PharmacyForward

John Gums, PharmD, FCCP - Professor and Associate Dean for Clinical and Administrative Affairs - and Eric A Dietrich, PharmD, BCACP, CPC-A, CEMC, CPB - Clinical Associate Professor from the University of Florida College of Pharmacy talk with us about billing for pharmacy services. Key Lessons: A sustainable clinical practice model is formulated by creating a business plan that considers the services to be provided as well as reasonable estimates of the number of patient encounters, the duration for each patient encounter, billable revenues, collections, and costs.  Evaluation and Management (EM) codes are used to bill services.  The complexity of the patient encounter characterizes the "level" of service, ranging from level 1 (minimal complexity, self-limiting problem) to level 5 (High, Chronic Conditions, Severe Exacerbation, Disease Progression). Comprehensive medication management services provided by pharmacists are typically billed by a recognized provider (physician / nurse practitioner) using an "incident to" billing method. Pharmacists can also bill for transitional care management (TCM), chronic care management (CCM), and annual wellness visits (AWV) - but each of these services must meet specific conditions and requirements under Medicare Part B. Learning to speak the language of billers and coders is critically important. Consider training or certification through the American Academy of Professional Coders (AAPC) There is a significant difference between what is billed and what is collected. Pharmacists should track their time, number of patient encounters, billable units of services, and collections to determine if their initial estimates are correct.  When there are discrepancies, determine the sources and address the causes. Check out these guidelines and resources on how to develop a business-practice plan and bill for pharmacists' patient care services: American College of Clinical Pharmacy (ACCP) - Developing a Business-Practice Model for Pharmacy Services in Ambulatory Care Settings American Association of College of Pharmacy (AACP) - Integration of Clinical Pharmacy Faculty in Professional Practice Care Settings National Council for Prescription Drug Programs (NCPDP) - Billing Guidance for Pharmacists' Professional and Patient Care Services

Lucinda L. Maine, Ph.D., R.Ph. - Executive Vice President and Chief Executive Officer of the American Association of Colleges of Pharmacy - talks with us about how to manage major career changes and why a degree in pharmacy is so valuable. Key Lessons: Career pivots can be welcomed and sought ... or arise from something unexpected and unwanted. Most professionals will experience several major career changes during their working years. A pharmacy degree enables a surprisingly broad range of career paths. Being prepared for new opportunities by continually updating your knowledge and skills is critical. Having the financial resources available to obtain additional education, training, or experience is an essential career insurance policy. Active engagement in professional pharmacy associations, at both the state and nation level, provides a great way to network and keep current with the latest trends. Many people, especially women, are reluctant to make a major career change without having "all the necessary" credentials and experiences.  But consider what is essential ... you can learn the rest on the job. Several resources are available to help you explore the career options that align with your strengths, skills, and interests: Check out the American Pharmacists Association Career Pathway Evaluation Program and ADVANCE for continuing professional development Coming Soon! AACP-APhA National Pharmacy Internship network

Cynthia Knapp Dlugosz, BSPharm, NBC-HWC - Solopreneur and Owner of Being in Balance Coaching and Artemis Health Care Communications - and Elizabeth Buckley, PharmD, CDCES - Professor, Department of Pharmacy Practice, Concordia University Wisconsin — talk to us about threats to our well-being and self-care practices. Key Lessons: We are surrounded by stressors that adversely impact our sense of well-being. The ubiquitous use of technology has increased the demands on our attention. The pillars of well-being based on research from the Center for Healthy Minds at the University of Wisconsin-Madison are: Awareness, Connection, Insight, and Purpose. Much of our dissatisfaction and psychological suffering stems from our desire to push away or change the unpleasantness in our lives. Mindfulness is a state of being where we are attentive in the present moment with receptivity, non-judgment, and compassion with what arises. Meditation and yoga are practices that cultivate our ability to be mindful - our ability to be more attentive, receptive, less judgmental, and compassionate. Gratitude increases our happiness. Those with the least material wealth are often able to recognize and express gratitude for the blessings in their lives but anyone can learn to be more grateful. Health professionals feel acutely stressed today because the environmental demands are beyond their ability to successfully cope due to unpredictability, uncontrollability, and overload. Organizations have a responsibility to implement strategies to address the environmental demands and the underlying causes of stress. Resources and Books: Center for Healthy Minds, the University of Wisconsin-Madison Brown B.  Atlas of the Heart.  Mapping Meaningful Connection and the Language of Human Experience.  New York: Random House, 2021. Moss J.  The Burnout Epidemic: The Rise of Chronic Stress and How to Fix It.  Boston: Harvard Business Press, 2021

Bruce Berger, Ph.D. - Berger Consulting LLC and Professor Emeritus, Auburn University - and Col. John D. Grabenstein, R.Ph., Ph.D. - Vaccine Dynamics SP - talk with us about treatment hesitancy, its root causes, and how health professionals can engage patients in treatment decisions more effectively. Key Lessons: Treatment and vaccine hesitancy is often grounded in inadequate information, changing information (leading to doubt), personal beliefs,  misinformation, distrust (of the health care professional's motivations), and (sometimes) apathy.  Actively soliciting and listening to a patient's concerns is the key to understanding the sources of doubt and hesitancy. Confrontation and dismissing a patient's understanding will cause "face loss" and lead to more resistance, not less. Monologues about "the facts" are not helpful. It is important to ask permission and then gently offer new information for the patient to consider. The patient is always driving the bus and all treatment decisions rest with them. The goal should be to become a trusted advisor who's always on the patient's side. It may take some patients several months (or even years) to arrive at a decision to start a new treatment or receive a vaccine. Our words can alienate a patient and sever a relationship. This is perhaps the worst possible outcome because it prevents us from having a positive influence in the future. Want to learn more about motivational interviewing and vaccinations?  Be sure to check out these resources:  Immunization Action Coalition (www.immunize.org)  ComMIt - Comprehensive Motivational Interviewing (MI) Training  eLearning MI Training for Health Professionals - Purdue University  Berger B.  Using Care and Compassion to Respond to Vaccine Hesitancy.

