliances have formed among physi-
Preferred provider PPO Permission is not required
cians, nurse practitioners, physician assistants, health
organization to see in-network special-
care institutions, and insurers, including provider net-
ists; some coverage for
works, prepaid group practices, and integrated delivery
out-of-network care.
systems. The medical home is a relatively new concept.
6 Clinical Skills for Pharmacists: A Patient-Focused Approach

Defined by the Association of American Medical Colleges Box 1-5Allied Health Care Professionals
as a concept or model of care delivery that includes an
ongoing relationship between a provider and patient, Anesthesiologist assistant
around-the-clock access to medical consultation, respect Anesthesia technologist/technician
for a patients cultural and religious beliefs, and a com- Athletic trainer
prehensive approach to care and coordination of care Cardiovascular technologist
through providers and community services,9 the medi- Electroneurodiagnostic technologist
cal home concept is of increasing interest to patients and Emergency medical technician/paramedic
health care professionals. Exercise scientist
Clinics, often affiliated with major medical centers Kinesiotherapist
and hospitals, are located in a variety of outpatient set- Medical assistant
tings, including community centers, medical offices, Medical illustrator
community pharmacies, and freestanding clinics. Clin- Occupational therapist
ics serve general unrestricted patient populations or Orthotist and prothetist
very specific patient groups (e.g., hypertension clinic, Perfusionist
diabetes clinic, anticoagulation clinic, medication refill Polysomnographic technologist
clinic). Several clinics may share the same physical Respiratory therapist
space; in this situation the schedule is set to allow each Surgical assistant
clinic to have a unique weekly or daily schedule (e.g., Surgical technologist
anticoagulation clinic on Tuesday afternoons, diabetes From Careers in Health Care. Available at: http://ama-assn.org/ama/pub/
clinic on Wednesday mornings, hypertension clinic on education-careers/careers-health-care/directory.shtml. Accessed October
Friday mornings). 21, 2009.
Hospitals are identified as public, private, or federal
hospitals, depending on the funding source. Public hospi-
tals are publicly funded and provide heath care services to Physicians are licensed by individual states and cre-
all patients, regardless of the patients type of insurance or dentialed by national examination. A physician must
ability to pay for the health care services. Some cities and graduate from an accredited medical school, receive pass-
states pay for public hospital services from tax revenues. ing grades on the medical licensure examination, and
Private hospitals are privately funded institutions whose complete 1 year of an accredited residency program to
services are generally not available, except for emergency become licensed to practice medicine. The United States
care, to patients who are not part of the private group. The Medical Licensing Examination (USMLE) consists of four
federal government funds federal hospitals. The Veterans examinations taken sequentially starting during medi-
Administration hospital system is an extensive nation- cal school and finishing after completion of the medical
wide system of hospitals, clinics, and nursing homes degree (Table 1-5).11 Relicensure requires successful com-
funded by the federal government to provide health care pletion of the number of continuing medical education
services to American armed forces veterans. (CME) credits specified by the state in which the physi-
Hospitals, regardless of the funding source, may be cian practices. Most physicians complete 1 year or more
affiliated with medical schools. These hospitals, known of supervised experience in residency programs; some
as teaching hospitals, provide training sites for physicians complete additional training in highly specialized fel-
and other health care professionals. Community-based, lowship programs. The length of the residency program
nonteaching hospitals are sometimes called community depends on the specialty or subspecialty. Internal medi-
hospitals. Some hospitals, recognized for their highly spe- cine residencies are typically 3 years in duration; surgical
cialized services (e.g., pediatrics, oncology, cardiology) residencies may be 5 to 7 years.
and large referral patient populations, are known as ter- Board certification is a voluntary but increasingly
tiary hospitals. important credential for physicians. Many health care
plans require board certification for inclusion in member
HEALTH CARE PROFESSIONALS networks; many hospitals require board certification for
admitting privileges. Approximately 87% of physicians are
The American Medical Association recognizes more than board certified.12 There are 26 approved medical board spe-
80 health carerelated careers, including physician, phar- cialties. The American Board of Medical Specialties (ABMS),
macist, nurse, and allied health professional.10 Allied a group of 24 member boards, certifies more than 145 physi-
health care professionals, also known as paramedicals, cian specialties and subspecialties (Box 1-6).13 For example,
provide health care services and perform tasks under the there are 21 internal medicine subspecialties (Box 1-7).14
direction of physicians (Box 1-5). Board certification is a comprehensive process involving
peer evaluation, specific educational requirements, and
Physicians examination. Maintenance of certification (MOC; recerti-
Physicians, doctors who have medical or osteopathic fication) is required and occurs at 6- to 10-year intervals
degrees, are generally considered the health care team depending on the specific specialty. MOC requires an active
leaders. Allopathic physicians rely on standard treat- and unrestricted license in the state in which the physician
ment modalities; osteopathic physicians use the addi- practices, periodic self-evaluation of knowledge (continu-
tional technique of spine and joint manipulation to treat ing education), assessment of knowledge by examination,
disease. and assessment of practice performance.12
Chapter 1 Introduction: The Practice of Clinical Pharmacy 7

