Promoting diversity, equity and inclusion awareness in clinical documentation through postgraduate year one training.

BACKGROUND AND PURPOSE: As healthcare providers increasingly focus on emerging issues of diversity, equity and inclusion (DEI) in patient care, less is known about the training in postgraduate year one (PGY1) pharmacy residency on DEI clinical documentation considerations. This pilot project explored whether training, discussion and self-reflection within a peer review activity promoted DEI self-awareness in clinical documentation through a centralized curriculum of a multisite PGY1. EDUCATIONAL ACTIVITY AND SETTING: Building upon an established peer review of clinical documentation activity, PGY1 pharmacy residents practicing in ambulatory care settings received training on DEI considerations and completed small and large group discussions, a post-activity mixed methods survey with self-reflection prompts, and a three-month follow-up survey. FINDINGS: Twenty-two residents participated in the peer review of clinical documentation activity, DEI training and discussions. Twelve residents completed the post-activity survey with reflection prompts; 6 (50%) reported similar previous DEI training prior to residency. After the DEI training and discussions, 12 (100%) agreed or strongly agreed that their awareness of DEI documentation considerations increased; 10 (83%) would document their submitted notes differently, while one resident was unsure and one would not make changes. Twelve residents completed the follow-up survey three months following the activity. Themes from the free-text responses on key learnings collected post-activity and three-month post (respectively) included: 1) new knowledge, increased self-awareness, and intended action and 2) increased self-awareness and changes in note-making convention. SUMMARY: Integrating DEI training, discussion, and self-reflection prompts into a peer review clinical documentation activity increased self-awareness and knowledge of DEI considerations and promoted intended changes in patient care documentation for pharmacy residents. Regardless of previous training, residents reported continued self-awareness and changes in documentation conventions continued three months later.

Addressing practical challenges with entrustable professional activities in ambulatory care experiential education.

BACKGROUND AND PURPOSE: Entrustable professional activities (EPAs) have been adopted and endorsed by the American Association of Colleges of Pharmacy as an assessment strategy. Application of EPAs in ambulatory care advanced pharmacy practice experiences (APPEs) has demonstrated potential internal grading consistency challenges and warrants further guidance. EDUCATIONAL ACTIVITY AND SETTING: Within a required ambulatory care APPE, a rubric was developed using purposeful and convenience sampling of preceptors, faculty, and students to concretely delineate expected EPA level progression from week one to week four based on setting specific activities. FINDINGS: The rubric was perceived to be accurate and useful as a tool for improving expectations of progression in the respective roles on ambulatory care APPEs. SUMMARY: Specifying performance of common clinical activities by weekly EPA level progression within an ambulatory care APPE was perceived to address some of the challenges in APPE grading consistency. Research for determining appropriate progression within an APPE and progression context within graduate and post-graduate training is needed. As more pharmacy training programs implement EPAs, collaboration in applying core EPAs into experiential education will be needed. This example of a setting specific progression rubric may serve as a useful tool for preceptors and students during their APPEs.

Beginning Early: Reflective Practice Development in a Pre-health Course on Health Literacy and Health Disparities.

Background: Learning reflective practices and understanding the complexity of health literacy and health disparities need to start early in health professions training. The primary objective of this inquiry was to evaluate the feasibility and effectiveness of using reflection categorization for assessing learner progression on reflective practice development. The secondary objective was to evaluate student reflection as a strategy for introducing and advancing pre-professional learners' understanding of health literacy and health disparities. Case Description: Within an online undergraduate health literacy course, two written reflection assignments were coded using Kember's four categories: habitual action, understanding, reflection, and critical reflection. Students received feedback based on this reflection categorization to promote development of reflective practices. However, reflections were not graded using the reflection categorization. Case Themes: Most (78%) students were at the level of understanding for the first reflection. For the second reflection, 29% of students were at the reflection level, demonstrating health literacy application and describing the important contributing role of personal context to health outcomes. Sixteen (33%) students progressed in their level of reflection. Within the reflections, students discussed knowledge gained and plans for future application. Conclusion: Using a structured reflection activity allowed pre-health students to begin developing reflection practices. Through reflection, students were able to describe and apply health literacy and health disparities knowledge.

