BCPS 2012 Results: Blonde Pharmacist will repeat!

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BCPS Pharmacotherapy ExamSo the results are rolling in now, and if you are at all finding this post because you are frantic about finding your results, you will know today or early next week.  Mine arrived yesterday and though I am a bit disappointed, I am ready to start studying again as soon as Christmas is over.  In hindsight, since it is 20/20, I can say I am proud of how I did.  I graduated with a Doctor of Pharmacy in 1999.  Things have changed a lot since then, including my personal life.  I now manage two toddlers, a full-time job, and a part-time gig.  (Multi-task much?)  I have dreams of all kinds as far as online things are concerned, want to change the world, and decided to take this BCPS challenge on as a way to propel myself, not only in my current knowledge, but as a great resume builder.  There are many reasons pharmacists take this test. The passing score this year is 122.  The average was 130.  The range was 50-188.  Standard deviation 25.

Domain 1:  Maximum score 120, Average score 77

Domain 2:  Maximum score 50, Average score 33

Domain 3:  Maximum score 30, Average score 20

I missed it by very little.  I am not at all upset and depressed or any of that.  I went into it as a practice because being out of school for 13.5 years is very significant.  New drugs have arrived, new guidelines have changed the scope of practice, and residency trained pharmacists along with newer grads (>3 yrs) are the majority of the test takers.  This last point may be an incorrect assumption because I do remember a couple of ladies I met who "had something to prove to the younger pharmacists."  I truly hope both of them passed because those are the types that will be a lot more disappointed with a fail letter than me.  I have a pharmacist friend that was so upset with her fail that she refused to talk to anyone about it and threw away all the material.  I guess if I went into it thinking I would pass, I would feel that way.

Do I plan to retake?

YES.

That was my plan all along, ask anyone who knows me.  I know that many may have thought my comments of "It was tricky.  I know I didn't pass or if I did 'barely.'" was an attempt to pretend or whatever, but it was the truth.

It was tricky.

Know your guidelines.

Realize that A LOT of studying is required unless you have a very diverse clinical program at your large hospital.  For example, we don't see any trauma, very few TPNs, and other big topics on the test.

And if you have children, especially babies/toddlers... it is VERY tough.  Where is the time?

I should have taken this back when I had a more clinical position at a larger hospital, wasn't married, and certainly had no children absorbing every single free moment.  So if that's your current situation, PLEASE for the love of God take the test.  It will be tougher later.  I am PROOF!

So there.  There's my result (missed it by just a hair)... and had I taken it last year (passing was 111) I would have passed by several points.

Every year is different.

I plan to start studying very soon.  May start listening to the lectures in my family van (HA) starting now since I know.

Nothing hard should be attained easily.

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The Perfect Medical Model

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I have been doing a lot of thinking lately in regards to my career.  I am still in waiting mode about the BCPS exam, but in the meantime have spent some time making lists of how pharmacists are utilized and even on a smaller level within pharmacy departments.  You see, it is tough being on this side of a career.  I guess you could say I'm in the middle in regards to time and experience.  I have been a pharmacist now for thirteen years. I have watched, usually with protest unfortunately, as pharmacists are labeled and grouped depending on different criteria.  Back in 1999, it was about having a residency in order to be a "clinical" pharmacist.  That is still the case today except in the smaller hospital where residency trained pharmacists aren't in supply.  Other criteria is used at that point.

In a perfect medical model, especially in the small hospital, I think it would be beneficial if the physician handled diagnoses, testing, and collaborated with the clinical pharmacist for treatment.  It is fairly obvious when you study the medical school curriculum that the focus is on diagnosis.  Yes, it is important to know what we are treating, but it does no good if you throwing ertapenem at pseudomonas or if you are dosing vancomycin at 1 gm every 12 hours in a young obese man for MRSA.

Hospitals really should consider encouraging all their pharmacists, especially PharmDs to learn the material that the BCPS requires.  It has seriously helped me in the past several months personally.  It is worth the investment of money and time and makes a FABULOUS resume' builder.

And in the end, it's about the patient receiving the best care possible.  Wouldn't a collaboration encourage that?

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BCPS 2012 | a small review of my thoughts of the test

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The BCPS is the abbreviation for Board Certified Pharmacotherapy Specialist.  Basically according to the BPS website:

Pharmacotherapy is that area of pharmacy practice that is responsible for ensuring the safe, appropriate, and economical use of drugs in patient care. The pharmacotherapy specialist has responsibility for direct patient care, often functions as a member of a multidisciplinary team and is frequently the primary source of drug information for other healthcare professionals. Those who are granted certification in this specialty may use the designation Board Certified Pharmacotherapy Specialist and the initials BCPS, as long as certification is valid.