Table 1-5 United States Medical Licensing Examination (USMLE)


Step Taken By Content
Step 1 Medical students and graduates seeking to Basic science knowledge
practice medicine in the U.S.
Step 2 Clinical Knowledge Medical students and graduates seeking to Normal conditions and disease and physician tasks (pre-
practice medicine in the U.S. ventive medicine, health maintenance, disease mecha-
nisms, determination of a diagnosis, patient management)
Step 2 Clinical Skills Medical students and graduates seeking to Integrated clinical encounters, communication and
practice medicine in the U.S. intrapersonal skills, spoken English proficiency
Step 3 Those who have successfully completed Step Normal conditions and disease categories, clinical
1 and Step 2 Clinical Knowledge and have a encounter, physician tasks, common clinical scenarios
medical degree (MD, DO)

From United States Medical Licensing Examination. Available at: http://www.usmle.org. Accessed October 22, 2009.

Box 1-6American Board of Medical Specialties Box 1-7American Board of Internal Medicine
Member Boards Specialties
Allergy and Immunology Internal Medicine
Anesthesiology Adolescent Medicine
Colon and Rectal Surgery Advanced Heart Failure and Transplant Cardiology
Dermatology Allergy and Immunology
Emergency Medicine Cardiovascular Disease
Family Medicine Clinical Cardiac Electrophysiology
Internal Medicine Critical Care Medicine
Medical Genetics Endocrinology, Diabetes, and Metabolism
Neurological Surgery Gastroenterology
Nuclear Medicine Geriatric Medicine
Obstetrics and Gynecology Hematology
Ophthalmology Hospice and Palliative Medicine
Orthopaedic Surgery Infectious Disease
Otolaryngology Interventional Cardiology
Pathology Medical Oncology
Pediatrics Nephrology
Physical Medicine and Rehabilitation Pulmonary Disease
Plastic Surgery Rheumatology
Preventive Medicine Sleep Medicine
Psychiatry and Neurology Sports Medicine
Radiology Transplant Hepatology
Surgery
From Details about Each Exam by Specialty. Available at: http://www.abim.
Thoracic Surgery
org/exam/exams.aspx. Accessed October 22, 2009.
Urology

From About ABMS Member Boards. Available at: http://www.abms.org/


About_ABMS/member_boards.aspx. Accessed October 22, 2009. categories related to disease states, patient age, and
acuity of illness. Certification is available for some of
these specialties. For example, nurses can be certified
Nurses in critical care and are then entitled to use the designa-
Nurses care for the physical and psychosocial needs of tion Certified Critical Care Registered Nurse (CCRN) in
patients and carry out physician-directed orders regard- their titles.
ing patient care. Nurses may have an associate degree
in nursing (ADN) obtained from a 2-year junior or com- Nurse Practitioners
munity college, a diploma from a 2- to 3-year nursing The American Academy of Nurse Practitioners (AANP)
program offered by some hospitals and private schools, defines nurse practitioners (NPs) as licensed indepen-
or a bachelor of science in nursing (BSN) degree from dent practitioners who practice in ambulatory, acute and
a 4-year college or university. Graduates from all three long term care as primary and/or specialty care provid-
programs are eligible for licensure as registered nurses ers.15 NP education is shifting from masters degrees
(RNs). Continuing licensure is often contingent on and/or post-masters certificates to the doctor of nurs-
completion of continuing nursing education require- ing practice (DNP). Regulated by state boards of nursing,
ments. Nurses may specialize in any of more than 38 NPs may practice independently or in collaboration with
8 Clinical Skills for Pharmacists: A Patient-Focused Approach