Andrew Taynor, Pharm.D., BCPS - Professor and Assistant Dean for Experiential Education at the University of Minnesota - and Brent Reed, Pharm.D., BCPS - Associate Professor at the University of Maryland and Doctoral Student in Organizational Sciences at UNC Charlotte - talk to us about job satisfaction. Key Lessons: Autonomy, mastery, and purpose contribute to our motivation and energy level ... and increase our sense of satisfaction from our work. Finding your "why" and being passionate about your work is helpful but doesn't account for the small, everyday things (tasks) that make the work fulfilling.  The job demands-resources model helps to explain why some jobs are more satisfying (or conversely dissatisfying) than others.  Do you have the right resources to meet the challenges and hindrances in your work? The pebbles in your shoes can really make a big difference in terms of your satisfaction with your job. Job satisfaction is not just about individuals learning to be more resilient and productive but it's also about the organization addressing the hindrances and providing sufficient resources to meet the demands of the work. High employee turnover and customer dissatisfaction can be "red flags" that the work environment may be problematic. Being self-aware - understanding your strengths and values - is important to finding employment that's a good fit. Try to get/set realistic expectations when entering a new job by getting an honest "preview" of the work. Job crafting can help an employee shape the work to make it more satisfying — finding new challenges, removing hindrances, and seeking resources.

Special Host Timothy Bloom, Ph.D. - Associate Dean of Academic Affairs and Associate Professor, Bernard J Dunn School of Pharmacy, Shenandoah University  - and Guests Heather Petrelli, MA, Ph.D. - Associate Dean of Students Affairs, Taneja College of Pharmacy, University of South Florida - and Teresa O'Sulliavan, Pharm.D. - Director of Experiential Education Scholarship and Metrics, School of Pharmacy, University of Washington - talk with us about how faculty can facilitate professional identity formation. Key Lessons Faculty and preceptors play a critical role in students' formation of their professional identity. Colleges/schools are now beginning to introduce the concept of professional identity to their students and faculty. Experiential education and practice-based experiences are critical to professional identity formation. Preceptors and faculty can promote reflection by asking questions about authentic practice-based experiences. Explore the why - what is the motivation?  Help students to identify their values, their future goals, and how their (current) behavior reflects (or fail to reflect) those values and goals.  Use motivational interviewing strategies to create cognitive dissonance when appropriate. Early and authentic practice experiences are important. Conversations with students about their journey toward "feeling like a pharmacist" can prompt reflection. Assessing professional identity formation is a major challenge. How will we know if the curriculum is building professional identity and preparing students well?  This is an area ripe for new evaluation models and scholarship. For more information about professional identity formation, read the Report of the 2020-2021 AACP Student Affairs Committee: A Pathway to Professional Identity Formation

Special Host Eric G. Boyce, PharmD - Professor of Pharmacy Practice, University of the Pacific Thomas J. Long School of Pharmacy - and Guests Alex N. Isaacs, PharmD, MS, BCPS - Clinical Associate Professor, Purdue University College of Pharmacy - and Sally A. Arif, PharmD, BCPS, BCCP - Associate Professor, Midwestern University College of Pharmacy, Downers Grove - talk with us about professional identity formation, people and events that influenced their professional identity, and the importance of reflection. Key Lessons Our identities are who we are and aren't easily changed (but can and do evolved over time) Our lived experiences have a significant influence on our professional identity Role models and mentors play a critical role in our professional identity formation Emotional experiences have a powerful effect in shaping our beliefs and motivations Reflection and introspection can help us solidify and clarify our values and beliefs Developing a regular and ongoing reflective practice can help us think through challenges and plan for the future so that we are clear about our purpose and what aspire to be For more information about professional identity formation, read the Report of the 2020-2021 AACP Student Affairs Committee: A Pathway to Professional Identity Formation

Special Host Kristin Janke, PhD - Senior Associate to the Dean and Professor, University of Minnesota College of Pharmacy - and Special Guests Jessica L. Johnson, PharmD, BCPS - Associate Professor, William Carey School of Pharmacy - and Karen Kopacek, BPharm, MS - Associate Dean and Associate Professor, University of Wisconsin School of Pharmacy - talk with us about professional identity formation, how our identities are formed, and why they are important. Key Lessons Our identities shape our sense of self ... which influence our values, beliefs, and actions All of us have multiple identities ... including a professional identity Professionalism and professional identity are related but distinct concepts Students and residents may feel uncomfortable or experience identity conflicts as they form their professional identity — assimilating the values and norms of the profession Our professional identities are developed through interactions with colleagues and mentors A strong professional identity can help counterbalance work stressors and negative emotions that lead to burnout For more information about professional identity formation, read the Report of the 2020-2021 AACP Student Affairs Committee: A Pathway to Professional Identity Formation

Charmaine Rochester-Eyeguokan, PharmD, BCACP, CDCES - University of Maryland School of Pharmacy - and Jeffrey Tingen, PharmD, MBA, BCPS, BCACP, CDCES - VCU Health, Department of Family Medicine & Population Health - talk to use about the ins and outs of collaborative practice agreements. Key Lessons Collaborative practice is governed by state law and regulations; it is important to be familiar with the specific rules for constructing collaborative practice agreements (CPA) in your state. Many states require pharmacists to have specific training and experience in order to enter into a CPA - but some states have relatively few requirements or none at all. CPAs are useful tools to enable greater efficiency by granting the pharmacist greater autonomy to carry out certain patient care functions; however, a CPA is not required to perform many functions that are ordinarily a part of a pharmacist's scope of practice. It's important to have a significant level of rapport and trust with your providers crafting a CPA together. While CPAs are fairly common in ambulatory clinics, they are a potentially useful tool in community pharmacy practice, long-term care facilities, and specialty pharmacy practice. To learn more about collaborative practice and CPA, check out the Collaborative Practice Resource Page on the iForumRx.org website.

