Pharmacy News

Entries for April 2018

Writing Letters of Recommendation

By Laura Hencken, Pharm.D., BCCCP, clinical pharmacist, Henry Ford Hospital, Detroit

Writing letters of recommendation for students and residents can be a daunting task for both new and seasoned practitioners. This skill is not taught in school, and there are a number of unwritten rules that can impact a person’s ability to get an interview and possibly even influence their career.

Before writing a letter of recommendation, it is critical to be honest about your ability to provide a strong letter of recommendation for an applicant. For example, if you did not work with the applicant for very long, or if it was not a good experience, it is important to be honest with the applicant and tell them this. While it will be difficult to tell them “no”, it will be better for the applicant and the application recipients in the long-run.

A well-written letter of recommendation should be packaged in a particular format for the recipient to ensure that key elements are included. Letters are typically at least three paragraphs. Some consider the length of the letter to be an indication of the letter’s strength. Letters less than one page can be considered a red flag. The first, or introductory, paragraph should describe who you are, who the applicant is, how and for how long you have known the applicant. This will help the reader gauge why you are qualified to write the letter of recommendation.

The middle paragraph or paragraphs should include specific examples of the applicant’s performance and unique qualities or strengths of the applicant. In this portion, show don’t tell. In these paragraphs it is important to avoid exaggerating or providing overly vague and generic descriptions of duties that any applicant would perform. Middle paragraphs are also opportunities to voice concerns. For very strong candidates, weaknesses can be framed positively by stating what they improved on rather than stating things that were not done well. Lastly, the middle paragraphs can include program specifics that identify why a particular program or job is a good fit for the applicant, how it will allow them to meet their short and long-term goals as well as what the applicant will bring to the program.

Letters of recommendation should then end with a concluding paragraph that summarizes the key strengths of a candidate and the strength of the recommendation. Statistics may be included when applicable by saying that an applicant is among the top five percent of students.

Effective letters of recommendation include how and in what context an applicant is known, specific examples of how an applicant performed, activities, projects or accomplishments that make an applicant stand out compared to their peers and an estimate of how an applicant ranks compared to others. Meanwhile, ineffective letters are vague and generic, and describe typical rotation activities that all applicants would perform. Additional letter of recommendation details that could be detrimental to an application include not using professional letterhead, not using a real, hand-written signature and using “generic” or “form” letters.

Today, the process for residency letters of recommendation has changed through the use of the Pharmacy Online Residency Centralized Application Service (PhORCAS) standardized reference form, but the key principles for a good reference still remain. Writing generic examples or statements and typical rotation activities in the standardized form will result in a weak recommendation for an applicant. Meanwhile, use of specific examples from a rotation that is unique to an applicant’s strengths and abilities within the sections of the standardized form will result in a strong reference for the applicant. The PhORCAS applications may include a program specific section, in which case it is critical to highlight specific program qualities that make it a good fit for the applicant and how the program aligns with the applicant’s career goals.

Whether you are writing a letter from scratch, or completing the standardized PhORCAS reference form, knowing some of these key characteristics of strong reference letters provides an outline to ensure your letter provides the necessary information about an individual.  Using this outline will help ensure that an applicant gets the strong reference that you intend for them.

References:

1. Teaching Tomorrow’s Pharmacists. Midwestern University website. https://www.midwestern.edu/Documents/CCP%20CTE/CCP%20Teaching%20Newsletter%20-%20Fall%202013.pdf. Accessed April 2018.

2. Tips for Strong Letters of Recommendation. University of Central Florida College of Medicine website. https://med.ucf.edu/media/2012/05/Writing-Letters-of-Recommendation.pdf. Accessed April 2018. 

