Hospital pharmacy sometimes feels exclusive. It is not as accessible as community pharmacies on every high street. Instead, pharmacy students hear whispers of what it is like: greater application of clinical knowledge, a wider range of drugs and the chance to have more of an impact on patient care. But what is hospital pharmacy really like and how does it differ from community practice?
Nearly everyone admitted into hospital will have an acute condition that justifies the admission. But these patients do not leave their chronic diseases at the door. The corollary is that hospital pharmacists are exposed to a wider variety of conditions than those found in community. The conditions also tend to be more severe or unusual, which leads to a greater variety of medicines being used, many off-licence. Hospital pharmacists, therefore, develop a broader clinical knowledge base that is further developed by postgraduate training, which hospitals actively encourage their pharmacists to undertake.
It is this strong knowledge base that has earned hospital pharmacists a place as valued members of healthcare teams. Pharmacists are responsible for individual wards and, as a result, develop strong, productive relationships with other healthcare professionals on the ward.
A doctor or nurse is not hesitant to contact a pharmacist when they need advice and pharmacists are accessible. They are frequently on the ward or can be easily paged. Contrast this with community practice, where relationships with GPs are sometimes distant. GPs rarely call partly because, when they do, they may think they are hindering the pharmacist.
In hospital other pharmacists are available to ask for advice, unlike in community where there is often only one pharmacist per store. Availability of others helps in situations where pharmacists are expected to exercise their professional judgment.
To give one example, it was approaching the end of the day and the pharmacist was presented with a prescription for metoclopramide 20mg three times daily. A quick check of the British National Formulary will tell you that the dose should normally be 10mg three times daily. It was clear from the patient’s notes that she was undergoing chemotherapy. The pharmacist consulted with other pharmacist colleagues and dispensed the item because everyone agreed that it was in the patients’ best interest.
The role of technicians in hospital makes community technicians look shackled in comparison. In the hospital dispensary, most of the accuracy checking is completed by technicians. In most cases, once the pharmacist has done a clinical check, the prescription is whisked away by technicians to be dispensed and accuracy checked, never to be seen again by the pharmacist.
Ward-based technicians work on wards and complete the paperwork, check which medicines patients have brought with them into hospital and even take patient drug histories. In both cases, this frees the pharmacist to concentrate on the clinical aspects of medicine use.
Technology is used readily and much to the same effect as technicians in that it (theoretically) saves time. It has also been shown to improve safety. The hospital I was at had a robotic dispenser and electronic medicines management, and was just beginning to roll out electronic discharge and electronic prescriptions.
I would love to say that this all worked perfectly, but unfortunately it did not. I am sure the robotic dispenser spent more time broken than working while I was there. Electronic discharge seemed to cause more problems than it solved.
Part of the issue is that the different systems are not yet working as a synchronous whole. If you close your eyes you can easily imagine what it should be like and, with time, I am confident it will be like that. It is better to start somewhere than never start at all. It would be recklessly myopic to say it is not worth the effort, especially in light of future spending constraint.
In community chains, it sometimes feels as if those at head office issue diktats that employee pharmacists begrudgingly accept. In hospital, it feels as if policies are devised and implemented from the bottom up rather than top-down. As a result, everyone can justify why a policy exists and policies are more readily accepted. It also means there is less tension between management and staff.
The culture and ethos is different in hospital in that no one talks of “generating profits”. They, instead, talk of “realising savings”, which can be invested back into patient care. This obviously stems from the fact that hospitals are public sector organisations.
Hospital pharmacists are not harassed by targets in the traditional sense but they are encouraged to make savings, where possible. This can be, for example, by challenging non-formulary drug use or using plain common sense by not throwing general waste in the cytotoxic waste, which costs 10 times more to dispose of.
One thing hospital and community pharmacists unfortunately have in common is time constraint. As I have blogged about previously on PJ Online, a typical moment in a community pharmacy might involve someone on the telephone, having medicines use review targets to meet, out of stock drugs to source and five people waiting for their prescriptions to be dispensed. Hospital pharmacists could make an equally daunting list. I calculated with one hospital pharmacist that, on average, she has less than five minutes to spend with each patient.
It might sound like I have been rubbishing community pharmacy throughout this article but I do not mean to. I think community pharmacy has its own advantages to offer. One of which is that it provides the opportunity to develop long-term relationships with patients. The goal in hospital is to get people out as quick as possible, partly for the patient’s own benefit but also for reasons of cost.
You rarely have the opportunity to get to know patients at a more significant level than their medical history. Similarly, the pharmacy team is a lot larger in hospital and is, therefore, not as close-knit as in community stores.
Hospitals are not integrated into the community like high street stores. Public health campaigns are difficult to conduct and there is less of an element of being a source of general health advice as patients have nearly always just seen a doctor. Diagnosing minor ailments and offering over-the-counter advice is non-existent.
There is also a key differentiating factor that every pharmacy student knows about: money. Community pharmacists are paid more than their hospital counterparts. This certainly holds true in the early stages of a person’s career but less so in the later stages because there are more opportunities for progression in hospital pharmacy. You also have to consider the value you place on doing a job you enjoy versus one you do not.
Whether you pick community or hospital, it is important to remember that it is not a decision that you can only make once. It might be harder to make the shift from community to hospital than vice versa but it is still very much possible (see this article: Moving from the community to hospital). The advice one pharmacist gave who had done exactly that was to do it as early as possible.
