It has been 4 years since I pressed submit on the keyboard

I am asked often about my decision to leave pharmacy four years ago. I stress with absolute certainty, I have no regrets. I had risen as far as I could within the company I worked, and I had no intention of leaving the city where I lived. My job had become something very computer-driven, and I had lost the ability to be a free-thinker due to checking the boxes. Healthcare has progressed in so many ways, but along the way it has become too reliant upon technology. There is always a gap between what is programmed, what is real and what is substantially important. That space is the space the best clinicians reside. I remember back in 2017 mentioning my idea to change careers and was told by a fellow pharmacist friend that no one really needs a financial advisor and that people can do-it-themselves. Isn’t that what we always said about pharmacists, too? Pharmacists do nothing but fill medications that anyone could do. We know as pharmacists that it is really far from the truth. Pharmacists do a lot, and so do financial advisors.

It’s not about chasing performance or building the most aggressive portfolio necessarily, but it’s also about tax harvesting and money placement based on the clients’ unique needs. Just like with pharmacy, medications change and within financial services, political administrations change changing laws with it.

I have spent the last few years since the career change learning the craft. I just finished and passed the CFP® certification on Friday and just waiting on the last bits to be able to use the letters. I had a sweet lady ask me 1 1/2 years ago if I was a fiduciary. It’s one of those questions where you want to respond, “I am in thought and action,” but the term has been coined by the industry to mean CFP® certification. I decided right then to entertain the idea within the next few months. COVID-19 arrived, and I found it to be the perfect opportunity for education. I’ll write a separate post about my experience and how I conquered it the first time and will say with little hesitation that the test was harder than pharmacy boards and BCPS certification combined. I am not sure if it was because the test was so tricky or if it was because I did not have a finance background as I did with pharmacy prior to those tests. I am so very proud of myself for getting through it. I know the amount of information I learned will really help me be a much better advisor than I could have been without it.

What's the Deal with the Vitamin C in the ICU?

I am noticing more physicians using Vitamin C and thiamine infusion along with steroid for patients with sepsis in the ICU. At first glance, the obvious issues are small sample study, retrospective study, and all patients at one hospital.

NPR's take

Another good one...

Another report

Need More Studies

He wants there to be a comprehensive study, and he said that Stanford University has expressed some interest. But he said it will be difficult to fund because it uses drugs that have been on the market for decades: “We are curing it for $60. No one will make any money off it.”

It will be interesting to see where this leads... if anywhere. But, in the meantime, a little Vitamin C never hurt anyone, right?

Pharmacy Forecast 2016-2020

The ASHP Foundation released a "Pharmacy Forecast: 2016-2020" Strategic Planning Advice back in December. My first thought is a pause thinking how long I have been out of pharmacy school. I start counting on my fingers from '99 and think, wait, what? SEVENTEEN years. I am officially the pharmacist I stood beside in one of my first pharmacy jobs. I considered him wiser. Maybe I am wiser, but I still sometimes feel like school was not too terribly long ago.

This is the fourth edition of this particular report, and I generally try to read every edition. This one somehow slipped by until this past week when I found it and read it rather quickly. There are some applicable topics for today's healthcare pharmacist that I want to dive into.

Strategic Planning versus Reactive Planning

I have not seen a lot of strategic planning within the hospital pharmacy model. We do a lot of reactive planning based on other departments mostly in line with cost management and saving money. We plan operations in how we staff our departments based solely on how many patients are in the hospital but do not use other metrics such how complicated medically is the patient? What if the patient comes in with a chronic infection versus the patient who comes in as a first-time infection? What if the patient has 20 or more home medications on board? Census is more than just number of patients. What if it is measured by a formula of disease states both acute and chronic along with number of hospital admissions in the past 5 years plus number of medications? A patient doesn't equal a patient. Maybe this applies in a surgical patient, but not in a patient with COPD, ARDS and decompensating on a ventilator due to a hospital-acquired infection.

Opening the report is a timely introduction:

"Since the start of the pay-for-performance movement1 and passage of the Patient Protection and Affordable Care Act (ACA), there has been intense pressure on healthcare organizations to improve quality while reducing costs. The stress created by this pressure has been exacerbated by proliferation of expensive specialty medications, egregious price increases for some sole-source drug products, and the escalation of generic drug prices. In response to this environment, many healthcare organizations are pursuing mergers and acquisitions in an attempt to create economies of scale without the cost of new construction. Another tactic is to partner with outside entities such as chain pharmacies."

Specifically what caught my eye this time was the section on work force. Change in practice models claim a shift from inpatient to ambulatory type practice.