So, this is what I have been doing with every (or most) every free moment since April.  It is over now, and this is the first day I have had to sit and reflect.  I did not have the opportunity to finish the review of the test itself, and I was seated last (my own choice) for the second part so did not receive the handwritten review of the test.  I really spent all my time on the test itself, and my feedback wasn't given.

I wish it had been in hindsight.

I signed this paragraph at the beginning of the test but I don't remember what it said.  Something about not trying to memorize the test itself or copying the questions in any way.  So with that in mind, my review will not be specific but broad.

I am a hospital pharmacist who graduated in 1999 from the University of TN School of Pharmacy.  At the time we were rated number 7 in the United States, and I have never had any issues with being clinical minded in the jobs that required that role in the past 13 years.  Times have changed.  Schools have multiplied, and the residency which was a "side thought" in 1999 is a must today.  BCPS certification is also important if one did not do a residency or the cherry on the top if you did.

So, I decided at the ripe old age of 39 to study like a fiend and pay all sort of money to this organization to have study materials including written, web, and audio.  I spent most days listening to the likes of pharmacy lecturers discuss things from stats to ID to cardiology to oncology to nephrology.  It kind of made me realize I haven't really been using my brain at work, and to all the patients out there I have treated, I am sorry I haven't been a more thorough and clinically-minded pharmacist.

You see, an order entry pharmacist enters orders and most of the time relies on the computer system itself to flag for interactions and other things, but you know what?  Just yesterday I found something pretty profound.  The computer fails.  I found a place in our current process where I made a difference.  Just one of the many that are to come.

The test:  200 questions.  2 sections of 100 questions each.  I found the first part harder; but many I heard said the reverse.  I have always been the one marching at the beat of a different drummer.  Topics:  tons of stats, pharmacy regulations was everywhere.  I wasn't prepared for regs.  Psoriasis.  Acne.  Both of those disappointing as I haven't had an acute admission to the hospital yet for either.  And I have not found acne guidelines with the American  Dermatological Society yet.  I know I missed the psoriasis question.  Tons of COPD, albuterol, and not so much STEMI.  Angina more stressed.  Maybe due to the new Chest Guidelines that came out.  One chemo question I remember.  Tons of stats.  Did I already say that?

There were a couple kinetics questions.  Guess what?  I bought a $5 cheapie calculator from Walgreens that died.  YEP.  I had THAT luck.

Temperature was given in C rather than F.  I was bummed about that.  Guess it's time to join the rest of the world on that one!

There was one INR question I remember.  Pretty specific.  I got it right ;).

And the usual question that appears every year was there.  I don't think I can say what it is on here, but if you talk to anyone that has taken the test, they can tell you what it is ;).

Psychiatry a couple of times.  All side effects of drugs.  CYP3A4.  All CYP really.  Pharmacoeconomics more than I would have liked.

Guideline driven.  Mostly accp.com material so would recommend studying that.  Keep in mind if there's something not in that material though, you may want to find a review book to read on the side.

If I failed, which is possible (last year passed 70% of test takers with cut-off being 111/200 or so) I will retake it again next October.  I really liked the challenge, liked the things I have learned, and like the possibility of continuing my education in this field to grow in my career.

What did I study?

1.  ACCP materials.  I purchased the slides, handouts, and audio to listen in the car on my iPhone.

2.  http://quizlet.com/  There were tons of BCPS flashcards made by some pretty smart pharmacists.  Just search BCPS on Quizlet.

3.  High Yield Med Reviews  We will see how this goes.  It's a subscription service with test questions.  I think it helped me.  I will probably resubscribe around July if I failed for next year.

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Who is David Matthew Kwiatkowski?

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Exeter, NH – Exeter Hospital worker David Matthew Kwiatkowski, who officials say had hepatitis C and spread the disease to 30 unsuspecting patients by stealing drugs, has been arrested, the U.S. Attorney's office in New Hampshire announced Thursday. Kwiatkowsi, 32, of Exeter, was arrested this morning at a hospital in Massachusetts, where he's receiving treatment for hepatitis C. He's charged with fraud and tampering.

He faces up to 24 years in prison and a $250,000 fine.

That is it?  A life sentence would be more appropriate.  Let us delve into the world which is Hepatitis C.  What future will these patients and any others that he so selfishly infected face?

Thomas Wharton, MD, FACC, medical director of the Cardiac Catheterization Unit at Exeter Hospital, now views Kwiatkowski as “the ultimate con artist and an extremely good cardiac technologist who pulled the wool over everyone's eyes.”