Whichever you choose, hospital and community pharmacy each offer fulfilling careers. The most important thing is to make an informed decision so that you can head into your future with confidence.
ACKNOWLEDGEMENT Dan Grant, teacher practitioner at the University of Reading, for his suggestions and advice
Ranveer Bassey is a third-year pharmacy student at the University of Reading and a blogger for PJ Online
Citation: Tomorrow's Pharmacist | URI: 11080945
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The University of Waterloo's innovative pharmacy co-op program is designed to give students the opportunity to learn on the job and to apply their academic skills to the real world. It differs from summer jobs in that preceptors are required to teach students in more depth and show students the roles of pharmacists in a variety of environments, including community, hospital, governmental and research sectors. It is distinct from internships because students are able to experiment and determine which practice settings they might like to enter in their future careers. As a strict requirement in Waterloo's pharmacy curriculum, the co-op program has, to some degree, helped compensate for the summer job losses students have experienced over the past few years.
It was during the pursuit of my first co-op placement that the provincial governments began to ban the professional allowances paid to pharmacies. Since our first-year class was competing with third-year students for job placements, many pharmacies opted for the more experienced students to fill the few positions they had available. Yet, because Waterloo believes it is imperative for pharmacy students to gain on-the-job experience, the university enlisted co-op advisors to help their co-op coordinator find work for all the students. These advisors worked day and night searching for potential jobs all over the country and managed to find a placement for every student by the end of the term. Waterloo's dedication to the pursuit of quality pharmacist mentoring is inspiring.
Although I had only completed my first year in pharmacy at the time, I believed I had already gained many skills and much knowledge through my work experience in the community setting these past months. To me, this experience has been at least as valuable as the lessons I've learned through my academic studies. For instance, pharmacists have taught me about different pharmacy settings and how difficult it may be to shift from one to another, depending on your experience. Both community and hospital practice have their merits and I would be happy working in either, but I wouldn't be aware of the differences if I hadn't received this information from an experienced pharmacist.
My co-op experience in community pharmacy has taught me that pharmacists must be able to stay calm under pressure and work quickly and efficiently. My first shift was on an extremely busy night. At one point, I looked at my preceptor and noticed that he was cool and collected despite all the chaos around him. He radiated an aura of calm that helped me and the technician relax; he even managed to soothe some of the frustrated patients. The technician — a former nurse with 30 years of experience — was extremely competent and had the patience to teach me even though she was busily performing multiple tasks.
Communication is another key aspect of being a pharmacist, and the co-op work experience has contributed to my understanding of its importance in everyday practice. A pharmacist needs to know what kind of information and language is suitable for patients, physicians and fellow pharmacists. In the community pharmacy setting, I have improved my ability to listen to patients, as well as gather clues from their body language and unspoken meanings. I have learned several communication tips to use when dealing with difficult patients; the most important lesson, in my opinion, being “it's not what you say; it's how you say it.” Telling the patient that you “can't” or “won't” be able to help him will arouse aggravation, whereas telling him “we'll work on this” or “I'll have it done by this other time” can help calm him, while still communicating the message.
The work program has also allowed me to hone my academic knowledge in a practice setting and experience first-hand the effects of this knowledge on patient health. One pharmacist I work with regularly assigns me side projects intended to demonstrate patient-focused care. This includes situations requiring in-depth research on the patient's behalf. On one particular occasion, one of our diabetic patients was planning a trip to a tropical destination where he would not have access to a fridge for his insulin for at least a week. After completing my research, I found that insulin stored at 37oC did not significantly differ in blood glucose–lowering performance compared to insulin stored at 5°C.1 Regardless, the temperature at which insulin is stored should be kept as low as possible and I suggested that the patient store the insulin in a lunch bag that had a reflective coating on the inside and maintain a lower temperature using instant ice packs (so that the environment for the insulin would be kept cold when he needed it to be). Not only was the patient extremely thankful on the phone, he visited the pharmacy a few days later for the sole purpose of thanking me for my work. This particular project taught me something new about insulin's shelf-life and how to serve patients on a more direct level.
In addition to the skills I am developing through the co-op program, I have been given the opportunity to work with excellent pharmacists. One of them has won the Canadian pharmacist of the year award, mainly due to his MacGyver-like ideas and fierce intellect. I have learned a lot from him and his constant medication quizzes, such as what to do in certain situations and how to deal with tough cases. Without him, I would not know that we can request that doctors give samples of rosuvastatin to patients who do not possess sufficient funds or a drug plan or how pharmacists can act as a patient advocate, assisting with arranging coverage of expensive drugs. Pharmacists like him earn patient appreciation and improve patient quality of life through their deep reservoirs of knowledge and compassion. It is because of these mentors that I am compelled to learn as much as possible for the sake of my current and future patients.
The future of pharmacy is dependent on the competence of the next generations of pharmacists. Though co-op programs are not the only means of improving the quality of practice of future pharmacists, they are a major step in the right direction, providing pharmacy students with a better understanding of the pharmacy world.
1. Vimalavathini R, Gitanjali B. Effect of temperature on the potency and pharmacological action of insulin. Indian J Med Res. 2009;130:166–9.[PubMed]