Posted in: Professional Practice
Single-Site Rotations: A Student’s Perspective

By Tricia Dyckman, Pharm.D. candidate 2018, Ferris State University College of Pharmacy, Big Rapids

 

The third year of pharmacy school is truly a transitional year. We begin applying what we learn and are thinking about the next step in our lives. I quickly discovered that hospital pharmacy was where I was meant to be and knew a residency was the natural next step. To adequately prepare, I wanted to make the most out of my rotational experiences. At the start of the year, there was talk of longitudinal advanced pharmacy practice experiences (APPEs) at nearby hospitals. Longitudinal APPEs were a new concept for me, but I thought they could be beneficial considering what I wanted out of rotations. Having been through a majority of the year, it is clear that there are both benefits and limitations to this type of experience.

 

There are many advantages to being at a single institution for all rotational experiences. First and foremost, there is a smaller learning curve at the beginning of each rotation, more time can be spent on patient care, and I learned a little something more on each rotation about the electronic medical record to apply to the next. Second, stronger relationships can be built with both preceptors and residents. The longer you are at one site, the more people you will meet and form personal relationships with. This can be extremely helpful if you are looking for strong letters of recommendation. Becoming familiar with everybody’s niches in the hospital also makes it easier to ask appropriate questions. Lastly, a longitudinal APPE experience prevents having to uproot every couple of weeks to a new location. I have heard of stories in which people were staying in motels or driving several hours to their rotation site. I was recently married this past year and wanted a stable home life during rotations. A longitudinal APPE experience is cost-effective and allowed us to live close to both mine and my husband’s work sites.

 

As with any decision made, there are some limitations to a longitudinal APPE. Because all of my rotations were at one site, I did not have the chance to see how other hospital pharmacies were run. I did not experience other electronic medical records. If I were to start a residency at a different location, there would probably be a longer learning curve until I became competent with their system. I was also limited to the preceptors at my institution. I did not feel as though this hindered my learning experience, but this could potentially be problematic elsewhere. Lastly, the location does not change every six weeks, which means there is never a fresh start. And if you determine that this longitudinal site is not the right fit, you must endure it for the rest of the year!

 

I believe the best way to determine if a longitudinal APPE site is right for you is to assess your career goals. What do you want to do after this year of rotation? Will the benefits of a longitudinal APPE experience contribute to your future plans? Once you establish the answers to these questions, the picture should be clearer. Regardless of your decision, though, rotations are the first steps into clinical practice, and you get out of them what you put in. It is important to make the most out of your experiences because they help you become the pharmacist you are meant to be!

Posted in: Member News
Regional Society Update: Southeastern Michigan Society of Health-System Pharmacy

By Neha Desai, Pharm.D., director of pharmacy, Beaumont Hospital, Dearborn, southeast regional representative

The Southeastern Michigan Society of Health-System Pharmacists (SMSHP) Board of Directors met in December to welcome new Board members and prepare for the upcoming year with discussions regarding committees and objectives. In January we had an educational activity for membership at The Gazebo in Warren. Cardiology pharmacy specialist Farzad Daneshvar, Pharm.D., BCPS presented: “Heart Failure Guideline Updates and New Therapies.” Dr. Daneshvar sought to educate on the recommended pharmacotherapy of heart failure as well as the financial burden associated with some heart failure therapies and patient outcomes. February’s continuing education program in Southfield was entitled “Evolving Arena of Hepatitis C Virus Treatment,” by speaker Nimisha Sulejmani, Pharm.D., BCPS. Dr. Sulejmani outlined the evolution of medications for treatment of hepatitis C as well as treatment regimens and monitoring. Both speakers were extremely knowledgeable in their respective areas and handled questions from the audience well. A big thank you to our speakers for providing valuable information to our membership!

On March 14, SMSHP had the honor of hosting the American Society of Health-System Pharmacists’ President-elect, Kelly M. Smith, Pharm.D., FASHP, FCCP. In addition to attending a dinner meeting with the SMSHP Board and Michigan Society of Health-System Pharmacists (MSHP) president Nancy MacDonald, Dr. Smith presented: "Avoiding Failure to Thrive: Towards a Resilient and Thriving Pharmacy Workforce" in Livonia. As one of the focuses of AHSP, Dr. Smith discussed information about clinician burnout and identifying strategies to impact well-being and resilience in pharmacists, pharmacy residents, student pharmacists and pharmacy technicians through the National Academy of Medicine Clinician Well-Being and Resilience Action Collaborative.