other health care professionals. NPs typically have unlim- pharmacy preceptor. Autonomy and the ability to pro-
ited prescriptive authority. spectively influence the health care team gradually
develop with experience. Although the types of experi-
Physician Assistants ences students have vary with the patient care environ-
The American Academy of Physician Assistants (AAPA) ment, the professional responsibilities remain the same.
defines physician assistants (PAs) as health care profession-
als licensed, or in the case of those employed by the federal THE MEDICAL TEAM
government they are credentialed, to practice medicine
with physician supervision.16 PAs perform many routine Teaching hospitals are the primary training sites for most
tasks (patient interviews, patient examinations), order and health care professionals. Health care services in teaching
interpret laboratory and diagnostic tests, treat minor ill- hospitals are structured around medical teaching teams
ness, counsel patients, and provide patient education. PAs composed of physicians, medical students, and, depend-
can prescribe medications in many states. PAs may have ing on the hospital, other health care professionals (Box
certificates, associate degrees, or masters degrees. Most 1-8). Medical teams, organized to provide a structured
states require graduates of accredited programs to pass training environment, are responsible for the care of
certifying examinations. Those who pass the examination patients located in assigned areas of the hospital (e.g., the
may use the designation Physician AssistantCertified cardiology unit) or patients located throughout the hospi-
(PA-C). Continuing licensure is contingent on comple- tal (e.g., patients with infectious disease or renal disease).
tion of continuing education requirements; recertification The team may provide consultative services in a medical
examinations must be passed periodically. subspecialty (e.g., dermatology) or be identified with a
specific physician group practice. The medical team func-
THE HEALTH CARE TEAM tions as a unit, with the division of labor and the responsi-
bility of each member determined according to the status
The health care team consists of all health care profes- of each individual. The team is structured so that each
sionals who have responsibility for patient care plus the team member receives guidance from a more experienced
patient (Figure 1-4). Although all members of the health health care professional. The team is the focus for group
care team interact directly with the patient, they rarely teaching and decision-making discussions. Most trainees
meet as a group; instead, information and recommen- spend about 4 weeks with a specific team. Physician team
dations are exchanged through written documentation. members include, in order of seniority, the attending
Verbal information exchange and recommendations physician, fellows, residents, and medical students.
occur on a less formal basis.
All members of the health care team contribute their Attending Physician
professions unique knowledge and skills. Pharmacists, The attending physician is the senior physician on the
the drug experts on the team, help teams develop, medical team. The attending physician assumes respon-
implement, and monitor the therapeutic regimen and sibility for all patients assigned to the team and provides
provide drug information and education services to the guidance and direction to team members. During team
patient and team. rounds, the attending physician leads the team through
Students have a unique role on the health care team. the decision-making process, helps the team make deci-
Students represent their profession and are expected to sions regarding patient care, and evaluates the perfor-
carry out their professional responsibilities under the mance of individual team members. Patient presentations
direct supervision of licensed professionals. For exam- may take place in a conference room, in the hallway out-
ple, pharmacy students are expected to provide patient- side of the patients room, or in the patients room. The
focused care under the direct supervision of a licensed
Box 1-8Medical Team Composition in Teaching
Hospitals

TYPICAL TEAM MEMBERS


Attending physician
Senior or junior medical resident
Intern
Senior medical student
Junior medical student

