5 years later, my thoughts on pharmacy practice

I haven’t been a practicing pharmacist in the traditional sense in about five years. I’ve spent the last 19 months as an independent consultant, which has been awesome. Prior to that I was a Product Manager for about two and a half years at a company that dealt in pharmacy automation and technology. Before that I was an IT Pharmacist, which did give me an occasional glimpse of “pharmacy practice”, but overall I figure it’s been at least 5 years since I worked at earnest as a staff pharmacist.

Recently I took a per diem position in a large acute care hospital as a staff pharmacist. I’m completely content being a consultant, and have enjoyed it very much, but I felt that I was losing touch with the daily grind that is pharmacy. I needed to get my hands dirty again and make sure that I wasn’t giving advice to people that was out of touch with reality. I think it’s important for any consultant to be able to relate to the actual problems that they’re being asked to solve. So for the past few months I’ve been staffing about a day a week. Below are some thoughts on what I’ve seen and heard.

• Pharmacy is the same as it was when I left. It’s the same chaotic, messy thing that it’s always been. That’s not to say that things haven’t changed, because they have. However, the changes haven’t solved, or even improved the practice. Actually, now that I think about it, things might be worse. It’s like boiling a frog in water, i.e. the people that have been doing it for years haven’t realized the temperature has been rising. They’re clearly sitting in a boiling situation and don’t know it.
• Regulatory requirements are literally killing the profession, and making things much more difficult along the way. Many of the new practices in pharmacy operations have nothing to do with improving efficiency or improving patient care. Instead, practice changes are clearly designed to meet the ever increasing onslaught of new regulations.
• There is an increased use of automation and technology, but it’s done in a haphazard sort of way. Some areas of the pharmacy are seeing great use of technology, such as standard room temperature storage, i.e. the shelves you see filled with drugs in every pharmacy. Other areas, like med tray management, the i.v. room, and refrigerated storage continue to be manually driven areas. Here’s the key to all this: the addition of automation is not aimed at patient safety or efficiency, it’s aimed directly at meeting regulatory requirements. See comment above.
• Watching people use pharmacy technology is painful. Very painful. The technology in place is the latest and greatest, but it looks and feels like something out of the 90’s. UI’s are confusing, and often times necessary functionality is buried so deep that no one can figure out how to use it. We have to do better. Lack of usability is what leads to workarounds, and workarounds abound throughout; as they always have.
• Digital references have caught on, which is good. There’s more information available online than ever before, even if it’s sometime difficult to find due to poor navigation. This is one area where I think pharmacy has excelled. That’s not to say that it couldn’t be better, but it’s improved significantly over the years.
• The concept of standards and rules apply, but only in a comical sort of way. There is an exception to everything, and an exception to every exception. Sometimes the exception is in direction violation of “the rule”. Funny. I have to giggle to myself each time I run into an exception to a rule. I come across at least one every single time I staff. Yes, every single shift I’ve worked. It’s confusing and frustrating.
• The addition of EHR’s has been a blessing and a curse. They seem to improve documentation and access to information, but have added a level of complexity that’s difficult to explain. For example, I believe the process for validating CPOE orders may be more error prone than entering the orders yourself. There’s a level of checking bias that goes along with looking at order after order that someone else has entered. It’s a bit unnerving.
• The concept of clinical pharmacy remains elusive. The use of pharmacists to follow-up on every black box warning, regulatory requirement and lab value is not clinical pharmacy. Sorry guys, but it’s not. True clinical pharmacy is practiced in very few healthcare systems in the U.S.
• Speaking of clinical pharmacy, documentation within the EHR is a nightmare. Just sayin’. There are still little sticky notes everywhere, and paper documents stuffed in folders and binders. When I asked pharmacists why they did that they told me it was because it’s easier than using the EHR to communication.
• Pharmacists are becoming more and more siloed from one another. The desire to specialize has created lack of accountability and an inability to problem solve. It’s sad. I miss the days of good general pharmacy practitioners, the guys that could “do it all”. I don’t see that anymore. Some of the best pharmacist I ever worked with were the ones that could handle the drug regimen for a difficult patient in the ICU, deal with a code on the floor, and then return to the pharmacy and deal with a difficult stability question coming out of the i.v. room. You just don’t see that anymore.
• Physicians ignore pharmacists and pharmacy recommendations the same as they always have. It’s cool though, because it doesn’t bother me like it used to. I do find one thing disturbing. Pharmacists used to teach medical residents about pharmacotherapy, kinetics, etc. Now it appears that most of that is done by the attending, which means there’s a lot of misinformation floating around out there. Things are going to be a real mess in another 5-10 years if that becomes the norm.

Overall it’s not as bad as it sounds. Really, it’s not. It’s more accurate to say that things have gotten slightly more difficult without improving the tools used to do the job. Five years out of the game and I don’t feel like I’ve missed much. Besides the nuances associated with processes specific to one particular pharmacy, I was very comfortable with the job in just a few hours. I haven’t missed a thing, and my knowledge base is a relevant as ever. My “clinical skills” may need a little work, but my operational skills are still solid.

It feels good to get my hands dirty once again, and as long as I can find time to staff a little here and there I’ll keep doing it. It gives me perspective.