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Part ii-october 2002.pdf
in a Family Practice Residency Training Program
Adrienne Z. Ables, PharmD; Otis L. Baughman III, MD
Background: According to a recent survey, 27% of 579 family practice residency programs in the UnitedStates employ a full-time clinical pharmacist. The majority of pharmacists’ time is spent teaching, usuallyat the point of care either on inpatient rounds or precepting in the outpatient clinic. This paper describesthe precepting activity of a full-time clinical pharmacist in a community-based family practice residencytraining program.
Methods: A computer program written in Microsoft Access® captured the followingdata on each pharmacist-physician encounter: date, time, requestor, topic, therapeutic category, type ofquestion, summary of question and answer, resources used to answer the question, and time spent answer-ing the question. The database was updated daily to include all encounters.
Results: Between February 1,1999, and January 31, 2001, we documented 2,260 precepting encounters. Almost half of the questionsrelated to general pharmacotherapeutic management of chronic or acute diseases. The most commontherapeutic categories encompassed cardiovascular, psychiatric, infectious disease, and neurologic dis-orders. Seventy-six percent of questions were answered using clinical knowledge and experience, while24% were based on published resources.
Conclusions: Based on more than 2,000 precepting encountersbetween a faculty pharmacist and family practice residents, most encounters represented requests byresidents for information on general drug management of diseases. The pharmacist answered most ques-tions based on clinical knowledge and experience. Evaluations of the pharmacist by the residents indi-cated that she is an effective teacher and useful in helping take care of patients.
With the increasing numbers of medications brought
in 49% of the interventions, and there was an average
to the US market every year and the publication of nu-
cost avoidance of $154 per intervention. Mason and
merous studies on those medications, attainment and
Colley, in a study involving two general medicine clin-
application of succinct pharmacotherapeutic informa-
ics, showed that the number of potential drug problems
tion is a challenge. Clinical pharmacists are in a unique
identified per patient was significantly greater in a clinic
position to complement physicians in the application
without pharmacist intervention, while the number of
of evidence-based pharmacotherapy and cost-effective
beneficial interventions implemented was significantly
greater in a pharmacist-staffed clinic.2 A cost savings
The contribution of clinical pharmacists in ambula-
of $185 per intervention was calculated. Finally, a ran-
tory clinics has been described. Hatoum et al reported
domized, controlled trial of elderly outpatients taking
on 199 pharmacotherapeutic interventions made by four
five or more chronic medications demonstrated that
clinical pharmacists in 1 month.1 Types of recommen-
inappropriate prescribing decreased significantly in
dations included adding or changing a drug, changing
patients whose regimens were reviewed by and inter-
a dose, educating the prescriber, suggesting or discon-
vened on by a clinical pharmacist, and the patients ex-
tinuing laboratory orders, discontinuing a drug, clari-
perienced fewer adverse drug events.3 In all three of
fying or correcting a prescription, and changing a drug
the aforementioned studies, physicians accepted the
regimen. Positive patient outcomes were documented
majority of the pharmacist’s recommendations. Indeed,in a study by Haxby et al, family physicians found 97%of pharmacist consultations useful, and 77% of the phy-sicians believed that the consultation enhanced the clini-cal outcome of their patients.4
Fro m t h e Sp art an b urg Fam i l y Med i ci n e Res i d en cy Pro g ram ,Spartanburg, SC.