OTHER TEAM MEMBERS


Medical ethicist
Nurse
Occupational therapist
Pharmacist
Respiratory therapist
Figure 1-4 The Health Care Team. The health care team
Social worker
consists of the patient and all health care professionals taking care
Students (dental, nursing, pharmacy)
of the patient, including students in health care professions.
Chapter 1 Introduction: The Practice of Clinical Pharmacy 9

attending physician spends a short portion of the day Medical Students


with the team and is available for consultation (usually Although medical students get some experience examin-
by telephone) throughout the rest of the day, 24 hours a ing and interviewing patients in the first or second year
day, 7 days a week. of medical school, clinical clerkships usually start in the
third year of medical school. Third-year medical students,
Fellows known as junior medical students, spend part of the year
Medical fellows are physicians who have completed resi- in the patient care environment in month-long rotations
dency training and have elected to continue their train- such as internal medicine, surgery, obstetrics and gyne-
ing in a research-oriented fellowship program. Fellows cology, and pediatric services. Their patient workloads are
work closely with the attending physician and have limited to a small number of patients, and medical school
fewer direct patient care responsibilities than residents. faculty and more experienced team members closely
Fellows teach the more junior members of the team. In supervise them. Senior medical students, also known as
some fellowship programs, fellows are responsible for externs, are in the last year of medical school. Depending
performing specific invasive procedures such as arterial on the medical school curriculum, senior medical students
line placement, bronchoscopy, and endoscopy. Research- may spend all or part of the last year of medical school
intensive, multiyear fellowship programs in medical in a variety of selective or elective rotations. Externs have
subspecialty areas such as gastroenterology, cardiology, more patient care responsibilities than do junior medical
neurology, and pulmonary medicine are available at students but less than interns or other residents.
many major teaching hospitals. The medical team, depending on institution-specific
policies, may include a variety of other health care profes-
Residents sionals. Some pharmacists provide patient care services to
Medical residents are physicians who have graduated specified patient populations (e.g., oncology, critical care,
from medical school and are in structured and supervised nutrition, transplant, or nephrology patients) and are con-
residency training programs. sidered integral members of the medical team. Pharmacy
First-year residents (sometimes designated as postgradu- residents, fellows, and students often are assigned to spe-
ate year 1, PGY1, or PG1 trainees) are known as interns. cific medical teams for part of their experiential training.
Internal medicine internships of at least 1 year often are NPs and PAs may provide patient care services to specific
required before the resident moves on to more specialized patient populations and attend rounds with the medical
training in areas such as surgery or psychiatry. The intern team. More commonly, nurse specialists join the medical
year also is the first of several years of training for physi- team as the team discusses specific patients and patient-
cians interested in practicing internal medicine. Interns, specific issues. Nursing students may be assigned to medi-
who are licensed physicians, have an intensive year of cal teams as part of their experiential training. Other health
training, with frequent night call duty and direct respon- care professionals who may be part of the team or join the
sibility for the care of a variety of inpatients and outpa- medical team on rounds to specific patients include social
tients. Interns typically spend 1-month periods gaining workers, dietitians, medical ethicists, occupational thera-
experience in a variety of internal medical services such pists, physical therapists, and respiratory therapists.
as general medicine, emergency department services, and
intensive care services. In addition, interns usually have THE INPATIENT ENVIRONMENT
set clinic hours and care for a variety of outpatients over
the course of the year. Patients admitted to the hospital are assigned beds on
Second-year internal medicine residents (sometimes des- specific floors, wards, or wings according to the specific
ignated as postgraduate year 2, PGY2, or PG2 trainees) also medical problem (e.g., obstetrics, general medicine, car-
are known as junior admitting residents (JARs). Third-year diology, orthopedics). The admitting physician evaluates
medical residents (sometimes designated as postgradu- the patient and orders laboratory tests, procedures, diets,
ate year 3, PGY3, or PG3 trainees), also known as senior and medications. The admitting physician may consult
admitting residents (SARs), are in the final year of 3-year with specialty physicians and other health care profes-
internal medicine residency programs. The senior medi- sionals, including pharmacists. In a teaching hospital,
cal resident sets the daily team rounding schedule, pri- medical residents, interns, and medical students also
oritizes the work schedule, coordinates the teams work, evaluate the patient; the physician of record (the resident
supervises the interns, supervises and works closely with or intern) generates patient orders and consults with a
the medical students on the team, and consults with the variety of physicians and other health care professionals
attending physician. Residents have frequent night call regarding patient care.
duty and direct responsibility for a variety of inpatients Nursing services are organized to provide 24-hour
and outpatients. nursing coverage for all patients. The number of patients
The chief medical resident is a senior medical resident assigned to each nurse depends on the severity of the
who, in addition to the usual resident responsibilities, patients illnesses or disabilities and ranges from 1 or more
has administrative responsibility for various aspects of nurses per critically ill patient to 10 or more patients per
the residency program, such as scheduling rotations and nurse on other units. Each floor, unit, or ward has a head
vacations and organizing and overseeing seminars and nurse with administrative responsibility for nursing ser-
other education programs. The chief medical resident vices. Some hospitals assign each patient to a primary NP
position is competitive; typically one or two residents per who determines the nursing care plan for the patient and
year are selected for this position. coordinates patient care.
10 Clinical Skills for Pharmacists: A Patient-Focused Approach