Pharmacists Are Not Mid-Level Providers.

Pharmacists should not be classified as "mid-level" providers. This classification implies that there are different levels or a hierarchy of providers when in fact each health care provider brings unique and essential knowledge and contributions to the health care team and to the care of patients. Pharmacists are no exception. Timely issues germane to pharmacists, including dependent and independent practice, provider status, and professional identity, contribute to the rationale that pharmacists, just like all other health care providers, should be classified by their professional identity. While use of the term mid-level provider to identify various practitioners may not seem consequential, in today's health care environment, words do matter when it comes to attributing value, and the contributions of all health care providers should be recognized as equally important to the patient care team.

The Report of the 2020-2021 Professional Affairs Standing Committee: Pharmacists' Unique Role and Integration in Healthcare Settings.

EXECUTIVE SUMMARY The 2020-21 Professional Affairs Committee was charged to (1) Read all six reports from the 2019-20 AACP standing committees to identify elements of these reports that are relevant to the committee's work this year; (2) Identify opportunities and models of integration of pharmacist care services in physician and other health provider practices beyond primary care; (3) Differentiate and make the case for the integration of pharmacist care services from that of other mid-level providers; and (4) From the work on the aforementioned charges, identify salient activities for the Center To Accelerate Pharmacy Practice Transformation and Academic Innovation (CTAP) for consideration by the AACP Strategic Planning Committee and AACP staff. This report provides information on the committee's process to address the committee charges, describes the rationale for and the results from a call to colleges and schools of pharmacy to provide information on their integrating pharmacist care services in physician and other health provider practices beyond primary care practice, and discusses how pharmacist-provided patient care services differ from those provided by other healthcare providers. The committee offers a revision to a current association policy statement, a proposed policy statement as well as recommendations to CTAP and AACP and suggestions to colleges and schools of pharmacy pertaining to the committee charges.

Trends in Clinical Pharmacist Integration in Family Medicine Residency Programs in North America.

(1) Objective: To determine the change in prevalence of clinical pharmacists as clinician educators within family medicine residency programs (FMRPs) in North America and to describe their clinical, educational and administrative scope over time. (2) Methods: A systematic review of the literature was performed starting with an electronic search of PubMed and Embase for articles published between January 1980 and December 2019. Studies were included if they surveyed clinical pharmacists regarding their clinical, educational, or other roles in FMRPs in the United States or Canada. The primary outcome was the change in prevalence of clinical pharmacists in North America. Secondary outcomes included: demographic information of clinical pharmacists, change in the prevalence in Canada and United States, and descriptions of clinical services, educational roles, and other activities of clinical pharmacists within FMRPs. (3) Results: Of the 65 articles identified, six articles met the inclusion criteria. The prevalence of clinical pharmacists as clinician educators in FMRPs in North America has grown from 24% to 53% in the United States (U.S.) and from 14% to 47% in Canada over the study period. The clinical and educational roles are similar including: the direct patient care, clinical education, and interprofessional education and practice. (4) Conclusion: The prevalence of clinical pharmacists in FMRPs is growing across North America. Clinical pharmacists are highly educated and trained to support these clinician educator positions. While educational roles are consistent, clinical pharmacists' patient care roles are unique to their clinical site and growing.

Tracked Patient Encounters During Advanced Pharmacy Practice Experiences and Skill Self-assessment Using Entrustable Professional Activities.

Objective. To determine if the number of patient encounters during advanced pharmacy practice experiences (APPEs) relates to student self-assessment of patient care skills using entrustable professional activities (EPAs). Methods. During 12-week acute care/institutional (AC/INST) APPEs, 15-week combined community pharmacy and ambulatory care (CPAC) APPEs, and three 5-week AC/INST or CPAC elective APPEs, fourth-year pharmacy students completed patient tracking surveys. Students documented the number of encounters, type of care provided, primary and secondary diagnoses, and special dosing/population considerations. Students completed self-assessment surveys for 12 EPAs. Students rated their ability to perform each EPA using a four-point scale (1=still developing this skill; 4=can do this independently) at the start and after each APPE semester. Results. Data were collected from May 2016 through April 2017. During this time, 165 students completed APPEs. Students reported 79,717 encounters. There was no significant correlation found between total number of encounters and EPA scores. The baseline EPA mean score was 3.1 and semester 3 EPA mean score was 3.7. The mean student-reported EPA scores did increase over time, some more quickly than others. Conclusion. Tracking student patient encounters provided insight into the quantity and variety of patients and conditions seen and level of care provided by students during APPEs. Mean scores on EPAs increased over time with increased exposure to patients. Patient tracking can be used to inform the curriculum by identifying potential gaps in both didactic and experiential education.