Alan J. Zillich, PharmD — William S. Bucke Professor and Head of the Department of Pharmacy Practice, Purdue University College of Pharmacy — talks with us about getting your work published; from identifying great ideas, collaborating, writing, and revising your manuscript. Key Lessons: From review articles to meta-analyses, from case reports to observational studies and controlled trials, getting your work published is immensely gratifying.  But it requires many months (and sometimes years) of effort. Working with a mentor who has experience producing scholarly work and getting published is a great first step. Good research questions arise from practice.  When there are gaps in our knowledge, that's where a scholarly project that's potentially publishable often emerges. Working with an authoring team - bringing together people with different skills - can really improve the quality and rigor of your scholarly work. Use explicit criteria to determine who qualifies as an author on a paper.  Be sure to acknowledge those who contributed but not meet the definition of author. Finding the "right" journal for your work is important.  Each journal has a different audience and mission. Getting rejected is part of the process. The feedback from peer reviewers can be extremely helpful and you are one step closer to getting published.   Beware of predatory journals (who don't provide a rigorous peer review but still charge high publication fees). Blocking time in your schedule to regularly engaging (at least weekly) in scholarly activities - researching and writing - is critical to success.  Make an appointment with yourself. Unfortunately, this might require early mornings, evenings, or weekends if you can't negotiate the time into your workday.

Jessica Louie, PharmD, BCCCP — president of Clarify Simplify Align, the host of the Burnout Doctor podcast, and Associate Professor of Pharmacy Practice at West Coast University — talks to us about developing a meaningful side gig to reinvigorate your passions. Key Lessons: Every career has ups and downs ... and health care professionals are prone to burnout.  Burnout is a syndrome of emotional & physical exhaustion, cynicism about work, and a lack of a sense of personal accomplishment. Overcoming burnout takes time to address -  examining your emotional, physical, and spiritual needs. Learning how to "own" your time and being intentional with your energy is critically important. Starting a small business can be very gratifying so long as the activity aligns with your core values and passions. The ten pillars of life can enhance one's sense of wellbeing.  A meaningful side gig can enhance the sense of wellbeing by address several of the life pillars. Surround yourself with like-minded people who are interested in or who have successfully developed a side gig. Be mindful of the big transitions in life - to minimize stress, whenever possible, limit your attention to one major life event at a time. Starting a side gig will require a significant time commitment but you can manage it by using time blocking and simplifying. You can download the Burnout Starter Kit to learn how to clarify, simplify, and align your life.

Christie Nemoto, PharmD, BCACP - Clinical Pharmacy Specialist in The Queen's Health Systems - Queen's Clinically Integrated Physician Network (QCIPN) - talks to us about providing care to patients at a distance and creating an effective work environment at home. Key Lessons: Health professionals had to learn new skills in order to deliver care to patients and interact with colleagues at a distance over the past year.  Remote work became the new norm during the COVID-19 pandemic. Clinical care models in Hawaii have evolved over the years to support patients at a distance.  Hawaii is an archipelago of islands and access to health care services is enabled by a variety of technologies. Pharmacists play a critical role on the healthcare team, even more so in the digital age. Remote communications with patients are challenging - particularly written patient education sheets and post-visit summaries. Clinicians need to rely on verbal clues (rather than visual clues) to ensure patient understanding. When working from home, it's important to create habits and routines that mimic your work at the office such as dressing professionally, starting and stopping the workday in normal work hours, creating a designated workspace, and setting ground rules with family. Be creative using remote activities to increase bonding and consistent communication between team members.

Donald Klepser, Ph.D., MBA - Professor and Associate Dean for Academic Affairs at the University of Nebraska Medical Center College of Pharmacy - and Michael Klepser, Pharm.D. - Professor of Pharmacy Practice at Ferris State University College of Pharmacy - talk to us about the role of point-of-care testing in disease state management and to achieve public health goals. Key Lessons: Point-of-care tests (POCT) can be performed in non-laboratory settings, such as the patient's home or in a community pharmacy, and provide clinical data to make treatment decisions. The sooner test results can be made available, the sooner treatment can be initiated.  This is particularly important for many infectious diseases because the outcome is closely tied to how rapidly the treatment is started. When deployed in community-based pharmacies and clinics, POCTs help increase access to care, particularly in rural and underserved areas. POCT can be used to test for influenza, SARS-CoV-2 (aka COVID-19), Streptococcal pharyngitis (aka strep throat), human immunodeficiency virus (HIV), and other sexually transmitted infections as well as monitor serum lipids, serum electrolytes, and renal function. Under a collaborative practice agreement (CPA), community pharmacists can use the results of POCT to quickly initiate treatment or adjust the doses of medications. POCT empower pharmacists to provide a range of health-related services. Student pharmacists can play a critical role in building our capacity to deploy POCT and provide disease management services in new locations. Key opportunities for the future: PrEP (pre-exposure prophylaxis) to prevent HIV Hepatitis C infection Sexually transmitted infections panel Lead exposure

Amanda Schartel, PharmD, BCACP - Clinical Pharmacy Specialist with ChristianaCare CareVio - talks with us about the roles and responsibilities of a population health pharmacist. Key Lessons: Population health involves holistically evaluating the health needs of a population and bringing together the resources and expertise needed to address those needs. Population health teams often include practitioners that many patients in primary care settings don't ordinarily have access including social workers, respiratory therapists, and clinical pharmacists. Sophisticated data analytics and remote monitoring tools help population health practitioners proactively identify patients who may need additional services or whose health status may be changing. Patient encounters are often conducting using videoconferencing technology and text-messaging can quickly capture patient experience data.  The role and responsibilities of the population health pharmacist often extend beyond what an ambulatory care pharmacist might address. Population health pharmacists often have the authority to adjust medication regimens and order laboratory tests. Residency training and board certification are not required but preferred for those seeking employment as a population health pharmacist.  The key skill sets needed by a population health pharmacist include patient management experience addressing complex medication-related issues as well as a deep knowledge of quality metrics and value-based payment structures.

