Aine Cryts

Follow news coverage about scientific discoveries to prepare for the questions you’re likely to get from patients: That’s the first piece of advice on communicating with patients about scientific information, says Cherokee Layson-Wolf, PharmD, BCACP, FAPhA, professor of practice, sciences, and health outcomes research at the University of Maryland School of Pharmacy.

Patients have a lot of information coming at them from watching television and engaging with social media. The challenge? According to Layson-Wolf, patients often don’t know how to analyze the news they are watching or the stories their friends and family are sharing on Facebook, Twitter, and Instagram.

Layson-Wolf is often asked about the effectiveness of influenza shots, for example. The CDC will typically determine that the effectiveness of influenza vaccines in a given year is between 30% and 40%, she said. When patients learn these statistics, they often weigh the possible adverse effects of a vaccine with the benefit of getting a vaccine. She explains to patients that the number of reported influenza cases is likely inaccurate because many people who were deemed to have the disease were never actually tested.

As a result, she advises patients to always get the influenza vaccine. “It absolutely, truly makes sense that you get [it] because the flu strains change every year,” she said. “The flu [vaccine] will have a different effectiveness based on the flu strain that’s circulating that year.”

She stressed that there can also be a cumulative effect when patients get the influenza vaccine each year, which means they have additional protection. Layson-Wolf’s advice to patients is simple: “Just keep it in your routine.”

Here are 3 more tips to help pharmacists become more effective scientific communicators:

1. Ask the patient what they’re concerned about.

“What are some of the questions you have?” That’s the question Layson-Wolf uses to understand why a patient doesn’t want to get an influenza vaccine, for example. Don’t assume, she said, that a patient is hesitant because of the effectiveness rate.

“Even if the concern, in your mind, isn’t logical, it’s still so important to convey yourself as a trustworthy resource,” said Layson-Wolf. “It takes a long time to build that kind of a relationship. A lot of the success of being able to [explain] some of the scientific information is being able to [be] somebody [the patient trusts].”

Each patient has a different background and a different level of health literacy. As a result, the pharmacist has to “level-set to see where [the patient] is coming from,” said Layson-Wolf.

Questions about the HPV vaccine and the potential impact on teenagers’ sexual activity are also common, according to Layson-Wolf. Here’s how she responds: “This is one of the first vaccines we’ve got that prevents cancer. And if you had that chance to prevent cancer for your kid down the road, wouldn’t you take that chance?”

2. Address misinformation while validating concerns.

Questions about medication-assisted treatment for opioid use disorder are common among patients and their family members, said Anita Jacobson, PharmD, a clinical professor at the University of Rhode Island College of Pharmacy. “A lot of times what we see is patients or caregivers come in with misinformation….People feel that their loved one has traded one addiction for another when they start taking methadone or buprenorphine for opioid use disorder. It’s a common thing.”

Jacobson advises pharmacists to validate the patient or family member’s concern using the principles of motivational interviewing. She suggested responding with: “This is something we hear from a lot of people, and it makes sense. The person that you are referring to was previously using opioids and now they’ve transitioned over to another opioid. Would it be OK if I take a few minutes to talk about how methadone and buprenorphine are different from opioids like heroin and synthetic fentanyl that are now in the drug supply?”

She stressed that it is important to ask patients for permission. “If we just launch into our explanation and blow past that first step of validating that person’s concerns and asking permission to give them information, it really causes them to lose face and dig deeper into their trench,” said Jacobson. “They feel challenged [and] they don’t feel heard. People really do need to feel heard by their health care provider.”

Once the pharmacist has permission, they can explain the difference between an addiction and physical dependence. With addiction, an individual’s thoughts are consumed by their next dose and they exhibit aberrant behaviors, whereas physical dependence is experienced by a patient who takes methadone or buprenorphine, she explains.

“Physical dependence just means that your body needs that drug in order to avoid going into withdrawal symptoms or develop[ing] cravings,” said Jacobson. She compared the experience to a patient who has diabetes and needs to take insulin.

“The key is to make the person feel that you are talking with them,” she added. “You are directly addressing their core concern and you’re hearing them. And you’re matching the information you’re providing with what their concern is.”

In addition, Jacobson said she often fields questions about research of which she’s not aware. Her way of handling these scenarios is to ask questions, such as about the sample size, for example.