Figure 1-6 Attending Team Rounds. Attending team rounds


often take place in a conference room. (From Perry AG: Clinical
Figure 1-5 The Hospitalized Patient. Team rounds may be con- nursing skills and techniques, ed 7, St Louis, Mosby.)
ducted in the patients room. (From Frownfelter D: Cardiovascular
and pulmonary physical therapy: evidence and practice, ed 4,
St Louis, 2006, Mosby.)

Medical team rounds usually occur in the morning.


Work rounds, led by the medical resident, usually take
place early in the morning. During work rounds the
patients progress is briefly reviewed by the resident,
intern, or medical student responsible for the patient;
the medical team visits each patient (Figure 1-5). Work
rounds allow all members of the team to catch up on the
status of each patient and plan for the days tests, consul-
tations, and other patient care activities.
Attending rounds, led by the attending physician, gen-
erally occur after work rounds and are held in conference
rooms rather than at the patients bedside (Figure 1-6).
Newly admitted patients are presented to the attending
physician, who leads the discussion of the differential
diagnosis and decision-making processes. Other patients Figure 1-7 The Ambulatory Patient. The patient and health
may be discussed in detail. Although some teaching takes care professional in an ambulatory patient care setting. (From
place during work rounds, most in-depth teaching discus- Wilson SF, Giddens JF: Health assessment for nursing practice, ed 4,
sions take place during attending rounds. St Louis, 2009, Mosby.)
Team members spend the rest of the day indepen-
dently evaluating patients, assessing laboratory and or freestanding facilities for laboratory and diagnostic pro-
diagnostic test results, documenting patient findings, cedures such as blood work, radiography, and imaging. The
consulting with other health care providers, and plan- results are sent to the referring health care provider.
ning for the care of their patients. The team may gather
for radiology rounds, during which recent patient radio- THE MEDICAL RECORD
graphs (e.g., chest films, computed tomography scans)
are reviewed. At the end of the day the team gathers for The inpatient medical record, also known as the chart,
sign-out rounds, during which the physician responsible is a legal document that includes sections for hospital-
for providing medical coverage in the evening and over- specific admission and insurance information, initial
night is briefed about each patient on the service. history and physical examination, daily progress notes
written by every health care professional who interacts
THE OUTPATIENT ENVIRONMENT with the patient, consultations, nursing notes, labora-
tory results, and radiology and surgery reports (Figure
Physicians and other health care professionals (e.g., PAs, NPs, 1-8). Most charts include sections for medication orders
pharmacists) interact with and care for ambulatory patients and other types of orders (e.g., laboratory testing, dietary
in private offices and clinics (Figure 1-7). Some clinics pro- orders, diagnostic procedures; Table 1-6). Some hospitals
vide first come, first served walk-in services; most require maintain a separate ordering system. Access to patient
appointments. The health care professionalpatient interac- charts is restricted to authorized health care profession-
tion generally is short (10 to 12 minutes) except for initial als. Upon patient discharge, the medical record is stored
patient evaluations, patients with more complex problems, in the medical records department and is retrievable by
and outpatient procedures. Patients are referred to affiliated referencing the patients hospital admission number.
Chapter 1 Introduction: The Practice of Clinical Pharmacy 11