Nominations are being accepted for SMSHP’s annual exemplary resident continuing education (CE) presentation from residency programs in southeast Michigan with an outstanding CE presentation. The winning presentation will be presented at the September SMSHP meeting. SMSHP committee work during the first quarter of 2018 included the Communications and Constitution/Bylaws Committees. SMSHP continues to enhance its website functionality and is fully functional with LecturePanda for CE administration.

Monthly educational offerings will continue through May. For more information, visit our website at www.SMSHP.org

 

 
 
 
Posted in: Member News
COPD Management: Increasing the Breadth of Inpatient Pharmacy Impact

By Mike Kwiatkowski, Pharm.D., PGY1 pharmacy resident and Dave Sudekum, Pharm.D., BCPS, pharmacy specialist - internal medicine, St. Joseph Mercy Hospital, Ann Arbor

 

Chronic obstructive pulmonary disease (COPD) is a common respiratory condition characterized by persistent respiratory symptoms and airspace inflammation that leads to inadequate airway patency during expiration.1 Sixteen million Americans are currently diagnosed with COPD, and it is the third leading cause of death in the United States.2 The economic burden of COPD-related patient care was a staggering $32 billion nationally in 2010 with acute exacerbation accounting for over $13 billion of the annual cost.2,3 Upwards of 22 percent of American patients require rehospitalization within 30 days following an acute exacerbation despite estimations that 10 to 55 percent of rehospitalizations after index admission may be preventable.3 Factors associated with early rehospitalization include premature initial discharge, poor discharge medication reconciliation and lack of family education on the disease.3 Pharmacists are positioned throughout the healthcare system to influence and optimize care for patients with COPD.

 

In May 2017, the National Institute of Health (NIH) published a COPD National Action Plan, calling for a multi-faceted, unified battle against the disease. One of the goals of this plan is to improve the quality of care delivered across the healthcare continuum.2 This can be accomplished through implementation of clinical practice guideline recommendations and disseminating educational information to healthcare providers and patients, amongst other suggestions.2 For inpatient pharmacists, the greatest impact in COPD management can be leveraged through these two aims.

 

The assessment and implementation of guideline recommendations is paramount in the treatment of COPD for both maintenance inhaler regimens and acute exacerbations. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines stratify patients in groups A-D based upon airflow limitation, symptom burden and exacerbation history.1 Whether a patient is being treated for an acute exacerbation or is admitted with a chief complaint independent of COPD, a pharmacist should ensure the patient is receiving a guideline-recommended inhaler regimen. Expounding upon inhaler selection, consideration of patient-specific factors (i.e., inhaler experience, actuation-breath coordination, fine motor skills, inspiratory flow capacity, and pulmonary function, amongst others) should be evaluated to improve drug delivery and ease of use.4 For patients requiring multiple inhalers, selecting one delivery device (i.e., MDI only) may be beneficial to simplify administration.5 In the event of an exacerbation, pharmacists can assist in determining whether treatment with an antibiotic is appropriate through a review of the three cardinal symptoms: increased dyspnea, sputum volume and sputum purulence.1 For patients satisfying these criteria, treatment for five to seven days with an antibiotic selected based upon local bacterial resistance trends is suggested.1

 

Providing education and counseling on inhaler administration is crucial for COPD patients as up to 85 percent of patients on chronic COPD treatment use their inhalers ineffectively.5 The pharmacy adage of “drugs don't work in patients who don’t take them”6 can be altered for COPD patients to “drugs don't work in patients who don’t take them properly.” Throughout a hospitalization, inpatient pharmacists have the onus to educate their patients on proper administration technique. Given the time constraint of individually educating all COPD patients admitted at your institution, opportunities to expand your impact include:

  • Leverage pharmacy students completing rotations at your institution to provide inhaler education
  • Develop nursing in-service trainings to educate and empower nursing staff, particularly if COPD patients are clustered to a particular floor upon admission
  • Create a multidisciplinary COPD action team responsible for interacting with each COPD patient during admission