What typically happens then is that the patient’s premise falls apart because they don’t know that information, she explains. But Jacobson counseled against losing the patient’s engagement, and suggested saying the following: “Well, it’s so tough, it’s really hard to know which studies are validated and well done [and] peer-reviewed.”

3. Offer to call the patient later if it’s busy.

If the line is long at the pharmacy counter, Layson-Wolf recommends that pharmacists use this response with patients: “Thank you for sharing that with me. Is it OK if I give you a call later when it’s a little bit slower so we can have some time to talk about this?”

Articles

Pharmacists can help educate patients as they try to analyze scientific information shared via the news or social media.

Science Communication Tips for Pharmacists

Cannabidiol (CBD) isn’t new in the pharmacy space, but Lisa Faast, PharmD, describes it as a “nascent category” because of the questions surrounding its legality. Also muddying the waters is its similarity to marijuana, she says.

Cannabis includes 2 compounds: Δ-9-tetrahydrocannabinol (THC) and CBD

; THC produces the high associated with marijuana use.

 And according to the FDA, it is “currently illegal to market CBD by adding it to a food or labeling it as a dietary supplement.”

 If a product has a maximum of 0.3% THC, it’s legal because it is mostly CBD.

Still, Faast expects changes from the FDA, despite the fact that selling CBD products is legal, because of the amount of clinical research that shows these products “benefit patients on a very broad scale.”

Faast described a conversation she had with a woman who experienced endometriosis severe enough to require multiple surgeries. After using a vaginally-applied CBD product, the woman’s life was, Faast said, changed. “A lot of women have already tried…the [nonsteroidal anti-inflammatory drugs], the birth control, the hot compresses; they’ve tried everything, but [they’re] still not having a normal life.”

For vaginal application, there aren’t any major drug interactions a pharmacist needs to worry about. And, frequency of use varies widely. “It really depends on the woman and her symptoms,” she said. “Some women only have bad cramps rarely; others have bad cramps every month. It’s one of those things where [if] you know you have [pain] every month, it’s recommended that you use [one applicator] every day.…Each patient finds their own ‘rhythm,’ but for patients with endometriosis, they’re probably going to want to take it daily.”

If a woman knows she has debilitating cramps 2 days a month, she may consider taking the CBD product 2 days before her period starts, which will prevent the pain, Faast added. And since each woman’s experience is different, Faast typically asks patients about the frequency of their menstrual cramps or endometrium-related pain before making any dosing recommendations.

Although these products are popular, pharmacists should pay attention to CBD products in the women’s health space. “There's a growing prevalence of use...but there’s still limited data on safety due to various different reasons,” said Jamie Lo, MD, associate professor of obstetrics and gynecology at Oregon Health and Science University in Portland. These products, she added, can be difficult to study due to the lack of reproducibility, and because they’re not approved by the FDA they are not comparable.

Lo compared CBD product usage to measures of alcohol consumption. “It’s not like you’re saying, ‘I had 4 cans of beer and 2 glasses of wine.’ That’s a lot easier to quantify the contents. [With] CBD,…It’s just not regulated.”

It’s important for pharmacists to be prepared for a variety of questions from women regarding CBD products, and those questions will be determined by the age of the patient, said Lo. Women are most likely to ask about the impact of CBD products on their fertility and pregnancy, in addition to the ability of CBD products to alleviate menopausal symptoms and menstrual and other types of pain, she explained.

The THC in CBD products can impact women’s menstrual cycles and their ability to get pregnant. In her research about daily THC edible use among female monkeys, Lo and her co-authors found that the monkeys with a 28-day menstrual cycle could see that cycle stretch to 38 days.

In another article, Lo and colleagues observed that the use of cannabis “has been associated with altered reproductive hormones, menstrual cyclicity, and semen parameters.…In females, cannabis use has been associated with infertility and abnormal embryo implantation and development.”

Other findings from the article: Cannabis use during pregnancy and while breastfeeding can lead to preterm birth or impact an infant’s size at birth, in addition to having neurodevelopmental consequences and sociobehavioral and cognitive development impacts. Lo also found that there isn’t enough information available about the impact of cannabis to understand its potential impact on reproductive health and fetal development.

Her advice? Pharmacists can counsel patients that “there’s a lot of research in this area in the pre-clinical and human studies [showing] that CBD and THC products may be associated with adverse impacts on reproductive health and fertility. As such, you should talk to your health care provider if you’re thinking about conceiving in the future before use.”