Table 1-6 Medical Record Content


Section Type of Information
Admitting data* Name, address, date of birth, insurance,
next of kin
Consent forms Consent for surgery, procedures,
research studies
Physician orders Medication, dietary, and laboratory
orders
Flow sheets and 24-hour charts of blood pressure, heart
graphic charts* rate, respiratory rate, temperature, and
fluid intake and output
Progress notes Physician notes, nursing shift notes,
consultant notes
Laboratory data Blood chemistry panel, arterial blood
gas analysis, culture and sensitivity
testing, histopathology reports
Diagnostic Radiology and other diagnostic
procedures procedures reports
Consults Consultant assessments and recom-
mendations
Operating room Preoperative checklist, anesthesia
reports* record, graphic records of vital signs,
description of events during surgery
Admission his- Initial history and physical examination
tory and physical findings
Figure 1-8 Components of the Medical Record. The medi- examination*
cal record contains sections for many types of patient-specific Medication Date, time, dose of medications admin-
information. administration istered; names and initials of nurses
record* who administered medications; lists of
all ordered medications
Every page of the medical record, all patient-specific Miscellaneous* Emergency department record
orders, and every page printed from the computerized
*Inpatient charts only.
chart is stamped or printed with a patient identification
number. In most hospitals a plastic card that includes the
patients name, race, address, physician, birth date, date increasingly, off site via remote access. Electronic charts
of admission, and hospital admission number is created contain the same sections and are structured the same as
upon admission. A ward secretary (also known as a ward traditional written charts, although features vary by sys-
clerk) coordinates the processing of paperwork on a hos- tem. The typical EMR includes computerized orders for
pital unit or part of a hospital unit. Some large units have prescriptions, computerized orders for tests, test results,
two or more ward secretaries. and health care professional progress notes.
Many institutions and practices chart in a specified for-
mat known as a problem-oriented medical record, or POMR.
The POMR is structured around a prioritized patient prob- THE HEALTH CARE DELIVERY SYSTEM
lem list. Progress notes and discharge summaries address
each patient problem as itemized on the patient problem The health care delivery system in the United States has
list. evolved over the past several decades from a system that
The outpatient medical record or chart contains the held individuals financially responsible for all aspects of
same type of information as the inpatient chart with the their health care to the current system, which advocates
exception of the admitting data, physician orders, admis- equal access and financial support for all components of
sion history and physical examination, and medication health care, including sophisticated and technologically
administration sections. Outpatient charts are used more advanced health care, for all individuals. Many Americans
to document patient-specific encounters and data than to believe that access to medical care is a national right.
communicate with other health care professionals. There- However, the financial burden of this belief has stimu-
fore outpatient chart documentation is limited compared lated considerable debate regarding the best way to use
with that on inpatient charts. limited societal health care resources.
There is growing interest in the electronic medical The health care system is a complex system influenced
record (EMR). Sophisticated computer systems enable and controlled by a variety of private and federal factors.
all or part of the medical record to be accessed electroni- Early attempts at some public support of needy individuals
cally by any member of the health care team on site or, date back to the early 1700s in Colonial America; however,
12 Clinical Skills for Pharmacists: A Patient-Focused Approach