For patients with chronic inhaler use, allow them to demonstrate their technique and ability while providing any recommendations for improvement, if necessary. Various educational videos are available to assist in training efforts. Utilizing devices that objectively assess inhalation ability and technique may be the next strategy pharmacists could explore to address proper inhaler usage to ultimately improve patient outcomes.7 Clinical pharmacist-led programs centering around patient self-management and development of an individualized action plan for exacerbations (instructing appropriate management with antibiotics and oral corticosteroids) resulted in a 50 percent decrease in emergency department visits and a 60 percent decline in hospitalizations over a 12-month period.8


Through inhaler administration education, serving as a resource for COPD disease state information to patients and other medical providers, assisting with the management of acute exacerbations and developing programs within your institution, pharmacists can improve patient care and reduce COPD-related rehospitalizations.      

 

References:

  1. Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary. Am J Respir Crit Care Med. 2017;95(5):557-582.
  2. COPD National Action Plan. National Heart, Lung, and Blood Institute website. https://www.nhlbi.nih.gov/sites/default/files/media/docs/COPD%20National%20Action%20Plan%20508_0.pdf. Published May 27, 2017. Accessed March 7, 2018.
  3. Shah T, Press VG, Huisingh-scheetz M, White SR. COPD Readmissions: Addressing COPD in the Era of Value-based Health Care. Chest. 2016;150(4):916-926.
  4. Miravitlles M, Soler-cataluña JJ, Alcázar B, Viejo JL, García-río F. Factors affecting the selection of an inhaler device for COPD and the ideal device for different patient profiles. Results of EPOCA Delphi consensus. Pulm Pharmacol Ther. 2018;48:97-103.
  5. Vaughan Bourdet S, Brock K. Focus On COPD: Pharmacists Helping Patients Improve Outcomes and Reduce Readmissions. American Pharmacists Association website. https://www.pharmacist.com/focus-copd. Accessed March 7, 2018.
  6. Lindenfeld J, Jessup M. 'Drugs don't work in patients who don't take them' (C. Everett Koop, MD, US Surgeon General, 1985). Eur J Heart Fail. 2017;19(11):1412-1413.
  7. Hardwell A, Barber V, Hargadon T, Mcknight E, Holmes J, Levy ML. Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs). Prim Care Respir J. 2011;20(1):92-6.
  8. Khdour MR, Kidney JC, Smyth BM, Mcelnay JC. Clinical pharmacy-led disease and medicine management programme for patients with COPD. Br J Clin Pharmacol. 2009;68(4):588-98.

 

Posted in: Professional Practice
Valuing Pharmacists – Is it our Profession or our Healthcare System?

By Curtis Smith, Pharm.D., BCPS, FCCP, professor, Sparrow Hospital and Ferris State University, Lansing

 

This year, Michigan Society of Health-System Pharmacists (MSHP) President MacDonald chose “Demonstrating Our Value” as the MSHP theme. In February and March, John Clark and Dana Staat, respectively, wrote in the MSHP Monitor about the importance of advancing each of our practices, including the use of pharmacist extenders like pharmacy technicians and students. As I considered what to share related to the value of a pharmacist, my first thought was “aren’t we already valued?” Healthcare providers share with me all the time the importance and their appreciation of having pharmacists directly involved in patient care. And I don’t think that I’m unique in receiving these comments. So my next thought was: “Maybe we just haven’t documented our value.” But there are countless published articles about how pharmacists improve patient care and save money at the same time (just look at the March 2018 issue of Journal of the American Medication Association – Internal Medicine).1 In fact, the American Pharmacists Association has developed and published a document titled “Pharmacistdelivered Patient Care Services Evidence Examples” that reviews the evidence supporting pharmacist value.2

 

So what more do we need to do? Obviously continuing to advance our skills and market our services is important. We can also publish even more articles about the value of a pharmacist and loudly disseminate the results to legislators, administrators and other healthcare providers. But maybe the problem is not so much our profession or the lack of data demonstrating our worth, but rather our healthcare system.