1. What you need to know (and what we’re working to find out) about products containing cannabis or cannabis-derived compounds, including CBD. FDA. Reviewed March 5, 2020. Accessed August 28, 2022. 

https://www.fda.gov/consumers/consumer-updates/what-you-need-know-and-what-were-working-find-out-about-products-containing-cannabis-or-cannabis

2. The controlled substances act. Drug Enforcement Administration. Updated July 25, 2018. Accessed August 28, 2022. 

3. Ryan KS, Mahalingaiah S, Campbell LR, et al. 

The effects of delta-9-tetrahydrocannabidinol exposure on female menstrual cyclicity and reproductive health in rhesus macaques.

i. 2021;2(3):287-294. doi:10.1016/j.xfss.2021.05.001

Impact of cannabinoids on pregnancy, reproductive health and offspring outcomes.

. 2022;S0002-9378(22)00420-3. doi:10.1016/j.ajog.2022.05.056

CBD can be used to treat a myriad of women’s health conditions, but research is still limited.

Women and CBD: Increased Interest, but Caution Is Warranted

Although Jenna Carmichael, PharmD, advises each pharmacist to look into the legal implications of selling CBD products in the state where they practice, CBD, or Cannabidiol, is legal on a federal level following the passage of The Agriculture Improvement Act of 2018, or the 2018 Farm Bill.

 Carmichael is a holistic oncology pharmacist at Clarks Summit, Pennsylvania-based Wobbly Arrow Wellness.

If a product has a maximum of 0.3% tetrahydrocannabinol (THC), it is legal because it’s mostly CBD, and Carmichael suspects that is the reason why CBD products are being sold at gas stations, online, and in local pharmacies. THC is the compound that produces the “high” that’s often associated with marijuana.

Just as important as demystifying CBD products for patients is “demythifying” them, said David Kroll, PhD, a professor in the department of pharmaceutical sciences at the University of Colorado Anschutz Medical Campus in Aurora.

One area with a need for education and awareness is around the conditions where CBD is approved by FDA as a treatment. CBD has been approved by FDA to treat children with rare childhood epilepsy syndromes where they may be debilitated by experiencing as many as tens of dozens of seizures each day, said Kroll.

In 2018, Epidiolex (cannabidiol) was approved by FDA for the treatment of seizures associated with two rare and severe forms of epilepsy, Lennox-Gastaut syndrome and Dravet syndrome, in patients 2 years of age and older.

With Lennox-Gastaut syndrome, patients can experience tonic seizures where the body stiffens, the eyes gaze upward, the pupils become dilated, and patients experience altered breathing patterns; often, periods of frequent seizures are mixed with relatively seizure-free periods.

 Seizures are often triggered by high temperatures with Dravet syndrome, where patients may experience loss of motor skills, intellectual disability, speech impairment, and difficulty with movement.

Here’s what pharmacists need to know about 4 different CBD products:

There is some disagreement among pharmacists and other experts on the effectiveness of topical CBD products. According to Carmichael, topicals can be a great way for patients to “put the relief right where they need it.” They can be used in a similar way as muscle rubs, she added. “[The patient] will get that local relief, right where [they] need it, [such as] on the knee or the hip, but it’s not going to be systemically absorbed.”

Still, as with any other treatment, it’s important to tell patients about potential drug interactions, Carmichael, who’s also an adjunct faculty member at Wilkes University’s Nesbitt School of Pharmacy in Wilkes-Barre, Pennsylvania, advised. For example, warfarin (Coumadin), which can be used to prevent blood clots from forming or growing larger, is one drug that could interact with a topical CBD product.

The hypothesis is that CBD product’s anti-inflammatory effects might be useful for a topical product for knee or back pain, Kroll explained. Still, the concentration of CBD in these products is unlikely to have a biologic effect in joints and through the skin.

Tim Gregorius, RPh, vice president of operations at Latrobe, Pennsylvania–based consulting firm PRS Pharmacy Services, typically advises pharmacists that the FDA hasn’t approved of CBD products to treat most conditions. While he admitted this can be a murky area for pharmacists, a topical cream can be a good place to start.

“[If] somebody comes in and says, ‘My knees hurt, my elbow hurts, my neck hurts,’ we can put them on a topical cream immediately. Most of the time, people come back in a day and say, ‘My goodness, I haven’t been pain-free like that for years.’”