"THE SHIFT TO AMBULATORY CARE As healthcare organizations respond to payment reforms that aim to lower costs and improve patient outcomes, health-system pharmacy practice leaders are challenged to optimize the role of the pharmacy work force in new models of care. One area of challenge is the shift in emphasis from inpatient to ambulatory care.1 Reflecting this change, three-fourths of Forecast Panelists (FPs) agreed that over the next five years, in at least 25% of health systems, patient care pharmacists will have umbrella responsibilities for both inpatients and outpatients (survey item 1). Further, 69% agreed that at least 25% of health systems will reallocate 10% or more of inpatient pharmacy positions to ambulatory-care positions (item 2). Consistent with anticipated growth in ambulatory care, 65% of FPs predicted a vacancy rate of greater than 10% for ambulatory-care pharmacy leadership positions over the next five years (item 5). Pharmacy staff development programs should ensure that there are adequate opportunities for education and training in management of ambulatory care pharmacy practice, transitions of care, and medication management of chronic illnesses. "

How do we lose money? Readmissions, using more inpatient days than necessary due to reasons in and out of our control, and not following certain standards that are attached to payment or removed when standards are not met while in-patient. 

Did you notice one thing? The salaries of newly hired entry-level pharmacists will decline by 10% while pharmacist technician salaries will increase?

You know I get excited about this one:

"PHARMACISTS AS PROVIDERS Nearly 80% of FPs predicted that at least 25% of health systems will have a formal plan for including pharmacists, along with nurse practitioners and physicians assistants, in advanced roles that allow primary-care physicians to care for more patients (item 4). Supporting the high level of agreement with this statement is the shortage of primary-care physicians, proposed federal legislation to grant provider status to pharmacists, and the large number of states that authorize pharmacists to establish collaborative practice agreements with physicians. 2 Recent changes in reimbursement rules related to complex chronic care and transitional care management3 support the addition of pharmacists to primary-care teams. Many health systems will be establishing a privileging process for pharmacists to ensure that those with expanded patient care roles have the necessary competence for those roles."

I suggest you read through the report. It is mostly put together through surveys, but has some very timely information for the next 4-5 years in pharmacy.

PHARMACY FORECAST 2016-2020

Sepsis and Septic Shock Guidelines

One of the main guidelines in sepsis is the Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock from 2012 (updating the 2008 guidelines).

Pocket Guide

Key recommendations and suggestions:

• Early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C)
• Blood cultures before antibiotic therapy (1C)
• Imaging studies performed to confirm a potential source of infection (UG)
• Administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B)
• Infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C)
• Initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C)
• Initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to acheive a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C)
• Fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG)
• Norepinephrine as the first-choice vasporessor to maintain mean arterial pressure >/= 65 mm Hg (1B)
• Epinephrine when an additional agent is needed to maintain adequate blood pressure (2B)
• Vasopression (0.03 U/min) can be added to NE to either raise MAP to target or to decrease NE dose but should not be used as the initial vasopressor (UG)
• Dopamine is not recommended except in highly selected circumstances (2C)
• Dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite acheiving adequate intravascular volume and adequate MAP (1C)
• Avoiding use of IV hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C)
• Hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B)
• Low tidal volume (1A) and limiation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS)
• Application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B)
• Higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C)
• Recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C)
• Prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of </= 100 mm Hg in facilities that have experience with such practicees (2C)
• Head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B)
• A conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C)
• Protocols for weaning and sedation (1A)
• Minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B)
• Avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C)
• A short course of neuromuscular blocker (no longer than 48 hours) for patients with early ARDS and a PaO2/FIO2 < 150 mm Hg (2C)
• A protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose </= 180 mg/dL (1A)
• Equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B)
• Prophylaxis for deep vein thrombosis (1B)
• Use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B)
• Oral or enteral (if necessary) feedings, as tolerated, rathern than either complete fasting or provision of only IV glucose with the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C)
• Addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hours of intesive care unit admission (2C). 

What's New This Flu Season

Flu vaccines are already available at many retail pharmacy locations, though the flu season typically startts on October 1st. 

The nasal spray flu vaccine is not recommended this year, much to the dismay of many children over the age of 2. Mine, included. 

Board Certification After Awhile

Was it worth it? I know many wonder this same question, and I believe it is. It is expensive to keep current. There is a yearly fee due to BPS every year. The required approved continuing education is pricey and complicated. 