Partnering for a Sustainable Interprofessional Psychiatric Mental Health Nurse Practitioner Education Curriculum.

BACKGROUND: The World Health Organization recommends that health care educators create a collaborative and practice-ready workforce. Focused interprofessional education (IPE) promotes collaborative practice, yet few examples of how to develop sustained IPE and clinical partnerships exist. Mental health care professionals competent in their specialty and prepared for interprofessional collaboration are needed to treat complex mental health needs of patients. METHOD: Doctor of Nursing Practice Psychiatric Mental Health Nurse Practitioner (PMHNP) faculty partnered with College of Pharmacy faculty to create didactic, clinical, and simulation coursework and IPE competencies within PMHNP courses. Students developed skills about providing interprofessional mental health care. RESULTS: Recommendations for faculties include: embrace the value of interprofessional faculty partnerships; plan for time, money, motivation, and recognition needed for sustainable IPE; and design courses that become part of the fabric of the curricula. CONCLUSION: Embedding IPE into PMHNP curricula creates increased faculty satisfaction and positive feedback from students and clinical sites. [J Nurs Educ. 2019;58(12):723-727.].

Educational Prescriptions to Document Evidence-Based Medicine Questions in Ambulatory Care Advanced Pharmacy Practice Experiences.

Objective. To design, implement, and assess the use of "educational prescriptions" or Education Rx assignments in advanced pharmacy practice experiences (APPEs) in ambulatory care, and to assess the impact of the assignments on Doctor of Pharmacy (PharmD) students' self-efficacy to practice evidence-based medicine (EBM). Methods. Students enrolled in select ambulatory care APPEs completed up to four Education Rx assignments. The assignments required students to report the context of the question, source of information, results, appraisal of validity, and relevance of the evidence, and to answer the clinical question. A rubric was used that contained three subparts: a patient/population, intervention, comparison, outcome (PICO) conformity score (8 points), presence of answer to the PICO (1 point), and quality of answer to the PICO (6 points). Demographic information was collected and students were surveyed at the end of the APPE to rate their self-efficacy executing seven evidence-based medicine (EBM) skills. Results. Thirty students completed 110 Education Rxs. The average score (SD) was 13.6 (2.2) with a PICO conformity subsection score of 7.3 (1.3), and quality of answer subsection score of 5.3 (1.2). Only one Education Rx did not have an answer. Students consulted point-of-care references for a majority of the answers (65%). Sixteen (53%) students completed the self-assessment survey, and all strongly agreed or agreed that the Education Rx activity improved their ability to formulate a well-constructed clinical question and evaluate and apply the evidence. Conclusion. Through Education Rxs, PharmD students' self-confidence and their skills in finding answers to clinical questions increased.

Preceptor and resident perceptions of entrustable professional activities for postgraduate pharmacy training.

BACKGROUND: Following the development and implementation of entrustable professional activities (EPAs) as a collective graduation standard for pharmacy students, the University of Minnesota's multi-site post-graduate year one pharmacy residency program made a similar transition. EDUCATIONAL ACTIVITY AND SETTING: An electronic survey was distributed to program preceptors and residents to describe the perceptions of using EPAs to assess performance. FINDINGS: Residents (66.7%) and preceptors (78.3%) found the EPA framework to be more helpful than the traditional progression ratings model, but both groups also described EPAs as less beneficial for some objectives. Sixteen (69.6%) preceptors felt the residency graduation standard for attainment should be an entrustment level 4 or 5. Preceptor's found the EPA scale to be more descriptive, more objective, and easier to understand; however, it did not always apply to all skills and was more challenging to provide residents information regarding what they needed to improve upon. Residents commented that the EPA scale was more descriptive, had better clarity, and gave them a better idea of where their progression was at on a continuum. Residents also commented that regardless of the rating scale, specific, day-to-day feedback is more helpful. SUMMARY: Residents and preceptors perceive the EPA framework to be more helpful than traditional rating scales when evaluating learning objectives. Preceptors were less certain of what the EPAs entrustment level should be to consider a learning objective or skill achieved for residency. Both found some learning objectives to be more challenging for EPA use.