“They’re discrete…and you don’t have to smoke them,” said Carmichael, observing the reason gummies are popular among patients. Still, patients often have the misconception that gummies are a “lighter" version of CBD, she said. “The problem with gummies is there’s a delay. You have to absorb the CBD, and it has to be activated by the liver. That takes time.”

Typically, it can take between 60 and 90 minutes, dependent on a person’s metabolism, for the gummy to kick in and deliver “the relief they’re looking for,” Carmichael noted. Some patients will take a second gummy before feeling the first gummy’s effect, which she counsels against. “Wait at least 2 hours,” Carmichael advised.

Patients who have had gastric bypass surgery have different gastric absorption than most people, said Carmichael; some of these patients say they can take “boatloads of gummies” and they have no effect, while others say gummies can take many hours to kick in. In addition, elderly patients or any patient with an unstable heart condition should be careful, according to Carmichael. The effect of CBD may stretch 6 to 8 hours, which could lead to stress or anxiety; the related anxiety could cause a heart attack, not the CBD, she said.

These products are oil extracts, Carmichael explained. It is common to find almond and coconut oils used with CBD. Tinctures are often used with children, she explained.

The ability to individualize the dose with a dropper is a benefit of tinctures, said Carmichael. She typically recommends tincture products to patients who want to be able to escalate or reduce the dose while avoiding the need to return for a new strength of a CBD product.

Although delta-8 is similar to delta-9 THC, it is not quite as psychoactive, according to Carmichael, since delta-8 is derived from hemp and not from medical cannabis. One thing Carmichael has learned about the use of delta-8 is that people will simply take more to get the level of effect expected with delta-9 THC.

“That can be problematic,” she said. ”These products are being vaped and these products are easy to conceal, so it’s easy for people to get their hands on [them].

Across all CBD products, Kroll advises pharmacists to conduct due diligence to ensure that the products meet quality standards. “It’s pretty much left to the manufacturers in most states," he said. "And even at the federal level, the FDA still hasn’t come out with strong guidance with CBD products."

1. The Agriculture Improvement Act of 2018 (2018 Farm Bill). H.R.2. 115th Congress (2017-2018).Accessed August 25, 2022.

https://www.congress.gov/bill/115th-congress/house-bill/2

2. FDA and cannabis: Research and drug approval process. FDA. Reviewed October 1, 2020. Accessed August 25, 2022. 

https://www.fda.gov/news-events/public-health-focus/fda-and-cannabis-research-and-drug-approval-process

3. FDA-approved drug Epidiolex placed in Schedule V of Controlled Substance Act. United States Drug Enforcement Administration. Published September 27, 2018. Accessed August 25, 2022. 

https://www.dea.gov/press-releases/2018/09/27/fda-approved-drug-epidiolex-placed-schedule-v-controlled-substance-act

4. Lennox-Gastaut Syndrome. National Institute of Neurological Disorders and Stroke, National Institutes of Health. Reviewed July 25, 2022. Accessed August 25, 2022. 

https://www.ninds.nih.gov/health-information/disorders/lennox-gastaut-syndrome

5. Dravet syndrome. National Center for Advancing Translational Sciences, National Institutes of Health. Updated November 8, 2021. Accessed August 25, 2022. 

https://rarediseases.info.nih.gov/diseases/10430/dravet-syndrome

CBD products range from gummies to tinctures to topical lotions and creams.

CBD Products: What Pharmacists Need to Know

Cigarette smoking claims more than 480,000 American lives—approximately 1 in 5 of total US deaths—each year, according to the CDC. This makes smoking the leading cause of preventable disease, disability, and death in the United States.

Although the number of smokers continues to fall, about 13 of every 100 US adults were smoking cigarettes in 2020 (12.5% vs 20.9% in 2005). This means that approximately 30.8 million American adults smoke cigarettes,

 and more than 16 million are living with smoking- related conditions.

Joe Moose, PharmD, clinical pharmacist, co-owner of Moose Pharmacy in Mount Pleasant, North Carolina

According to Joe Moose, PharmD, a clinical pharmacist, co-owner of Mount Pleasant, North Carolina-based Moose Pharmacy, and director of strategy and luminary development with CPESN USA, smoking-cessation programs are an ideal way for independent pharmacists to collaborate with physician practices.