Rear Admiral (RADM) Pamela Schweitzer - retired Chief Professional Officer of Pharmacy for the United States Public Health Service (USPHS) - talks to us about the roles and responsibilities of pharmacists during a public health crisis.  Dr. Schweitzer was responsible for providing leadership and coordination of USPHS pharmacy programs for the Office of the Surgeon General and the Department of Health & Human Services from 2014-2018. Key Lessons: Pharmacists play a critical role in the USPHS because they have a unique skill set. A pandemic, like COVID-19, requires a coordinated effort between the public and private sectors to address mass vaccination efforts as well as shortages of medications, testing, and personal protective equipment. Behind the scenes, USPHS pharmacists are deeply involved in policy development.  Recent policy changes have empowered pharmacists to vaccinate children to meet an unmet public health need. Pharmacists in the USPHS must wear many hats. While formal training is helpful, getting a wide breadth of on-the-job experiences is critical. Be curious. Learn new skills in every position/job. Be flexible and positive. Be comfortable with shifting conditions. Step up, speak up, and volunteer.  Act when you can.  Be a role model. If you'd like to get more involved, consider volunteering with your local Medical Reserve Corps or becoming a Commissioned Officer in the USPHS.

Ashley Barlow, PharmD (MD Anderson Cancer Center) & Brooke Barlow, PharmD (University of Kentucky Chandler Medical Center) - @theABofPharmaC and PGY2 Pharmacy Practice Residents - talk to us about developing their professional brand using Twitter and why creating an online presence can help you achieve your career goals. Key Lessons: Social media, especially Twitter, has become an increasingly important forum for connecting with professional colleagues and engaging in dialog about cutting edge issues that impact patient care and pharmacy practice. To get started, read this brief article by Robert Pugliese entitled How Twitter Has Made Me a Better Pharmacist. Consider maintaining separate professional and personal social media accounts. Instagram, Facebook, LinkedIn, and Twitter are the most commonly used social media platforms for professional networking purposes. Everyone should purposefully develop their professional brand online.  Your digital footprint ultimately reflects your reputation. Your online persona is perhaps the first and most important impression that others with have of you. Think about the ABCDEs of your social media presence. A - align your social media with your professional goals.  B - build your profile with a professional bio and photo.  C - curate the content you find interesting and important.  D - define your audience.  E - engage in conversations ... be sure to like, comment, and retweet! Your online network through social media can lead to many new opportunities. Get the Social Media Infographic by Ashley and Brooke Barlow (@theABofPharmaC)

Dave L. Dixon, PharmD, BCACP, BCPS, CDE, CLS  - Virginia Commonwealth University School of Pharmacy and - Brent N. Reed, PharmD, BCPS, BCCP  - University of Maryland School of Pharmacy - talk with us about using social media for professional development and staying current with the latest evidence to support your practice. Key Lessons: Social media includes a wide range of online applications intended to interact with other users in a public setting. Social media, especially Twitter, has become an increasingly important forum for connecting with professional colleagues and engaging in dialog about cutting edge issues that impact patient care and pharmacy practice. Social media use should be done in a systematic, thoughtful way - you need to decide what your goals are, who to follow, and how frequently to check your social media feeds. Being a passive recipient of social media posts (aka being a "lurker") is a great way to get started but eventually, you may wish to share and comment on content you find valuable ... as well as create your own original content. Learning how to curate your social media feed can help prevent information overload. Following a professional conference (and the people attending) on Twitter can enhance the conference experience and enable those who are not able to attend the conference to learn about what's happening. Engaging in social media can be personally and professionally rewarding.  Share your personality!  It should be fun. Get the Social Media Infographic by Ashley and Brooke Barlow (@theABofPharmaC)

Casey Tak, PhD, MPH - University of North Carolina Eschelman School of Pharmacy and - Karen Gunning, PharmD, BCPS, BCACP - University of Utah College of Pharmacy - talk with us about hormonal contraception and how pharmacists in community and ambulatory care settings can increase women's access to care. Key Lessons: A variety of contraceptive methods have been available through pharmacies for decades but many states now permit pharmacists to directly "provide" hormonal contraception without a prescription. A state-wide standing order is the most common mechanism for authorizing pharmacists to provide hormonal contraception directly to patients, but state laws and regulations vary. The CDC Guidance for Healthcare Providers - US Medical Eligibility Criteria do not require a woman to have a pelvic exam prior to receiving hormonal contraception. The pharmacist needs to ask about and document the patient's medical and medication history, take the patient's blood pressure, and inquire about contraceptive preferences before providing hormonal contraception. Some states require pharmacists to refer patients to a primary care provider to receive recommended preventive care, such as pelvic exams, breast exams, and Pap smears.  Even when this is not required by state law, it's a best practice to ensure all women are receiving appropriate health maintenance services. Insurance coverage for pharmacist-provided hormonal contraception is not universal - many private insurance plans do not cover the cost of hormonal contraception or compensate for the pharmacist's time.  However, Medicaid programs often do (varies by state). Increasing access to hormonal contraception is good public policy because it can positively impact Medicaid costs by reducing unintended pregnancies, high-risk pregnancies, and infant mortality. Student pharmacists can (and have) played an important role in advocating for pharmacist-provided hormonal contraction.