Of the isolated incidents that fellow Cardiac Catheterization Unit employees began reporting in the spring, Dr. Wharton said, “David had stories for everything that pulled at your heart-strings and we had no reason to disbelieve him. David claimed to have several important medical conditions, and we had no reason to challenge this. The day he reportedly arrived to work with red eyes he told us his aunt had died the night before and he had been up all night crying.”

And the kicker really is his response to investigators about the people he spread the virus to:

"You know, I'm more concerned about myself, my own well being," he told investigators. "That's all I'm really concerned about and I've learned here to just worry about myself and that's all I really care about now."

From http://www.epidemic.org:

Although few prospective long-term survival and health care cost studies are available for hepatitis C, it has been possible to estimate the life-long economic impact of the disease for both the individual patient and for the U.S. population with chronic hepatitis B. Lifetime health care costs for a patient with chronic hepatitis B has been estimated at $65,000 in the absence of liver transplantation. For the 150,000 HBV carriers with significant liver damage, the lifetime health care costs in the U.S. have been estimated to be $9 billion. Assuming an estimated survival of 25 years, the annual health care costs for the affected U.S. population with chronic hepatitis B is $360 million. Based on the same economic analysis, treatment of chronic hepatitis B with interferon is projected to increase life expectancy by about three years and cut the total health care costs.

Hepatitis C can only represent a far greater economic cost. While it infects about 3 and a half more times as many people in the United States than does hepatitis B, more than 80% of hepatitis C patients will develop chronic liver disease, as compared to only 20% of hepatitis B patients. Limited data suggest that 15-20% of those with chronic hepatitis C will develop cirrhosis within a five-year period, and as many as 25% may have cirrhosis by 10-20 years. The risk of developing liver cancer is uncertain, but may approach or exceed 1% during the first 20 years of infection and increase afterwards. Hepatitis C is responsible for about one-third of all liver transplants in the United States.

Approximately 1,000 patients are transplanted each year for liver disease due to hepatitis C. With the cost per liver transplantation in the range of $280,000 for one year, liver transplantation for hepatitis C alone reaches a cost of nearly $300 million per year.

Moreover, the average lifetime cost for hepatitis C, in the absence of liver transplant, has been estimated to be about $100,000 for individual patients. Assuming that 80% of the 4.5 million Americans believed to be infected develop chronic liver disease, the total lifetime cost for this group (3.6 million) will be a staggering $360 billion in today's dollars. Assuming an estimated survival of 40 years, the annual health care costs for the affected U.S. population with chronic hepatitis C may be as high as $9 billion.

It would be prudent to consider that every single person that he has infected would at the VERY least receive $100,000 up front PLUS the cost of transplant and the cost of the emotional toll.  He should never be able to walk in society again and spend the rest of his time working to pay this debt.

I also believe that the hospital should cover the rest of the cost considering the signs were there for him being under the influence.  All it would have taken would be ONE person, ONE coworker, ONE physician to take the chance and get this guy tested.  Also, pharmacists should have a bigger role in a cath lab like this to prevent nurses and staff from having such access to be able to hide something like this.  I'm just appalled at this man's evil behavior coupled with the lack of safe policy at the hospital(s) in question.

This is just my opinion.

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Oxycontin Reformulation and the Heroin Effect

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According to multiple news agencies and a letter published by New England Journal of Medicine, former Oxycontin addicts are moving over to a cheaper readily available illegal substance to get high -- heroin.

Effect of Abuse-Deterrent Formulation of OxyContin

N Engl J Med 2012; 367:187-189July 12, 2012

Article

TO THE EDITOR:

In August 2010, an abuse-deterrent formulation of the widely abused prescription opioid OxyContin was introduced. The intent was to make OxyContin more difficult to solubilize or crush, thus discouraging abuse through injection and inhalation. We examined the effect of the abuse-deterrent formulation on the abuse of OxyContin and other opioids.

Data were collected quarterly from July 1, 2009, through March 31, 2012, with the use of self-administered surveys that were completed anonymously by independent cohorts of 2566 patients with opioid dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders,4th edition, who were entering treatment programs around the United States and for whom a prescription opioid was the primary drug of abuse (i.e., heroin use was acceptable but could not be the patient's primary drug). Of these patients, 103 agreed to online or telephone interviews to gather qualitative information in order to amplify and interpret findings from the structured national survey.