Integration of Clinical Pharmacists in Family Medicine Residency Programs.

BACKGROUND AND OBJECTIVES: Clinical pharmacists are valued educators and practitioners within family medicine residency programs (FMRPs). Since the last survey of clinical pharmacists within FMRPs, there have been significant advancements to pharmacy education and training as well as growth of interprofessional education and collaborative practice within family medicine. The objective of this study is to describe the integration of clinical pharmacists within FMRPs. METHODS: All 480 Accreditation Council for Graduate Medical Education (ACGME)-approved FMRPs were contacted to identify clinical pharmacists involved with their programs. An electronic survey was distributed to these 253 pharmacists. Questions addressed educational, clinical, scholarly, and administrative activities. RESULTS: Of 396 FMRPs reached, 208 (52.5%) reported 253 clinical pharmacists within their programs. Survey responses were received from 142 (56.1%) pharmacists. Academic appointments in colleges/schools of pharmacy and medicine were held by 105 (75.5%) and 69 (50.0%) respondents, respectively. Eighty-nine (64.0%) pharmacists reported a single source of salary, 19.1% of which received full support from the FMRP. Clinical pharmacists dedicated an average of 50.4% of their overall time to the FMRP, and 14.5% of pharmacists dedicated all of their time to the FMRP. Time within the FMRP was spent on patient care (52.9%), teaching (31.6%), research/scholarship (7.5%), administrative activities (5.9%), and drug dispensing (0.7%). DISCUSSION: Prevalence of clinical pharmacists within FMRPs has increased since 2000, from 27.9% to 52.5%. However, the amount of time dedicated to the FMRPs has decreased. This shift from teaching to a more clinical role may reflect both a growth of patient-centered, interprofessional care and a needed mechanism to assist funding these positions.

Tracking Patient Encounters and Clinical Skills to Determine Competency in Ambulatory Care Advanced Pharmacy Practice Experiences.

OBJECTIVE: To determine if the amount of exposure to patient encounters and clinical skills correlates to student clinical competency on ambulatory care advanced pharmacy practice experiences (APPEs). DESIGN: Students in ambulatory care APPEs tracked the number of patients encountered by medical condition and the number of patient care skills performed. At the end of the APPE, preceptors evaluated students' competency for each medical condition and skill, referencing the Dreyfus model for skill acquisition. ASSESSMENT: Data was collected from September 2012 through August 2014. Forty-six responses from a student tracking tool were matched to preceptor ratings. Students rated as competent saw more patients and performed more skills overall. Preceptors noted minimal impact on workload. CONCLUSIONS: Increased exposure to patient encounters and skills performed had a positive association with higher Dreyfus stage, which may represent a starting point in the conversation for more thoughtful design of ambulatory care APPEs.

Clinical Pharmacists as Educators in Family Medicine Residency Programs: A CERA Study of Program Directors.

