Internal Medicine Clinical Pharmacist (Renal): A Day in the Life

Our "Day in the Life" series increases your knowledge about what career paths are available, and what a typical workday entails for these professionals!

With so many career options available to pharmacists after graduation, the "Day in the Life" series is meant to provide you with insights into what it's like to be a pharmacist in various areas so that you can pursue what's right for you!

Introduction

1. Tell us a bit about your background (school, training, etc…)

• I completed my undergraduate (Biology and Psychology) at the University of Missouri – Columbia ­before deciding to pursue pharmacy. I then received my PharmD from Duquesne University in Pittsburgh, PA – specifically through their weekend program while I worked as a technician/student at a closed-door compliance packaging pharmacy. I did pursue a PGY1 and matched with Christian Hospital in St. Louis, MO, where I have been working ever since. We are a community hospital on the smaller side. I’ve worked about every shift and area we offer a pharmacist, but I’m currently a clinical pharmacy specialist rounding on our renal floor. I also precept pharmacy students and PGY1 residents (my rotation is Internal Medicine), both of which I thoroughly enjoy. 

2. What are some of the best and worst things about working as a clinical pharmacist primarily covering renal patients?

• We can have a real impact. Any clinical pharmacist needs to be considerate of renal dosing, including in dialysis, and hospitals often have renal dosing protocols available – doses can be changed automatically by pharmacists at my site. Where we can be of further use is in patient workups, taking renal considerations into account. Some examples include recognizing which medications could be contributing to renal failure, medications that could accumulate and be considered in the differential causes of a patient’s symptoms, pharmacokinetic considerations in the various dialysis modalities, electrolyte considerations (especially when adjusting TPNs), etc. Again, these are things almost all clinical pharmacists are concerned with – I just may see proportionally more dialysis patients than the average bear. The downside is that these patients often present many challenges to the healthcare team. Social and economic barriers, availability of dialysis beds, transportation, drug accumulation, graft/catheter infections, and other complications can contribute to longer hospital stays and undesired outcomes. 

3. What are the main barriers to entry? (PGY1 or PGY2, fellowships, 3-4 years experience, etc…)

• Speaking to my current position, nowadays institutions often require (or at least prefer) a PGY1 or decent experience in the area, or even both, though I can’t speak for everyone or every position that’s out there. A PGY2 wouldn’t hurt and may be required for further specialization at certain institutions, but it’s usually not needed for internal medicine in general. A PGY1 got me into hospital pharmacy, and then once I became BCPS certified plus more experience, I was able to sneak into my current role. For an interested new grad, I’d definitely recommend a PGY1, but know you may still have to gain some more experience for a specialist position. Again, I can’t possibly speak for every institution, and there are many different clinical pharmacist roles out there. Connections/relationships can go a long way, too.

4. Can you provide some background into how you found clinical pharmacy as your field of interest?

• Slightly embarrassed to say I got into pharmacy on somewhat of a whim, having decided on pharmacy school after going through my undergraduate studies. It certainly intrigued me, but I feel very fortunate that I ended up loving it. During pharmacy school, I wasn’t very interested in pursuing a residency at first. A friend basically dragged me along to meetings, special classes, and research projects geared toward the clinical side – he just didn’t want to go alone. I’m glad he did, because after my first APPE, I knew I wanted to at least be in hospital pharmacy. Residency then really helped me dive into this area and figure out what I wanted. So, I’d recommend keeping your mind and options open, knowing that your interests and passions will change over time. For example, I initially wanted to get into psychiatric pharmacy, while the aforementioned friend did not care for psych. He went on to work in that field and even precepted a psychiatric rotation.

5. What are some of the challenges you face as a clinical pharmacist?

• Quite a few, but there are always challenges in healthcare. Resource and personnel allocation can hold us back sometimes from doing the most optimal treatment and/or monitoring. Effective communication and collaboration across healthcare teams and providers often pose challenges. Attendings and consulting physicians often switch on and off the patient, and so getting everyone on the same page every day can be difficult at times. We’re also limited in general in what we can do. I certainly don’t wish I were a physician, but there are some things that I wish we had more authority to do (ordering certain labs, etc.). We do have MTS protocols for some things, such as pharmacokinetics, but protocols and policies can lag behind practice.

6. How can current students or pharmacists best prepare for a career in clinical pharmacy?

• There’s no substitute for experience. For students, outside of the usual studying, I would recommend choosing challenging APPE rotations. Some will be more stressful, difficult, and take up more of your time, but you will get much more out of it. It will make studying for the NAPLEX that much easier as well – for example: if you learn a lot on a challenging cardiology rotation, then you won’t have to study cardiology as much. For both students and pharmacists, a residency provides concentrated experience – some say it’s like cramming three years into one. Aside from that, however you can get the experience is useful, such as starting at a PRN position in a field you’re interested in. You learn and get your foot in the door at the same time. Additionally, staying up to date on literature is important as well. 