Special Articles: Pharmacists in Family Practice Residency Programs
In the early 1980s, involving clinical pharmacists in
precepting in the residency program’s outpatient clinic,
family practice residency programs was an innovative
the Center for Family Medicine (CFM). Residents in
trend.5 Pharmacists spent the majority of their time
the CFM come to the pharmacist’s office during their
teaching via formal lectures and providing drug infor-
assigned clinic hours with questions regarding patient
mation.6,7 They also provided direct patient care ser-
management as it relates to drug therapy. Each resi-
vices such as patient counseling, diabetic teaching, or
dent makes the decision about whether to review cases
patient monitoring. Since that time, clinical pharma-
with or ask questions of the pharmacist, depending on
cists have continued these roles with family practice
whether the resident deems it beneficial to do so. The
residency programs and now also develop comprehen-
pharmacist’s office is located in the patient care area of
sive pharmacotherapy curricula.8,9 According to a re-
the CFM and is readily accessible to residents as they
cent survey, however, only 27% of 579 family practice
residency programs in the United States employ a full-
In addition, the pharmacist provides drug informa-
time clinical pharmacist.10 The typical pharmacist in a
tion to the CFM faculty, residents, medical students,
residency training program holds a doctor of pharmacy
and nursing and laboratory staff; serves as a resource
degree and has completed a clinical pharmacy residency
for patient education; and is an intermediary for pro-
program. The survey indicates that, on average, phar-
fessional pharmaceutical sales representatives. She also
macists spend 43% of their time teaching, 37% in pa-
participates in scholarly activity and coordinates the
tient care, and 12% in research activities. Point-of-care
teaching takes place in the outpatient setting 59% of
The pharmacist provides direct patient care by phy-
the time and during inpatient rounds 38% of the time.
sician consultation only—ie, when specifically asked
None of the aforementioned publications specifically
describe the role of clinical pharmacists as preceptors.
This paper describes the precepting activity of a full-
time clinical pharmacist in the ambulatory setting of a
To document the precepting activity of the pharma-
family practice residency training program.
cist, we collected data and entered it into a Microsoft
munity-ba se d fa milypractice residency train-
ing program, with 12 ap-proved positions in eachof the 3 postgra dua teyears. The full-time fam-ily medicine faculty con-sists of nine family phy-sicians, one clinical phar-mac ist (PharmD ), oneclinical psychologist, andone substa nc e a busecounselor.
pharmacist in our pro-gram is responsible forteaching family practiceresidents and medical stu-dents about rational andcost-effective drug ther-apy. This is accomplishedvia formal lectures, par-ticipation in daily teach-
ing rounds on the inpa-tient service, small-group
Note—The categories run clockwise on the pie chart, ie, cardiovascular 29%, psychiatry 14%, infectious disease
Patient with NYHA IV heart failure and renal insufficiency with a SCr=3.9 mg/dl who presentswith major fluid overload and pulmonary edema. He also has hypertension and type 2 diabetesmellitus. Help with medication management.
How are formoterol (Foradil®) and salmeterol (Serevent®) different?
What is the dose of oral acyclovir (Zovirax®) for oral herpes?
Can valproic acid cause an increase in transaminase levels (LFTs)?
Does grapefruit juice decrease amiodarone (Cordarone®) metabolism?
Is there a generic enalapril/HCTZ combination?
Is it true that Glucotrol XL® is the same price as generic glipizide?
What is a white, round scored tablet with 5601 on one side and Dan on the other?
I have a patient on bupropion (Wellbutrin SR®), fluoxetine (Prozac®), and valproic aci d (Depakote®).
She discovered that she is pregnant. Are any of these drugs teratogenic?
Do you know who makes Premarin® and if they have a medication assistance program?
After beginning warfarin therapy in a patient with atrial fibrillation, when should I check in INR?
Please teach this patient how to use a metered dose inhaler.
Discussion of over-the-counter drugs for cold symptoms
How much lidocaine should be used to dilute ceftriaxone (Rocephin®) for pediatric use?
* Pharmacokinetics, toxicology, stabili ty/compatibili ty
NYHA IV—New York Heart Association classification system (functional class IV)SCr—serum creatinineLFT—liver function testHCTZ—hydrochlorothiazideINR—international normalized ratio
Access 97® computer file (Microsoft Corporation,
The content of the precepting questions was docu-
Redmond, Wash). Data included the following infor-
mented by examining whether the pharmacist reviewed
mation on each encounter between the pharmacist and
the patient’s underlying conditions and current medi-
health care providers: date and time, requestor name
cations, made recommendations for medication addi-
and type (eg, resident, faculty physician, nurse, etc),
tions/deletions or adjustments, and discussed monitor-
topic of the precepting encounter, therapeutic category,
ing parameters. Information about pharmacotherapeu-
type of question, summary of the question and its an-
tic management that was not related to a specific pa-
swer, resources used to answer the question, and time
tient was categorized as a drug information question.
spent answering the question. Data on topics of
Simpler questions on a side effect or drug interaction
precepting encounters were usually classified as a drug
were documented separately. The summary of the ques-
(listed by generic name), a drug class, or a disease
tion and its answer were entered into the database us-
state. Therapeutic categories were classified as shown
ing a free-text format. Resources used to answer the
in Figure 1. Questions not falling into one of these
questions were categorized as books, journal articles,
categories were labeled as “miscellaneous.” Question
types were summarized and classified in one of 16types (Table 1).