Kristin Wiisanen, PharmD - Clinical Professor and Director of the Graduate Program in Precision Medicine at the University of Florida College of Pharmacy - talks with us about using genomics to guide therapeutic decisions. Key Lessons: Precision medicine and personalized medicine are synonymous terms. Pharmacogenomics is a tool to personalize treatment decisions.  However, it is not the only tool.  Other readily available and routinely collected clinical information has been used to personalize therapy for decades (e.g. blood type, serum creatinine, CV risk score). While creating a separate pharmacogenomic service can help ease practitioners into using pharmacogenomic tests, learning how to integrate genetic information as a routine part of clinical decision-making is the ultimate goal. Pharmacists have a unique role (and responsibility) to know when and how to use the results of pharmacogenomic tests. Teaching students, residents, and fellows to use pharmacogenomic information should be done in an integrated manner - considered alongside other clinical data, not in isolation. Several excellent resources now exist that can assist pharmacists and other providers use the results of pharmacogenomic tests including the Pharmacogenomics Knowledge Base (PharmGKB) and the Clinical Pharmacogenetics Implementation Consortium (CPIC) Guidelines.

Lucas Berenbrok, PharmD, BCACP, TTS - Assistant Professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy - talks with us about hearing loss and the important role pharmacists can play as OTC hearing aids become available in 2020. Key Lessons: Most older adults have some degree of hearing loss and it can significantly impact the quality of life There are many causes of hearing loss including medications, infections, cerumen, and aging A screening exam for hearing impairment is part of the Welcome to Medicare Exam, but hearing aids are not covered by Medicare. OTC hearing aids are predicted to be a far more affordable option for patients with mild-to-moderate hearing loss. Pharmacists have an important role in assessing patients and referring them to an audiologist for hearing exams. Pharmacists can assist patients select an appropriate OTC hearing aid To find an audiologist: American Academy of Audiology

Cheyenne C. Newsome, PharmD, BCACP and Jessica Conklin, PharmD, BCACP, CDE, AAHIV — passionate advocates for the role of pharmacists in the care of transgender persons — talk with us about the need for patient and provider education and about the benefits and risks of gender-affirming treatment. Key Lessons: Gender-affirming therapy is highly effective, improving the quality of life in more than 80% of patients. Hormonal therapy is the cornerstone of gender-affirming therapy.  Testosterone is used for masculinization by trans-men.  It is traditionally given by intramuscular injection but subcutaneous injections are easier to administered and may have a smoother effect (e.g. lower peak effect).  Side effects from testosterone are common including body and facial hair growth (you don't get to pick!), deepened voice (irreversible), clitoral enlargement, acne, menstrual irregularities, and weight gain from increased appetite. Estradiol (preferred estrogen) is used for feminization by trans-women. In addition, spironolactone is used in high doses for its anti-androgen effects.  Side effects are similar to those experienced by cisgender women. While trans-men often develop amenorrhea, pregnancy is still possible.  Frank discussions about the use of contraception, if sexually active, is important. A number of great resources are available to inform drug therapy decision making particularly the Endocrine Society Guidelines. Pharmacists can uniquely contribute to optimizing the care of trans-men and -women. To learn more, view and download the Show Notes!

Abby Frye, PharmD, BCACP, Dawn Fuke, PharmD, BCPS, and Justin Bachman, PharmD, BCACP — Clinical Pharmacist Specialists in Primary Care from the Providence Medical Group in Portland, Oregon — talk with us about creating gender-affirming care environments. Key Lessons: Current estimates suggest that about 1 million adults in Adults in the United States don't identify with the gender assigned to them at birth  - but this is likely an underestimate. Transgender and gender non-conforming individuals face enormous and persistent stigma within our (and many other) cultures. Social stigma is associated with higher rates of anxiety, depression, and substance use disorders. Health professionals have a responsibility to take pro-active steps to counteract the discrimination that patients from vulnerable and marginalized populations face. Self-awareness and self-examination about communication practices are critical - this includes the information collected on patient intake forms and electronic health records as well as a patient's preferred name and pronoun.  Insurance coverage for gender-affirming therapies as well as health screening exams for transgender persons are sometimes denied and health professionals may need to advocate for coverage. A wide variety of resources are available to health professionals to learn more about the care of transgender and gender non-conforming individuals. To learn more, view and download the Show Notes!

Nicole Avant, PharmD, BCACP - Assistant Professor at the University of Cincinnati and Founder/CEO of Avant Consulting Group - and Tennille McKinney - HIV Educator and Consultant with Avant Consulting Group - talk with us about gender expression/identity, cis-privilege, and transphobia. Key Lessons: Sex and gender are not synonymous.  Sex is based on biology and gender is a social construct. Sex is determined by genes and assigned at birth. Gender is influenced by cultural norms and internal sense of self. Transgender persons identify with a gender that is different from the sex that was assigned at birth.  Cis-gender persons identify with the gender that is congruent with the sex assigned at birth. Some transgender persons, but certainly not all, seek medical and/or surgical gender-affirming treatments to express their gender identity. Cis-privilege includes the rights and advantages that cis-gender persons enjoy.  This includes respect for one's gender identity and freedom from harassing comments or intrusive questioning. Deadnaming is the act of referring to and calling someone by their birth name rather than their chosen name which is congruent with their current identity. Transgender persons face social stigma from both the lay public and health professionals.  This sigma often results in transgender persons seeking care outside of traditional institutions and relying on self-care. To learn more, view and download the Show Notes!