7. How do you keep up with the ever-changing literature and new medications coming to market?

• You can sign up for JAMA, NEJM, and other journals/organizations that will email you with updated literature and guidelines. This can be a bit much at times, as there’s so much always coming out, but you can pick and choose if a title or area strikes your interest. We also try to educate each other as much as possible. Anytime we learn new information that we find to be useful and/or affects our practice, we try to share it with each other at my institution. It’s not a competition when it comes to providing the best possible care. We also have students and residents complete presentations, journal clubs, etc., with current literature and new medications, so in those cases, it’s made easy for me.

8. What are some of the most common questions you are asked on the job?

• That depends on who’s asking the question. From nursing, the most common are: “Where is this medication?”, “Can I give these together?”, and “Can you fix this order for me?”. From providers, most questions revolve around home medication reconciliation, antibiotics (stewardship, coverage, length of therapy), and medication side effects contributing to the differential diagnoses. We are well-positioned and trained to complete optimal medication reconciliations, and while it’s seldom easy, figuring out just what a patient takes can be very useful to providers. Antimicrobial stewardship is not limited to ID specialists – hospital pharmacists are often leaned on to provide the optimal antimicrobial regimens (there’s no escaping ID in the hospital!). 

9. What is the biggest impact you think you have on patient care?

• I believe it’s really about being a second set of eyes in general, on each individual’s personalized care. We certainly make recommendations to improve a patient’s well-being, but more often than not, we’re there to prevent harm. As I’ve stated previously, with so many different providers involved in the care of a single patient, more things slip through the cracks than one would like to think. While it may make some uncomfortable hearing that, it’s really the main reason we’re on the team. It’s not always limited to pharmacotherapy, as well. I’ll spare you examples, but I feel we provide comfort to providers by being someone who’s hyper-focused on certain areas of care and watching their backs. 

10. What are your responsibilities/tasks during a typical workday?

• I’m responsible for reviewing and rounding on roughly 20 patients a day (though that number has been higher recently). Rounds are later in the morning, so patient workup with or without a student/resident essentially fills up my entire morning. However, it’s all about triaging the most time-sensitive issue in front of you. Morning pharmacokinetics may need to be handled right away if levels are out of range. Some other medication issues arise on the floor, and so assessing the urgency and organizing the day’s tasks based on urgency is important. In the afternoon, I’m typically completing home medication reconciliations, providing education, following up on any unresolved issues from rounds, attending local and health system meetings, assisting with or completing my own projects and presentations, and the list goes on. I rarely find myself idle or bored, which is what I like most about my current day-to-day. I’m also never above helping out in the central pharmacy or helping with medication distribution. It can’t be forgotten that our single most important function is getting the meds to where they need to be. All the clinical things that I like doing mean nothing if medications do not get to the patient in a timely manner. 

11. What are some helpful tips for everyday pharmacists to know about inpatient care?

• I’ll reemphasize my previous statement – know that above all that an effective medication distribution process is the most important thing. The following is true for most jobs and environments, but the ability to work as a team and communicate effectively is also key, especially when time is of the essence. Time management skills can be very important, but more specifically, triaging patient care issues. It’s important to be able to recognize when something simply cannot wait/when a patient’s life is potentially in the balance or harm could be imminent.  In a similar fashion, it takes some experience to tease out which patient care issues absolutely need to be addressed and which not to push on. The providers are ultimately the decision makers and bear most of the responsibility – we’re there to help and support. Other than that, just be ready to think on your feet and keep learning. I encounter situations every day where the information is scarce or processes are not well defined, and a decision has to be made with the best reasoning while keeping the patient’s well-being as the main focus.

The next three questions are more entertaining. Please answer some (or all) if you would like!

1. What is one book you would recommend to a friend?

• Just because the TV show made a comeback and seems quite popular again – Darkly Dreaming Dexter. I think the first book is excellent, though if you haven’t seen the show Dexter, then I advise caution (it can be graphic…).

2. Which two companies would you like to be sponsored by?

• Dick’s Sporting Goods and Amazon – I rarely shop anywhere else. 

3. Which pharmacy specialty is the best and why (not allowed to pick your own)

• I guess I’d say oncology – I appreciate all those who handle the chemo meds and issues, since I want very little to do with that area (unless I must).

*Information presented on RxTeach does not represent the opinion of any specific company, organization, or team other than the authors themselves. No patient-provider relationship is created.