BACKGROUND AND OBJECTIVES: The clinical pharmacist's role within family medicine residency programs (FMRPs) is well established. However, there is limited information regarding perceptions of program directors (PDs) about clinical pharmacy educators. The study objectives were (1) to estimate the prevalence of clinical pharmacists within FMRPs and (2) to determine barriers and motivations for incorporation of clinical pharmacists as educators. METHODS: The Council of Academic Family Medicine Educational Research Alliance (CERA) distributed an electronic survey to PDs. Questions addressed formalized pharmacotherapy education, clinical pharmacists in educator roles, and barriers and benefits of clinical pharmacists in FMRPs. RESULTS: The overall response rate was 50% (224/451). Seventy-six percent (170/224) of the responding PDs reported that clinical pharmacists provide pharmacotherapy education in their FMRPs, and 57% (97/170) consider clinical pharmacists as faculty members. In programs with clinical pharmacists, 72% (83/116) of PDs reported having a systematic approach for teaching pharmacotherapy versus 22% (21/95) in programs without. In programs without clinical pharmacists, the top barrier to incorporation was limited ability to bill for clinical services 48% (43/89) versus 29% (32/112) in programs with clinical pharmacists. In both programs with and without clinical pharmacists, the top benefit of having clinical pharmacists was providing a collaborative approach to pharmacotherapy education for residents (35% and 36%, respectively). CONCLUSIONS: Less than half of FMRPs incorporate clinical pharmacists as faculty members. Despite providing collaborative approaches to pharmacotherapy education, their limited ability to bill for services is a major barrier.

Assessing collaboration between family medicine residents and pharmacy residents during an interprofessional paired visit.

BACKGROUND AND OBJECTIVES: As health care embraces an interprofessional team approach toward care delivery, examples quantifying team members' collaboration in care delivery are limited. Our study objective was to determine the type of and satisfaction with collaboration that occurs between family medicine residents and pharmacy residents during an interprofessional paired visit. METHODS: For 1 half day a week for 10 months, residents were paired to see patients together and complete an evaluation tool. The tool asked participants to rank the contribution of each team member on medication-related patient care tasks and to evaluate the interprofessional pairs' skills on four interprofessional competencies for collaborative practice (values and ethics for interprofessional practice, roles and responsibilities, interprofessional communication, and team and teamwork). Residents participated in focus groups 2 months after the conclusion of the paired visits, and responses were analyzed for common themes. RESULTS: There were 38 half days of paired visits over the 10 months. Shared contribution was found on all tasks, both for self-assessment and of the interprofessional partner. Resident evaluation of the pairs' skills on four interprofessional competencies averaged in the 4 range of the scale (good skills, above average ability). Themes from the focus groups focused on provider experience, perceived impact on patient care, and considerations for ongoing use of paired visits. CONCLUSIONS: Participants of the interprofessional paired visits were able to identify mutual contributions to patient care tasks at the point of care. Focus groups identified potential benefits, impact on patient care, and areas for improvement of paired visits.

Optimizing resident physician use of clinical pharmacy services.

BACKGROUND AND OBJECTIVES: Clinical pharmacists provide pharmacy services in family medicine residency programs across the nation. Currently, clinical pharmacy services are not optimally used by most residents. The objective of this study was to design strategies to educate family medicine resident physicians on optimal use of clinical pharmacy services. METHODS: Between April 2009 and May 2010, surveys and focus groups were conducted to develop educational strategies tailored to physician residents' needs. Strategies included visual reminders and one-on-one time between pharmacists and residents. Data on pharmacy services use was collected before and after implementing the educational strategies and analyzed to assess the effectiveness of the strategies. RESULTS: Clinical pharmacy services use by resident physicians increased after the intervention (51.5% to 57.2%). Reasons providers used pharmacy services changed after the intervention, with increases in drug information (66.2% to 69.4%) and patient education services (2.5% to 7.2%) and a decrease in patient care services (31.2% to 23.3%). Pharmacists saw fewer uncomplicated patients (59.1% to 53.9%) and more complicated patients (19.7% to 38.5%) after the intervention. CONCLUSIONS: Educating resident physicians on optimal use of pharmacy services required clarification of the pharmacist's role on the care team and in the educational process. The educational strategies defined the pharmacist role to include that of a preceptor and not just patient care provider, a distinction that is congruent with the medical teaching model. These strategies could be applied at other training sites to optimize use of clinical pharmacy services in physician residency training programs.

Case-based assessment in an online nursing pharmacotherapy course.