Lea Eiland, PharmD, BCPS, BCPPS - Clinical Professor and Associate Department Head, Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy — talks to us about the impact of generational differences ... and why these differences influences our patients' communication perferences, beliefs, and expectations. Key Lessons: Our patients and workforce are more diverse than ever - including their generational experiences that influence their expectations related to work, healthcare delivery, and communication. Generational differences are generalizations - so not all people within a generation fit the stereotype and we need to be careful to not make assumptions. The generations currrently in the workforce and healthcare delivery systems are Traditionalist, Baby Boomers, Gen-X, Millennials, and Gen-Z/iGeneration. Comfort levels with digital technology and communication formats vary by generation.  Older generations tend to prefer face-to-face and long-form written communications ... while more recent generations prefer short-form written communications.  But everyone can learn to adapt! Recent generations prefer short, action-oriented, on-demand learning methods. Feedback preferences are also generational. Older generations generally desire less frequent feedback and more recent generations prefer more. Learning how to function well as a team requires a shared vision about the goals and valuing the contributions of each person on the team.

Magaly Rodriguez de Bittner, PharmD, BCPS, CDE - Professor and Associate Dean for Clinical Services and Practice Transformation, University of Maryland School of Pharmacy - talks to us about the impact of culture on behaviors and health outcomes ... and why healthcare practitioners need to develop cultural awareness and move toward cultural proficiency to achieve optimal outcomes for the patients they serve. Key Lessons: Culture is the characteristics, knowledge, and beliefs of a group of people including their shared language, religious/spiritual beliefs, habits, and values.   Culture impact beliefs about diseases, medications, and healthcare. Many patients are reluctant to tell healthcare providers about their culturally-related health behaviors for fear of being judged or may believe such information is irrelevant. Behaviors and beliefs, regardless of source, can impact health outcomes and can augment, detract, or have no impact on the recommended treatment plan. Openly discussing beliefs and behaviors is critical.  Supporting patient decisions based on their beliefs builds trust. Communicating in the patient's preferred language is mandated by law. Use trained interpreters. Have written materials available in the patient's preferred language. Cultural awareness and moving toward cultural proficiency makes good business sense as you are better able to understand the needs of your patients.

William J Stilling, BS Pharm, JD - Founding Partner, Stilling & Harrison, PLLC and Clinical Associate Professor, Department of Pharmacy Practice at the University of Utah College of Pharmacy - talks to us about some of the legal issues related to the medical and recreational use of marijuana. Key Lessons: Marijuana (in its raw form) is a schedule I substance under Federal Law.  However, the US Congress has prohited the Department of Justice from using its funds to enforce Federal law superceding State laws related to marijuana. Medical marijuana is typically legal to use under State laws only in specific "use cases" or "qualifying conditions."  Physicians and other prescribers can't legally prescribe marijuana because it would violate their DEA issued license but may "recommend" or "authorize" the use of marijuana. Healthcare instutitions need to consider the use of marijuana for therapeutic purposes by their patients and develop clear policies and procedures on how marijuana use will be accommodated in their facility. Pharmacists and pharmacies are subject to oversight by the board of pharmacy and most state boards require pharmacists to abide by Federal laws.  Thus, pharmacists who use marijuana, even for "legal" therapeutic purposes, may be subject to sanctions and lose their license to practice. Employers may terminate a pharmacist or health professional for marijuana use because it is a violation of Federal law. The FDA is unlikely to approve marijuana (in its raw form) for medical indications because it can not be easily studied or standardized. The legal status of marijuana in the years to come will be significantly impacted by political and economic forces. View and Download the Show Notes

Laura Borgelt, Pharm.D., BCPS - Professor, Departments of Pharmacy Practice and Family Medicine at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences - talks to us about the recreational use of marijuana and its potential health consequences. Key Lessons: Cannabis (marijuana) use has increased substantially in the past decade.  Young adults are the most likely to report using marijuana in the past year or month but use among older adults (age > 65 years) is growing as well. Its important to ask patients in a non-judgmental, open-ended manner about their cannabis use including the intended purpose(s), frequency of use, and forms used. Numerous cannabis products are available. Inhaling (smoking or vaping) remains the most common method for use.  Edible products are available in a wide variety of food-like delivery systems (e.g. baked goods, candies).  Topical products are more commonly used for medical purposes. The THC concentrations found in cannabis products today are much higher than years ago. This has resulted in higher rates of unintentional overdoses leading to paranoia and psychotic symptoms. Overdosing is most common with edible products due their delayed absorption. There are several short-term and long-term health consequences related to marijuana use. Regular cannabis use can lead to neurocognitive effects including impaired memory. Cannabis use is more likely to have a detrimental impact for adolescents and young adults. Cannabis use during pregnancy also appears to have detrimental neurocognitive effects on children. There are several potential drug-drug interactions with THC and medications metabolized through CPY2C9 and CPY3A4 as well as receptor interactions. Pharmacists have an important public health role by screening for cannabis use, educating patients about the potential risks associated with marijuana use, and identifying potential drug-drug interactions. View and Download the Show Notes

Kari Franson, Pharm.D., Ph.D., BCPP - Associate Dean for Professional Education at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences - talks to us about the medical use of marijuana, THC, and CBD. Key Lessons: Cannabis plants have been used for medical, recreational, and industrial purposes for thousands of years. The two active ingredients in cannabis plants include tetrahydrocannabinol (THC) and cannabidiol (CBD) - collectively known as cannabinoids.  They have distinctly different pharmacological properties. Cannabis plants that contain less than 0.3% of THC by dry weight are legally classified as hemp.  Cannabis plants can be cultivated to have more (or less) THC and CBD content. Prescription products containing THC have been available for more than 30 years. A buccal spray containing THC + CBD has been approved (but not in the United States) for the treatment of muscle spasms/stiffness associated with multiple sclerosis.  A purified CBD product was approved by the FDA for the treatment of rare childhood seizure disorders in 2018. There is a long list of claimed medical uses of marijuana (typically contains high concentrations of THC).  Not all claims are supported by sufficient evidence and some have been refuted by the evidence.  Far less is known about the medical uses of CBD. Cannabinoids are erratically and slowly absorbed from the GI tract. There are substantial legal barriers to studying cannabis and its health consequences in the United States. View and Download the Show Notes

Brandon Shank, PharmD, BCOP - Clinical Pharmacy Specialist at the University of Texas MD Anderson Cancer Center - talks to us about credentialing & privileging from a front-line clinician's point of view. Key Lessons: Building rapport and trust with your team is an essential first step from which clinical privileges follow. State laws vary.  Some authorize privileging of pharmacists at the institutional level. Obtaining and maintaining clinical privileges requires additional training ... and paperwork. Pharmacists have a unique understanding of the dosing and available dosage forms of drugs - this brings value to the patient care team. Privileging pharmacists to take on advanced clinical responsibilities can increase team efficiency and effectiveness. View and Download the Show Notes!