 

We are in the midst of a major change in healthcare in the US from a primarily fee-for-service model to a value-based model of reimbursement. Although this shift has started, fee-for-service continues to dominate (in fact, the push for provider status for pharmacists was established and is still based on a fee-for-service model). Because of this, our healthcare system remains physician-centered, service-heavy, costly, and arguably, lacking in quality. In this model, pharmacists are frequently left behind.

 

In a recent editorial in the New England Journal of Medicine Catalyst, Kaplan and Blackmore argue that physicians have both actively and passively resisted moving to a value-based model of reimbursement. Physician organizations have also lobbied against a change to value-based payments. Kaplan and Blackmore suggest that this stance is misguided based on ethical, professional and business reasons. However, because of this resistance, as well as other reasons, changing our reimbursement model remains slow. In fact in 2017, policy uncertainty in Washington related to value-based reimbursement led to a noticeable slowing of healthcare organizations implementing key changes necessary to move from fee-for-service to value-based care.4

 

A move to value-based care and reimbursement will be a boon for pharmacists. With our knowledge and skills, we will be one of the most important healthcare providers to ensure quality outcomes in the U.S. population. Our enhanced presence in hospitals (including the transitions of care process), ambulatory clinics, patient-centered medical homes and community pharmacies will improve outcomes and patient well-being (we have the data to back that up!). So, we need to be an integral part of this shift and not sit on the sidelines. On March 5, 2018, the new Secretary of Health and Human Services, Alex Azar, re-ignited the shift to value-based care by stating that “today’s healthcare system is simply not delivering outcomes commensurate with its cost.” He stressed one of the biggest challenges is that the U.S. healthcare system is “paying for procedures and sickness” instead of “outcomes and wellness.”5 Also, on March 22, 2018, four representatives in Congress launched the Health Care Innovation Caucus. These representatives noted that “...with the healthcare industry rapidly transforming from a volume-driven system to one that rewards value and outcomes, it is vital that we maintain this acceleration by encouraging a marketplace of multiple payment models.” Their main focus will be “...to explore and advance successful, innovative payment models as well as the technologies needed to support these models.”6

 

So yes, it is vitally important to demonstrate our value – every day. But, it’s just as important that we are an integral part of the ongoing shift to value-based care and reimbursement. This year as you consider ways that you can demonstrate and document the value of your services, consider also encouraging your representatives in Congress to actively support the move to value-based care and reimbursement. The recent efforts pharmacy has invested in obtaining provider status should, just as importantly, continue in this area.

 

 

References:

1.Ravn-Nielsen LV, Duckert ML, Lund ML, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission: A Randomized Clinical Trial. JAMA Intern Med. 2018 Mar 1;178(3):375-382.

2. American Pharmacists Association. Pharmacistdelivered Patient Care Services Evidence Examples. American Pharmacists Association website. http://www.pharmacist.com/sites/default/files/EvidenceforPharmacistsServices2000-2016.pdf. Accessed March 29, 2018.

3. Kaplan GS, Blackmore C. Time to Sink the Two-Canoe Argument. NEJM Catalyst website. https://catalyst.nejm.org/sink-two-canoe-payment-models/. Accessed March 29, 2018.

4. Belliveau, J. Slow and Steady Still the Motto for Value-Based Reimbursement. RevCycle Intelligence website. https://revcycleintelligence.com/news/slow-and-steady-still-the-motto-for-value-based-reimbursement. Accessed March 29, 2018.

5. Remarks on Value-Based Transformation to the Federation of American Hospitals. U.S. Department of Health and Human Services website. https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/remarks-on-value-based-transformation-to-the-federation-of-american-hospitals.html. Accessed March 29, 2018.

6. Rep. Kelly Launches Bipartisan Health Care Innovation Caucus. U.S. Representative Mike Kelly website. https://kelly.house.gov/press-release/house-leaders-launch-bipartisan-health-care-innovation-caucus. Accessed March 29, 2018.

Posted in: Professional Practice
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