January 12: National Pharmacist Day

Today was National Pharmacists Day - the first holiday of our year that honors a profession.  We are so glad it was this profession that we were able to highlight first.  Not only is it one of the less understood professional callings, it is one which three of our close friends are members.  I was lucky to get a chance to ask one of those friends some of my most burning questions about the profession as our celebration for the day.

We also feasted.  But not really.

Our good friend Lisa (my maid of honor) is a pharmacist in the Cardiology department of a major hospital.  Before that, she worked at the VA hospital and in retail, so she was able to speak to several different professional settings that pharmacists encounter.  Sadly, because BOO TEXAS, we don't live near enough to have had the interview in person.  Instead, we chatted on the phone.  Below are my notes from that call - edited to correct the several grammatical mistakes and shortcuts I took in trying to keep up.  One thing that always stands out to me when someone loves their job - they get excited about it.  Lisa is no exception and that made the call so much more fun.  I hope everyone finds her answers as neat and informative as we did.

What is the day to day work of a pharmacist like?
Working in a hospital is so different from other locations.  I am assigned to one of the teams – I work in cardiology and get assigned to two nursing units in the area.  I process the orders from the doctors and makes sure that no doses are too high, too low, or dangerous for a patient based on the rest of their chart.  I look at every patient’s medication list and make sure everything on the list makes sense.  I also make sure everything is being monitored and kept track of throughout the day.

Today, for example, only a couple of pharmacists were assigned so only the orders and problems were taken care of.  Doctors often don’t realize that the patient is on certain meds when they order others or they don’t know what other procedures the patient is undergoing at the same time.

In hospitals, there is a strong preference for the hospital to provide all of the medications, including those the patient is on at home.  Usually the nurse enters the home medications into the system and those get ordered and provided by the hospital instead of bringing in their own.  This is for the patients’ safety and to make sure the nurses know everything the person is taking.  With certain meds, like those for heart arrhythmias, it could be dangerous for the patient to miss doses.  The pharmacists double check to make sure important home medications have been continued- this is called medication reconciliation.

We are also there to help the nurses on the unit – sometimes they will call if a medication isn't there and it should be and we do ad hoc things in the moment for patient.  We will also be asked questions about the medications through IV lines to make sure they are compatible.  Some combinations of medicines will crystallize in the IV so we make sure that doesn't happen.

There are also specialty medications that are not available at all retail pharmacies that are then provided by the hospital because a gap in care would be bad for the patient.  We also counsel the patient to make sure they understand the drug and all the side effects and interactions.  We are a lot closer to the medical team and make a lot more of the dosing decisions than there would be in a retail situation.

During my residency at VA, I found out that there are also pharmacists at outpatient clinics who work closely with doctors to try and solve medicine problems.  Basically they work to modify the medicines based on the blood sugar logs for diabetics, for example – it is not just giving meds, but also modifying combinations of medications to provide the best care.

What surprised you most about the profession?
I got the idea from my mom – I was thinking about medical research.  Previously I thought it was basically counting pills and came to understand there were more opportunities to research and understand the medicines in a medical setting.

Pharmacists also sometimes work for insurance companies to help them determine which drugs to cover and at what cost.  Sometimes they consult for nursing homes because there is a mandate that pharmacists review the medicines for patients in nursing homes for safety.  Some will drive around to nursing homes and review those meds.

A long time ago – pharmacists actually mixed and created their own medicines.  Nowadays, specialty compounding pharmacies can mix own compounds that wouldn’t be available commercially.  Sometimes they mix hormonal creams and compounds as well for women, or medications for children to make medicine easier to take.  These specialty pharmacies are becoming more common again.

The basic skill of figuring out the mixtures is taught in pharmacy school – and compounding was practiced in school as well.  Getting good at it would require on the job training or studying with someone who had done it more.  It is done sometimes in the hospital setting for things not available commercially (or much cheaper to compound it) – there is a compound specialist at the hospital who does that the majority of the time.


While interning, it was my job to mix big batches of butt cream for babies and people with rashes.  Mixing is similar to cooking – it can be fun – it needs to be correct, but can also be neat to do.  Also, one of the things we learned in school was “pharmaceutical elegance” – for creams: swoop it around so it looks new in the jar.

What about the idea that pharmacists are just “pill counters”?

The techs tend to do the actual counting – in retail, the pharmacist’s job is to check the legality, dosing and ensure that the patient isn’t going to have drug interactions.  They would have to call the doctor and make sure the doc knows about other meds if there is a possible interaction.  You’re then the final check to make sure it is the right drug, right amount and sometimes you have work with the insurance company when drugs get rejected by people’s insurance.

One thing that has changed is the addition of vaccines at pharmacies – now many pharmacists are trained to do vaccinations when they weren’t before.  Some are trying to be more proactive about the medications and making sure there are no interactions and if there are would call the doctor – that’s called medication therapy management and they can actually bill some insurance plans for the time for that service if it is provided.

The problem is – big chains are focused on pushing prescriptions for profit so pharmacists aren’t encouraged to do as much as they should – even the reimbursement doesn’t cover the cost of the time.  There are clocks on computers a lot of the time that time the filling of the prescriptions and a lot of pressure to be fast instead of spending a lot of time understanding the patient.  They sometimes get called ‘fast food pharmacies’ and that is where the pill counter reputation comes from.

Is there anything that is exactly what you thought it would be?
I always expected to be focusing on the patients and making everything safe and appropriate – that is true across all previous jobs and settings.  My main role and benefit to the team is making sure patients get the right medication and right dose safely and appropriately – mostly catching interactions and issues.

It is very common that there are potential mistakes, dosing, etc… sometimes even every third or fourth order has an issue.  Really there are two double checks because both the pharmacist and the nurse end up looking at everything.  When there is an interaction – it isn’t just about correcting – it is about recommending a solution to the problem and sending that recommendation back to the doctor along with noting the concern.

Are there sometimes hard cases?

The hardest are when there are different doctors managing the patient at the same time – getting them all to agree and make changes is hard.  For example, we had a heart transplant patient with a lot of complications.  Doctors found a type mold growing in his lungs because his immune system had to be suppressed for the surgery.  It takes forever to figure out what the mold is so they had him on two different anti-fungals and both could harm kidneys and interact with transplant drugs – most of the doctors agreed that one of the drugs needed to be dropped because of damage, but the infectious disease team insisted because they didn’t know which would do it.  Sadly, the patient ended up on dialysis because of the medications.  

We can make recommendations and point out interactions, but at the end of the day, the doctors make the call and sometimes they decide a possible interaction is worth the risk.  Sometimes the patient has two issues that rule out all drug options, one there is an allergy to and the other would harm an already sensitive organ, for example.  They don’t always turn out sad like that, but there are definitely no-win situations at times.

What is your favorite part of the job?

I love working with patients one-on-one.  I get to go to the heart transplant clinic and talk to them about the drugs they’re taking.  A lot of times, no one had explained the drugs to the patient before I got to talk to them – so they are very appreciative and want to take the drugs the right way because they understand how it works.  That is a really good feeling.

It was great to chat with Lisa about being a pharmacist - we learned a lot about the importance of having someone who really and truly understand medications helping treat the patient.  I hope everyone takes a few minutes to think about the hard work and detailed knowledge that goes into being a pharmacist and to appreciate everything they contribute to our health.  Happy Pharmacist Day everybody!