Effect of Abuse-Deterrent OxyContin., the selection of OxyContin as a primary drug of abuse decreased from 35.6% of respondents before the release of the abuse-deterrent formulation to just 12.8% 21 months later (P<0.001). Simultaneously, selection of hydrocodone and other oxycodone agents increased slightly, whereas for other opioids, including high-potency fentanyl and hydromorphone, selection rose markedly, from 20.1% to 32.3% (P=0.005). Of all opioids used to “get high in the past 30 days at least once” OxyContin fell from 47.4% of respondents to 30.0% (P<0.001), whereas heroin use nearly doubled.

Interviews with patients who abused both formulations of OxyContin indicated a unanimous preference for the older version. Although 24% found a way to defeat the tamper-resistant properties of the abuse-deterrent formulation, 66% indicated a switch to another opioid, with “heroin” the most common response. These changes appear to be causally linked, as typified by one response: “Most people that I know don't use OxyContin to get high anymore. They have moved on to heroin [because] it is easier to use, much cheaper, and easily available.” It is important to note that there was no evidence that OxyContin abusers ceased their drug abuse as a result of the abuse-deterrent formulation. Rather, it appears that they simply shifted their drug of choice.

Our data show that an abuse-deterrent formulation successfully reduced abuse of a specific drug but also generated an unanticipated outcome: replacement of the abuse-deterrent formulation with alternative opioid medications and heroin, a drug that may pose a much greater overall risk to public health than OxyContin. Thus, abuse-deterrent formulations may not be the “magic bullets” that many hoped they would be in solving the growing problem of opioid abuse.

Theodore J. Cicero, Ph.D. Matthew S. Ellis, M.P.E. Washington University in St. Louis, St. Louis, MO cicerot@wustl.edu

Hilary L. Surratt, Ph.D. Nova Southeastern University, Coral Gables, FL

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Physical Punishment and Mental Disorders

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I do not care for statistics.  It's not in my DNA to ENJOY them but this is the perfect example why all pharmacists (and the lay public, for that matter) should understand and interpret study results.  Just the other night, I was watching the news and the anchor states, "Parents should think twice about spanking their children."  Most people would look at the anchor, hear the words, and then turn right around and pass it on as though it was spoken by God Himself. A study was cited:

BACKGROUND: The use of physical punishment is controversial. Few studies have examined the relationship between physical punishment and a wide range of mental disorders in a nationally representative sample. The current research investigated the possible link between harsh physical punishment (ie, pushing, grabbing, shoving, slapping, hitting) in the absence of more severe child maltreatment (ie, physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, exposure to intimate partner violence) and Axis I and II mental disorders.

METHODS: Data were from the National Epidemiologic Survey on Alcohol and Related Conditions collected between 2004 and 2005 (N = 34 653). The survey was conducted with a representative US adult population sample (aged ≥20 years). Statistical methods included logistic regression models and population-attributable fractions.

This is a retrospective study which automatically introduces bias.  Correlation does not imply causation.  That's the biggest issue I see with this study.  For example, the media will pick up a press release about this type of study and report that spankings make children grow into adults with mental disorders, but correlation does not imply causation.  For example, children who were spanked may end up with a mental disorder, but there is no proof that it was the spanking itself that caused the mental illness but perhaps several other factors or combinations of factors.  Even schizophrenia and depression have had genetic components.  What happened to pure genetics?

The next big issue with this study is they looked at many types of mental illnesses since it is not very efficient to run a large study, gather data, and analyze it to look at only one type of mental illness.  Scientific studies, however, rely on statistical analysis to determine whether something is true.  Even if your estimated error is less than one percent, in a study examining thousands of items some will appear to have an effect even though they are just statistical aberrations.  These false positives are then reported, and when a new study fails to confirm them as true, the press reports a scientific “change of mind”.

Finally, when a cohort study is retrospective, the problem is compounded since retrospective studies often rely on memory.  If you developed a mental illness, you may have a different memory recall of punishment and its effect and your perception vs if you did not have a mental disorder.

Be careful with retrospective studies!   As in this case, there are many flaws and biased automatically introduced.

I definitely understand the rationale for wanting to run this study as many parents are probably over the top with physical punishment; however, I don't believe those parents that reserve a spanking for a type of punishment as abusive or that their child will end up with a mental illness due to that one decision.  Too bad the media doesn't know how to interpret studies!

Another critique:

While the new study rules out the most severe cases of physically lashing out at children, "it does nothing to move beyond correlations to figure out what is actually causing the mental health problems," says psychologist Robert Larzelere of Oklahoma State University,. He criticized the study's reliance on memories of events from years earlier, and says it's not clear when punishment occurred.

Afifi acknowledges that it's difficult to change people's mind on this topic, but says "we're confident of the reliability of our data, and the data strongly indicate that physical punishment should not be used on children — at any age. And it's important for parents to be aware of that."