Special Articles: Pharmacists in Family Practice Residency Programs
An evaluation of all family medicine faculty mem-
The most commonly used resource used by the phar-
bers, including the clinical pharmacist, was distributed
macist to answer questions was personal clinical knowl-
to the residents for completion on a quarterly basis. All
edge and experience. Seventy-six percent of encoun-
evaluations were anonymous. Residents gave their com-
ters relied on such personal knowledge. Micromedex®
pleted evaluations to a faculty secretary, who entered
Healthcare Series (MICROMEDEX, Greenwood Vil-
the scores into a computer file. The cumulative report
lage, Colo) and Drug Facts and Comparisons
did not have any resident identifiers. Residents scored
TH, Noval KK, Schweain SL, eds) were the next most
the pharmacist on four characteristics (Table 2). The
common information sources, used in 13% of encoun-
ters, primarily for questions dealing with side effects
or drug interactions. The National Library of Medicine
Data analysis was performed via queries within the
was used 4% of the time for questions requiring litera-
Access program to document activity and look for
ture searches. Various other resources were used to
trends. Descriptive statistics are reported.
answer the remaining questions (7%).
Of a possible 288 evaluations, 33% were completed
Between February 1, 1999, and January 31, 2001,
during the study period. Residents’ evaluations of the
2,260 precepting encounters were documented. Close
clinical pharmacist, conducted every 3 months, yielded
to one third of questions asked by residents fell into the
a total average score of 28.75 out of a possible 30 points
cardiovascular therapeutic category (Figure 1). The
most common question type was about pharmacothera-peutic management (Table 1).
Family practice residents asked 84% of the 2,260
This paper describes the precepting role of a clinical
questions. Faculty physicians, registered nurses, and
pharmacist in a family practice residency program. The
students asked 11%, 3%, and 1% of questions, respec-
pharmacist serves as an on-site, evidence-based knowl-
tively. Licensed practical nurses and employees made
edge advisor to guide the residents in making decisions
up the remainder of the requestors. The proportion of
about drug therapy. Based on 2,260 encounters over
questions asked by residents increased in a linear fash-
2 years, the majority of advice related to pharmaco-
ion with postgraduate year, with first-, second-, and
therapeutic management (ie, how to manage medica-
third-year residents asking 14%, 34%, and 52% of the
tions in patients with multiple disease states, taking into
questions, respectively. The busiest times of the day
account effectiveness, safety, and cost). This finding
for the pharmacist were between 11 am–12 pm and 4–
points to the residents’ need for learning the practical
application of pharmacology on a daily basis. Cardio-
The average length of time spent per encounter was
va sc ula r thera pe utic s domina ted the re side nts’
7 minutes (range 5–90 minutes). Questions asked by
precepting encounters. This is not surprising, since es-
residents that took the pharmacist ≥ 30 minutes to an-
sential hypertension and heart disease are among the
swer were typically those categorized as pharmaco-
top 20 reasons for visits to physician offices in the
therapeutic management or drug information. The phar-
United States,11 and heart disease is the leading cause
macist spent between 30 and 90 seconds entering each
of death in patients >45 years of age.12 Other promi-
encounter into the database or about 10–15 minutes per
nent therapeutic categories of questions in this study,
including psychiatry, infectious disease, neurology, andendocrinology, are also among patients’ most impor-tant reasons for ambulatory care visits.11
The analysis of the data also showed an increased
number of questions as the residents matured into thethird year of training. The higher number of patient
Residents’ Evaluation* of the Clinical Pharmacist
contacts in the PGY-III year explains part of this in-
crease. The increase in encounters may also, however,
suggest the development of professional relationships
between the resident physician and the clinical phar-
macist or a greater awareness of the need for pharma-
The clinical experience and personal knowledge of
* n = 94** A higher number indicates a more desirable performance.