Julie Groppi, PharmD - National Program Manager, Clinical Pharmacy Practice Policy and Standards, Department of Veteran's Affairs and Todd Nesbit, PharmD, MBA - Director of Pharmacy Patient Care Services, the Johns Hopkins Hospital - discuss the credentialing and privileging of pharmacists. Key Lessons Credentialing is the process of verifying someone education, training, certifications, and experience.  Privileging is the process of determining an appropriate scope of practice based on the practitioner's credentials and granting authority to carry out specific patient care services/decisions. All health systems should credential the pharmacists they employ. Pharmacists can be privileged to initiate, modify, continue, or discontinue medication therapies as well as order tests and referrals as needed to achieve treatment goals. A pharmacist's privileges may be restricted to specific drugs and disease (e.g. collaboratory drug therapy management agreement) or may be service-specific (e.g. all patients enrolled in or assigned to a specific clinical service unit). The credentials necessary to be privileged to carry out advanced patient care services typically include residency training and board certification. View and Download the Show Notes!

Joseph Saseen, Pharm.D., BCPS, BCACP, CLS - Professor of Clinical Pharmacy and Family Medicine, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences - discusses the various credentials pharmacists can earn following graduation and licensure. Key Lessons Credentials include degrees, licensure, post-graduate training, and board certification. Earning a certificate is not synonymous with becoming board certified. Board certification requires candidates to meet specific eligibility criteria and pass a comprehensive examination to validate the breadth and depth of knowledge in the area of specialization. Board certification can give pharmacists a competitive advantage for employment and open doors to new opportunities. Candidates should consider preparing for a board certification exam either through a formal, structured program or forming a study group ... or both. Obtaining advanced credentials is ultimately about improving the quality of care pharmacists provide to patients. View and Download the Show Notes!

Carol Ott, Pharm.D., BCPP - Clinical Professor of Pharmacy Practice, Purdue University College of Pharmacy and Residency Program Director for the Eskenazi Health/Purdue University PGY2 Psychiatric Pharmacy Residency Program - discusses how sigma adversely impacts patients with opioid use disorder and how the BoilerwoRx program is helping to address the opioid crises at the community level. Key Lessons Health professionals too often use stigmatizing language when describing patients with a substance use disorder and their behaviors. We need to critically examine our unconscious biases toward patients with substance use disorder. Substance use disorders are most often co-morbid with other mental health conditions. Needle exchange programs are an evidence-based intervention that can reduce harm by preventing the spread of infectious diseases and be an important touchpoint to get people into treatment. There are numerous ways pharmacists can help patients with substance use disorders - approaching them with empathy, volunteering, and using evidence-based resources to guide care and combat misinformation. View and Download the ShowNotes!

Suzanne Nesbit, Pharm.D., BCPS - Clinical Pharmacy Specialist in Pain and Palliative Care at the Johns Hopkins Health System - and Lucas Hill, Pharm.D., BCPS, BCACP - Clinical Assistant Professor at the University of Texas at Austin and Director of Operation Naloxone - discuss how to improve patient safety by implementing opioid stewardship and harm-reduction strategies. Key Lessons Opioid stewardship requires multiple components starting first with a commitment to change and includes opioid prescribing guidelines, provider feedback, and patient education. Discussing the goals of therapy, intended treatment duration, and realistic expectations with patients when opioids are prescribed is critical. Patients at high risk of opioid overdose should receive naloxone and trained how to use it. Naloxone standing orders or collaborative practice agreements can facilitate access. Information from prescription drug monitoring programs can be helpful during the medication review process but providers must recognize their limitations. Pain relief requires a patient-specific approach. Patients with a substance use disorder deserve to have their pain addressed too. View and Download the ShowNotes!

Jeffrey Bratberg, Pharm.D., BCPS - Professor of Pharmacy Practice at the University of Rhode Island talks with us about the opioid overdose crisis - it's causes and potential solutions. Key Lessons The causes of the opioid overdose crisis are multifactorial but rooted in hopeless and despair Illicitly obtained synthetic opioids are very potent and the leading cause of opioid overdose deaths today Opioid use disorder is a brain disease and all patients deserve compassionate care The response to the opioid overdose crisis (to date) has been anemic due to societal stigma and unconscious bias Supply-side solutions (e.g. prescription drug monitoring programs) to the problem may seem helpful but have unintended consequences Naloxone should be widely available and all health professionals should carry it View and Download the ShowNotes!

Kristina Butler, Pharm.D., BCPS, BCACP - Manager of Clinical Pharmacy Specialists in Primary at the Providence Medical Group in Portland, Oregon talks with us about implementing a consistent patient care practice model across multiple sites. Key Lessons: Implementing a consistent model of care begins with hiring people who have the appropriate training & experience followed by a robust orientation process and supplemented by ongoing peer review; high-quality clinical pharmacy services need to be consistently available; more experienced practitioners may need to reframe their thinking and update their terminology in order to consistently teach learners about the pharmacists patient care process. Helpful Resources:  Check out the Patient Care Process chapter in Pharmacotherapy: A Pathophysiologic Approach and the Patient Care Process for Delivering Comprehensive Medication Management report.