The reason I continue to believe it is worth it is because prior to obtaining this, I feel like I had something to prove. Many newer grads felt or assumed I was a BS Pharm even though I was a PharmD. Many assume that because I have been out of school over 15 years, I am behind the times. Experience is sometimes not as valued in every job culture no matter what field it is. Bright and eager new graduates come out feeling as though we are behind the times, and sometimes they are right. 

Prior to obtaining my BCPS, I had no residency to point to. Yes, we had residencies back then, but my debt load didn't endorse another year of the same at half the price. The return on investment didn't seem good enough. If I was graduating today, I would definitely do a residency. 

What happened to me after the board certification is that I quit trying to prove myself to peers. I refocused my efforts on the patients by doing a better job in going the extra mile and also by noticing the system issues that aren't being exposed. I also have stopped trying to make my career the thing I work on the most and have let it fall to a healthier place behind God and family. What will be will be.  

Should a job in pharmacy open up where I can do more of the things I enjoy: clinical decision making, brainstorming, patient advocacy, and writing, I will be moved. Until then I credit certification to validating competiveness with newer pharmacists while also solidifying my belief that experience is king. I am glad I invested in myself and hope you will too! 

Pharmacists are Poised to Help with Opioid Addiction!

Drug addiction is in the news in a big way lately with Obama talking about a war on drug addiction rather than the past war on drugs with other administrations. It is definitely a combination of both. The drug lords who profit greatly from sales of drugs and the person who tries and becomes addicted. It is not uncommon in the medical field whether physician, pharmacist or nurse to know someone who has or will become addicted. I have had friends and colleagues to get involved either in the selling of medications or on the addiction and both are destructive. Pharmacists need to be involved in helping this growing problem.

Addiction is particularly sad. I cannot imagine anyone who is in their right frame of mind without addiction would choose to lose their job and family. It cannot just be a choice after choice but something much deeper and ingrained in a person’s DNA.

We see the patients who are being treated for addiction with buprenorphine, a partial mu-opioid receptor agonist, and methadone. We see patients coming in for routine surgeries and being placed on multiple pain medications with no real oversight on managing if the patient has the propensity toward opiate addiction and if the actual surgery itself will spiral them back into the addiction they once overcame.

The Centers for Disease Control (CDC) has spoken recently about the addiction crisis facing our nation and has released guidelines in prescribing pain medications to patients. The biggest message from the CDC is DON’T. The gist:

• In the cases of pain not including cancer pain, end-of-life care, or palliative care, use non-opioid medications.
• If you must use opioids, use the lowest dose.
• Monitor the patient

While some prescribers are careful in prescribing opioids, others are much more judicious. Not only is addiction a problem in some, oversedation and other side effects as well.

Personally, there was a time in my life when I was trying to find relief for low back pain that had plagued me from my running days. I was heavier and had had two children and felt like the pain was unrelenting. Ibuprofen and naproxen no longer helped, and I was desperate. You kind of know if you have a propensity toward pain medications (opioids), and I personally wanted to avoid them if at all possible. I ended up trying physical therapy and begged for back surgery but slowed down when a neurosurgeon said he would not operate on me and that I would be a fool to find someone who would. I listened and started working on weight reduction and core strength and found another alternative (radiofrequency lesioning) that bought me time to reduce facet joint lower back pain and increase my core strength. I’m happy to say it worked, but I know others who went the surgery route and their pain has only worsened. Their back was compromised further with fusion and the disc spaces above and below the fused joint has issues as well.

There are other causes of pain that are not mechanical like autoimmune disorders and neurological pain. In every single case, pain must be evaluated and treated at the lowest possible dose and side effects monitored. Gastroparesis happens. Oversedation and overmedication can cause death. Addiction can happen and cause a patient to seek illegal pathways to find something they are craving to feel normal.

How can a pharmacist help? Pharmacists can manage pain medications and are able to do so. They are able to help in finding the best possible pain med for the level of pain that a patient is experiencing. They understand how other medications like docusate can help alleviate some of the side effects that are very troublesome. There has been movement nationwide for better access for naloxone in opioid reversal in overdose. We need to have an ability to be paid for doing more to help pain medication patients, because pharmacists know more about the medications than anyone on the healthcare team.

Politics and Pharmacy

Healthcare is always a hot topic when it comes to politics and elections and this year is no exception. The two leading winners of each party have expressed their opinions and goals many times in regards to healthcare over the past couple of years.

Donald Trump says he plans to repeal the Affordable Healthcare Act and replace it with a government-funded universal health care plan. Trump is a little unclear on what his health care plan would look like, but it would be a market-based alternative. Becker’s Hospital Review has an article which unveils Trump’s healthcare policy. Other websites have differing Trump plans basically because he answers the questions differently over time.