Table 1-7 Public Health Policy Development Each team identifies a leader and a latecomer. Give
the latecomer a few pieces of the puzzle and have him
Date Issue or her go to another room or another area of the room
away from the team. Show each team leader the pic-
1930s-1940s Limited support for special patient
ture of the puzzle but do not give the leader the picture.
populations
Give the leader the rest of the puzzle pieces. Tell the
1940s-1950s Support for research, facilities, team leader that this is a competition between teams to
and training see which team can assemble its puzzle first. Give the
1960s Broadened health care coverage teams about 20 minutes to assemble the puzzles. Send
1970s Infrastructure support the latecomers back to their teams after 15 minutes.
1980s-1990s Cost, quality, and outcomes After the puzzles are assembled, discuss the following
2000s Health care reform
questions.
Describe the team leaders leadership style. Was the
Adapted from Kissick WL: The evolution of American health policy. Trans leadership style effective for this group and this
Stud Coll Phys Phila 11:187-200, 1989. task?
How well did the team work together? Did everyone
the prevailing attitude of the time was that individuals, contribute? Would you change the group dynamics if
not society, should pay for health care. Health care pro- you had another task to accomplish?
fessionals and institutions were free to charge custom- How did the latecomer feel when he or she joined
ary, prevailing, and reasonable fees for services; patients the team? Did the team welcome or ignore the
paid for private insurance or whatever they could afford latecomer?
to purchase if not covered by insurance. The health care How did the team feel about being interrupted by the
system thus evolved to meet the needs of those who could latecomer?
afford to purchase expensive and inclusive services. Unfor-
tunately, this type of health care system excluded portions
of society. The federal government has had to gradually SELF-ASSESSMENT QUESTIONS
assume financial and regulatory control of larger portions
of the system.17 Public health policy evolved from a focus 1. Which one of the following is not an outcome
on limited support for special patient populations in the included in the definition of pharmaceutical
1930s and 1940s to interest in cost, quality, and outcomes care?
in the 1990s to health care reform in the 2000s (Table 1-7). a. Cure of disease
Many health care issues remain unresolved. The most b. Elimination or reduction of symptoms
pressing of these is how to decrease costs while maintain- c. Arrest or slowing of disease processes
ing high-quality health care. Inequities in the health care d. Prevention of disease or symptoms
system are significant; approximately 15.4% of the U.S. e. Reduction of health care costs
population did not have health insurance coverage in 2. Skills required for patient-centered pharmacy prac-
2008.18 People with preexisting medical conditions rou- tice include which of the following?
tinely are denied health insurance. The number of unoc- a. Therapeutic planning and monitoring skills
cupied hospital beds is large, which increases competition b. Physical assessment skills
in the provision of traditional and new hospital services. c. Communication skills
Regional oversupply and undersupply of physicians and d. All of the above
other health care professionals exists. The cost of medi- e. None of the above
cal malpractice to both the physician and the health 3. Which of the following is(are) core elements of MTM?
care system is high. Defensive medicine accounts for an I. Provide a comprehensive or targeted medication
estimated 15% of the total U.S. expenditures for physi- therapy review
cian services. The historic health care reform bill signed II. Complete and update the patients personal
into law by President Obama in March 2010 begins to medication record
address many of these issues, but until its provisions are III. Develop a medication-related patient-directed
fully implemented, the impact and cost of reform remain action plan
unknown. In addition, the roles of pharmacists, nurses, a. I only
and PAs are still evolving, and many questions regard- b. III only
ing authority and responsibility for patient care remain c. I and II only
unanswered. d. II and III only
e. I, II, and III
4. Which of the following is a voluntary certificate pro-
APPLICATION ACTIVITY gram just for pharmacists?
a. Pharmacy-Based Immunization Delivery
b. Certified Diabetic Educator
Activity 1-1 c. Certified Asthma Educator
The goal of this activity is to explore group dynamics as a d. Added Qualifications in Infectious Disease
team assembles a 100-piece jigsaw puzzle. This activity is Pharmacotherapy
best performed in small groups (five or six people). e. Clinical Lipid Specialist
Chapter 1 Introduction: The Practice of Clinical Pharmacy 13

5. To be eligible for board certification, pharmacists


need which of the following?
a. A doctor of pharmacy degree http://evolve.elsevier.com/Tietze
b. Advanced education and training or equivalent
experience Audio glossary terms
c. A postgraduate residency
d. At least 5 years of work experience
e. Three letters of recommendation
6. Board certification for pharmacists is not available in REFERENCES
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12. Unresolved health care issues include which of the
following?
a. How to decrease the cost of quality health care
b. The imbalance between supply and distribution
of physician services
c. The role of clinical pharmacists, NPs, and PAs
d. All of the above
e. None of the above