the pharmacist were the source of information for thelargest number of precepting encounters. While this may
make the pharmacist appear to be a non-evidence-based
Special thanks to James C. Ables, PharmD, for his expertise in database
source of information, reading and analyzing original
research articles, evidence-based clinical practice guide-
Address correspondence to Dr Ables, Spartanburg
lines, and systematic reviews and attending continuing
Family Medicine Residency Program, 853 N. Church Street, Suite 510,
education seminars continually enhance personal
Spart anb urg , SC 29 30 3. 8 64 -5 60 -15 07 . Fax : 8 6 4-5 60 -05 04 .
knowledge. This is likely similar to faculty physicianswho rely on their accumulated knowledge and practiceexperience when supervising and teaching family prac-
1. Hatoum HT, Witte KW, Hutchinson RA. Patient care contributions of
clinical pharmacists in four amb ulatory care clinics. Hosp Pharm
2. Mason JD, Colley CA. Effectiveness of an ambulatory care clinical
This study has limitations. Although every attempt
pharmacist: a controlled trial. Ann Pharmacother 1993;27:555-9.
was made to document each encounter, it is possible
3. Hanlon JT, Weinberger M, Samsa GP, et al. A randomized, controlled
that not all were entered into the database. In addition,
trial of a clinical pharmacist intervention to improve inappropriate pre-scri bi ng i n el derl y o ut pat i ent s wi t h pol yph arm acy. Am J Med
the results in our program may not predict results in
another residency program. Lastly, not all residents
4. Haxby DG, Weart CW, Goodman BW Jr. Family practice physicians’
completed evaluations of the pharmacist every quarter,
perceptions of the usefulness of drug therapy recommendations fromclinical pharmacists. Am J Hosp Pharm 1988;45:824-7.
which may have affected the cumulative score.
5. Geyman J P. Cli ni cal pharm acy in fami ly practice. J Fam Pract
6. Love DW, Hodge NA, Foley WA. The clinical pharmacist in a family
practice residency program. J Fam Pract 1980;10:67-72.
Based on more than 2,000 precepting encounters
7. Johnston TS, Heffron WA. Clinical pharmacy in family practice resi-
between a faculty pharmacist and family practice resi-
dency programs. J Fam Pract 1981;13:91-4.
dents, most encounters represented requests by resi-
8. Shaughnessy AF, Hume AL. Clinical pharmacists in family practice
residency programs. J Fam Pract 1990;31:305-9.
dents for information on general pharmacotherapeutic
9. Bucci KK, Frey KA. A description of a pharmacotherapy curriculum in
management of diseases. The pharmacist answered
a universi ty-b ased famil y m edicine prog ram. Ann Pharmacoth er
most questions based on clinical knowledge and expe-
10. Dickerson LM, Denham AM, Lynch T. The state of clinical pharmacy
rience. Evaluations by the residents indicated that a
practice in fami ly practice residency p rograms. Fam M ed 200 2;
pharmacist can be an effective teacher and useful in
11. Cherry DK, Burt CW, Woodwell DA. National ambulatory medical care
survey: 1999 summary. Advance data from Vital and Health Statistics,no. 322. Hyattsville, Md: National Center for Health Statisti cs, 2001.
This paper was presented at the Society of Teachers of
12. Communi ty health status report. Spartanburg County, SC: US Depart-
Family Medicine 2001 Annual Spring Conference in Denver.
ment of Health and Human Services, July 2000.
http://www.eps1.comlink.ne.jp/~mayus/eng/ Commercial cows’ milk has estrogenic activity as revealed by the hypertrophic effects on the uteri of young ovariectomized rats and immature rats Ganmaa D, Tezuka H, Enkhmaa D, Hoshi K, Sato A. Commercial cows’ milk has uterotrophic activity on the uteri of young International Journal of Cancer 2006;118:2363-65. Abstract Cows’ mil
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