Mary Ann Kliethermes, Pharm.D. - Professor and Vice Chair for Ambulatory Care in the Department of Pharmacy Practice at the Midwestern University Chicago College of Pharmacy talks with us about the business case for implementing the pharmacists patient care process. Key Lessons: Using a reliably consistent process results in reliably consistent outcomes; health information systems require providers to use a consistent method of documentation; pharmacists patient care services will be billed within the existing payment framework and infrastructure; payment for services is contingent on the scope of practice (state pharmacy practice act!), provider status (at state level!), and insurance regulations (state laws!). Helpful Resources:  Check out the Patient Care Process chapter in Pharmacotherapy: A Pathophysiologic Approach and the Patient Care Process for Delivering Comprehensive Medication Management report.

Todd Sorensen, Pharm.D. - Professor in the Department of Pharmaceutical Care and Health Systems at the University of Minnesota College of Pharmacy and Executive Director of the Alliance for Integrated Medication Management talks with us about the importance of applying a systematic process of care during every patient encounter. Key Lessons: All health professions have a similar process of care but each has a different focus and assessment strategy; inconsistencies in the process of care provided by pharmacists has led to inconsistent outcomes in clinical trials; several new resources are available to help pharmacy practitioners deliver the pharmacists patient care process with greater "fidelity." Helpful Resources:  Check out the Patient Care Process chapter in Pharmacotherapy: A Pathophysiologic Approach and the Patient Care Process for Delivering Comprehensive Medication Management report.

Cody Clifton, Pharm.D. - Clinical Pharmacist and Special Projects Manager at Moose Pharmacy and Coordinator of Quality Assurance and Best Practices for the Community Pharmacy Enhanced Services Network U.S.A. (CPESN-USA) - talks about the use of mobile devices and apps to remotely monitor patients to improve medication adherence, effectiveness, and safety. Key Lessons: Numerous devices and apps are available to assist patients with medication adherence; the Spencer device (by Spencer Health Solutions)* provides medication monitoring data and helps connect patients, caregivers, and pharmacists; pharmacists can partner with accountable care organizations (ACOs) to improve outcomes and reduce healthcare cost using mHealth devices and apps. *Please note that PharmacyForward does not endorse or recommend any products or services.  The Spencer device is one of several potential options that pharmacists and patients may wish to consider when adopting a mHealth solution.

Julie Lauffenburger, Pharm.D., Ph.D. - Assistant Director of the Center for Healthcare Delivery Sciences at the Brigham and Women's Hospital and co-investigator for the MedISAFE-BP study talks to us about the use of smartphone applications to improve medication adherence. Key Lessons: Improvements in medication adherence don't necessarily lead to improvements in outcomes (e.g. blood pressure control or cardiovascular events) unless patient-monitoring data is shared and used by clinicians to make medication adjustments; smartphone apps should provide nudges to patients in a manner they find most useful; technology should make the medication use process easier, not more difficult.

Timothy Aungst, Pharm.D. - Associate Professor at the MCPHS University in Worcester, Massachusetts and the author of The Digital Apothecary blog talks to us about the current digital health landscape. Key Lessons:  Stand alone mobile health devices and apps have limited value; patient-specific data can inform diagnosis and treatment decisions; aggregated data from 1000's of users can help direct public health efforts; and pharmacists can and should play a bigger role in mHealth/digital health.

Rosemary Duncan, Pharm.D., BCPS - Medication Safety Officer - and Jacob Smith, Pharm.D. - Assistant Director of Medication Safety and Quality at The Johns Hopkins Hospital talk about measuring quality in hospital settings and how quality metrics are used for accreditation and value-based payments. Key Lessons:  Measuring quality is difficult and event rates are not an adequate metric of medication safety; pharmacists can help improve HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores by providing patient and provider education; quality in healthcare is advanced by implementing high-reliability systems and processes by interprofessional teams.

Laura Cranston, R.Ph. - Chief Executive Office of the Pharmacy Quality Alliance (PQA) - talks about the work of PQA and the National Quality Strategy which aims to make care delivery higher quality and more affordable to achieve healthier people and communities.  Key Lessons:  PQA plays an important role by convening key stakeholders and creating quality measures that are used by the payer community.  Pharmacists and student pharmacists can play an important role in PQA's work.  

Troy Trygstad, Pharm.D., MBA, Ph.D. - Executive Director of CPESN-USA, a network of pharmacies that provides a portfolio of medication optimization and patient care services - talks about the "quality movement" and how it's impacting the practice of pharmacy in community and ambulatory care settings. Key Lessons:  Create supports to help patients to optimally use medications; follow-up is critical; fully engage staff and student pharmacists to deliver care.

Dr. Jean-Venable "Kelly" Goode from the Virginia Commonwealth University (VCU) talks about relationship building in the community setting.  Dr. Goode is Past-President of the American Pharmacists Association (APhA) and helped develop several innovative community-based pharmacy practices during her career. She serves as the residency program director for the highly regarded VCU Community-based Residency Program. Key Lessons:  understand the needs first, make time to meet providers in their space, consider practice model changes, and always follow through.

Sara J. White - former Director of Pharmacy at Stanford Hospitals and Clinics - talks about relationship building in hospitals and health systems.  Ms. White is a Past-President of the American Society of Health-System Pharmacists (ASHP) and a Scholar-in-Residence with the ASHP Foundation in 2004. Key Lessons:  know the distinction between interactions and relationships, connect with people - not just communicate, and be visible.

Dr. Hae Mi Choe from the University of Michigan College of Pharmacy talks about relationship building in ambulatory care environments.  Dr. Choe is Director of Pharmacy Innovations and Partnerships for the U-M Medical Group and lead the development of innovative pharmacy services at 14 U-M affiliated hospitals and health centers. Key Lessons:  align your goals with institutional goals, tell your patient's success story, be visible, and be persistent.