OBJECTIVE: To implement and evaluate the effectiveness of case-based assessments in an online pharmacotherapy course for nursing students. DESIGN: Four case-based examinations developed in parallel for the midterm and final examinations and designed to address potential barriers to maintaining academic integrity were compared. ASSESSMENT: The use of online, case-based assessments was successful in providing 4 parallel examinations that assessed case-based decision making while maintaining academic integrity and minimizing instructor grading burden. CONCLUSIONS: Using an online, case-based assessment strategy is effective and feasible for evaluating the clinical application knowledge of nursing students enrolled in a pharmacotherapy course.

Student-generated questions to assess learning in an online orientation to pharmacy course.

OBJECTIVE: To develop a formative assessment strategy for use in an online pharmacy orientation course that fosters student engagement with the course content and facilitates a manageable grading workload for the instructor. DESIGN: A formative assessment strategy involving student-generated, multiple-choice questions was developed for use in a high-enrollment, online course. ASSESSMENT: Three primary outcomes were assessed: success of the assessment in effectively engaging students with the content, interrater reliability of the grading rubric, and instructor perception of grading workload. The project also evaluated whether this metacognitive strategy transferred to other aspects of the students' academic lives. The instructor perception was that the grading workload was manageable. CONCLUSION: Using student-generated multiple-choice questions is an effective approach to assessment in an online course introducing students to and informing them about the profession of pharmacy.

Evaluation of pharmacists' barriers to the implementation of medication therapy management services.

OBJECTIVES: To assess pharmacists' actual and perceived barriers to implementing medication therapy management (MTM) services in the outpatient setting and to assess demographic and other factors associated with identified barriers. DESIGN: Cross-sectional study. SETTING: United States in 2007. PARTICIPANTS: 970 pharmacists practicing in an outpatient setting. INTERVENTION: E-mail invitation to participate in an Internet-based survey. MAIN OUTCOME MEASURES: Barriers to implementing MTM, practice characteristic influences on barriers, and personal characteristic influences on barriers. RESULTS: 776 of the 970 respondents (80.0%) were providing MTM or direct patient care services. Of respondents, 35% were compensated and 45% were not compensated for providing MTM services they provided to patients. The most common barriers identified for pharmacists providing MTM services with or without compensation were related to compensation. The most common barriers identified for those interested in providing MTM services were lack of additional staffing (89.6%) and poor access to medical information (84.0%). Pharmacists providing MTM with compensation were significantly less likely to agree with barriers relating to management, documentation, and compensation compared with those providing MTM without compensation. Those providing MTM with compensation were less likely to agree with most barriers compared with pharmacists who were interested in providing MTM services. Pharmacists practicing in a noncommunity setting were less likely to agree with barriers related to interprofessional relationships and documentation. CONCLUSION: These results show that the most important barriers to implementing MTM services in the outpatient setting identified by pharmacist survey respondents were related to interprofessional relationships, documentation, and compensation. Despite the resources available to pharmacists, barriers continue to hinder the expansion of MTM and direct patient care services.

Severe constipation associated with extended-release bupropion therapy.

PURPOSE: A case of bupropion-induced constipation is reported. SUMMARY: A 38-year-old man went to a clinic with a chief complaint of depression. He was prescribed extended-release bupropion 150 mg orally daily. Three weeks later, the patient returned to the clinic for a follow-up visit regarding his depression. He reported that his depression symptoms improved, but he complained of constipation and inflamed hemorrhoids from straining with defecation. He used docusate sodium, fiber supplements, and Preparation H(Wyeth) products with some relief. The bupropion was continued for his depression. Recommendations were given to the patient to increase fluids, maintain fiber intake, and add exercise. One week later, the patient complained of rectal pain and minimal bleeding. Prescriptions were given to the patient for hydrocortisone suppositories and 2.5% cream to be used twice daily. Three days later, the patient returned to the clinic complaining of increased pain and no relief from the hydrocortisone suppositories and cream. The rectal examination showed 3- and 5-cm hemorrhoids, one of which was thrombotic. The patient was instructed to continue hydrocortisone products, increase fluids, and continue docusate. Hemorrhoidectomy surgery was eventually performed, as well as a fissurectomy. The patient discontinued bupropion on his own due to the constipation approximately one week before the surgery. The constipation resolved after discontinuation of bupropion. CONCLUSION: Extended-release bupropion was the probable cause of severe constipation in a man with multiple medical problems.