Hillary Clinton plans to build upon the healthcare plan that Obama started. She wants to expand health care access for rural Americans and work to lower the costs of deductibles, copays and medications. She wants to exempt three doctor’s visits per year from deductibles, provide a refundable tax credit for out-of-pocket health care expenses that are more than 5% of income and block insurance rate increases. Hillary also wants taxpayers to pay for drug research and development, not drug companies among other views.

Sources:

http://www.nbcnews.com/meet-the-press/video/full-interview-trump-on-healthcare-planned-parenthood-and-the-iraq-war-627627587531

https://www.hillaryclinton.com/issues/health-care/

https://www.donaldjtrump.com/positions/healthcare-reform

http://thehill.com/policy/healthcare/272918-study-trumps-healthcare-plan-would-cause-21m-people-to-lose-coverage

http://www.ontheissues.org

E-cigarettes and Safety

An acquaintance of mine recently celebrated his success in quitting cigarettes after multiple attempts.
 
“Good for you!” I said. “That is a very hard habit to break.”
 
But then he came clean.
 
He hadn’t really stopped smoking cigarettes but had switched over to electronic cigarettes, or “vaping.” Should those who vape view themselves as tobacco quitters? Are e-cigarettes safe or even safer than tobacco cigarettes?

E-cigarette use among adults and adolescents has increased since 2010. Many believe that e-cigarettes are a tool to quit or greatly reduce tobacco intake. Whatever the reasons, e-cigarette sales represent a $6 billion industry.

The main ingredients of e-cigarette liquids are nicotine, propylene glycol or glycerol, and choices of up to 5000 flavorings. The product can also contain other ingredients.

The issues surrounding e-cigarette use are as follows:

• The nicotine content is not consistent. The range can be from 6 mg/mL to all the way up to or above 36 mg/mL. The labeling can be incorrect in identifying how much nicotine is contained in the liquid. Even cartridges labeled nicotine-free can contain nicotine.
• No one knows for sure whether e-cigarettes are safe or even whether inhaling propylene glycol or glycerol is safe. There has been mention of studies suggesting that the vapors contain several carcinogens along with tiny particles of nickel, chromium, tin, or heavy metals that could damage the lungs. Some e-cigarettes have been found to give off formaldehyde and silicate particles.
• E-cigarettes are not regulated.
• Many of the flavors in e-cigarettes target youth. Data have provided evidence that e-cigarette use is prospectively associated with increased risk of combustible tobacco use initiation during early adolescence. While evidence has shown that adult e-cigarette use can aid in tobacco cessation, this has not been the case in youth.
• Nicotine overdoses are increasing because of the lack of product consistency.

It will be interesting to see the evolution of e-cigarettes and regulation over the next few years.

Reference
Orellana-Barrios MA, Payne D, Mulkey Z, Nugent K. Electronic cigarettes—a narrative review for clinicians.Am J Med. 2015;128:674.

Should Board Certification in Pharmacy Equal a Residency?

There has been a lot of debate about whether board certification should equate to or replace a pharmacy residency.
 
A couple of years ago, I read a letter from a pharmacist to the editor of Annals of Pharmacotherapy that brought forth some thoughts against board certification for new pharmacy school graduates who lack residency experience. The pharmacist author opined that new graduates should not be allowed to sit for the Board Certified Pharmacotherapy Specialist (BCPS) test without residency training.

The author argued that pharmacists were using board certification as a replacement for postgraduate residency or fellowship education. He also cited that employers were starting to require board certification as a condition of employment. In addition, he pointed to the need for revisions of the test over time, 3 years of experience equaling a residency, and a requirement of residency prior to board certification testing for new graduates after 2018.

One argument for board certification as a condition of pharmacist employment is that it is a standardized test, whereas not all residency programs are created equal. Some residency programs are very diverse and situated in teaching hospitals, while others are very similar to on-the-job training.
 
Programs must meet certain criteria as a requirement for accreditation, but not all residency experiences are created equal, either. On the other hand, board certification is a standardized test that shows a certain level of expertise.

I’m sure that the same issues came about when pharmacy schools first began offering the Doctor of Pharmacy degree. Would the PharmD be worth more than the Bachelor of Science (BS) in Pharmacy? Would graduates with PharmDs be more clinically minded?
 
Over time, the BS in pharmacy was phased out and the PharmD became the norm. I’m sure the same will happen as residencies become the norm, too.

If a residency should be a prerequisite for taking the BCPS exam, I believe pharmacy school curriculums need to change so that the residency program is built into the actual school model.