“What we don’t have in health care are good signals of failure,” said Moose. A primary care physician (PCP) can tell their patient to quit smoking, write prescriptions for nicotine patches and amlodipine to control their blood pressure, and ask the patient to buy a blood pressure cuff for monitoring purposes. But too often, the patient doesn’t act on their physician’s recommendations.

The PCP’s goals include controlling their patient’s blood pressure and starting them on a smoking-cessation program. But without access to the patient’s care plan, the pharmacist doesn’t know that the PCP wants their patient to start the program and monitor their blood pressure in the first place.

At Moose Pharmacy, prescriptions will pop up for smoking-cessation patches and amlodipine, but the patient may tell Moose they are not ready to quit smoking. The conversation could end right there, the patient becoming a statistic who joins the more than 16 million Americans living with smoking-related conditions. Or the pharmacist can seize the opportunity to partner with the PCP and ensure they have access to the patient’s care plan, said Moose. The challenge is getting paid for this work. The solution, according to Moose, is what he calls a neighborhood accountable care organization (ACO).

Embed Pharmacists in the Physician’s Practice

The immediate impact of the pharmacist’s lack of awareness of the patient’s care plan is that the patient may pick up their amlodipine but not start the smoking-cessation program or use the cuff to monitor their blood pressure at home, said Moose.

The remedy is to embed a pharmacist in the PCP’s office for 40 hours a week to learn about patients’ care plans and reinforce and support their efforts to quit smoking, manage their diabetes, or control their blood pressure, he added. This enables the pharmacist to meet with patients directly following their visits to the practice. Immediate benefits include the opportunity for the pharmacist to earn in real time about patients’ care plans, access the practice’s electronic health record, and receive a “warm hand-off” from the clinicians at the practice as an integrated part of the patient experience, Moose explained. These connections are initially made in person at the practice between the embedded pharmacist and the clinical team. And when patients receive a follow-up call from a pharmacy technician at Moose Pharmacy, the whole process feels seamless.

This same collaborative model can be applied in the treatment of other chronic conditions, such as diabetes and hypertension. It can also help the practice successfully achieve quality measures to ensure the practice gets its full value-based care payments, Moose added.

That’s where the neighborhood ACO model comes in, explained Moose. Creating a neighborhood ACO means that accountability for patients doesn’t just rest with the PCP while the pharmacist focuses only on dispensing medications and working with the pharmacy benefit manager. Instead, both physician and pharmacist are accountable for the same measures, which can include reducing blood pressure or getting patients to stop smoking, 2 goals of the value-based model, according to Moose.

What’s missing, though, is assurances that the pharmacist is paid in addition to the PCP’s practice. Moose kickstarts compensation conversations with the practice leader after collaborating on data mining to determine missed annual wellness visits for adult patients, chronic care management opportunities, remote patient monitoring opportunities, and the number of patients with diabetes whose glycated hemoglobin A1C levels are above 9, an indication their condition is being poorly treated.

The simple question Moose poses to practice leaders is this: “If [our pharmacists] complete these things and bring in half a million dollars in payments to the practice, is that worth making a $100,000 payment to Moose Pharmacy?”

But even if Moose is successful with this pitch and delivers on the value promised to the practice, he knows his pharmacists must continue to deliver value or he risks the practice choosing to hire a nurse to take on the same work at 70% of the cost.

Moose’s advice? “You have to be valuable...and help generate income.”

Jessica Gustin, PharmD, pharmacy manager at Gwinnett Drugs in Lawrenceville, Georgia

Jessica Gustin, PharmD, pharmacy manager at Gwinnett Drugs in Lawrenceville, Georgia, agreed it’s important for pharmacists to show their worth to physicians. Consultations with patients experiencing chronic pain is one area in which she has achieved success. Providing this service is important because many people pass judgment on individuals taking opioids for pain management when they may actually need them, said Gustin. She is also cofounder and chief operating officer of SynerGrx, based in Chamblee, Georgia, which facilitates collaboration between pharmacists and physicians.

After asking patients about their pain management challenges, Gustin can discuss the adverse effects of opioids, provide access to naloxone HCl (Narcan), and suggest patients participate in physical therapy.

Collaborate With Physicians on Diabetes Management

Eklavya Lalwani, PharmD, pharmacist-in-charge at Olden Pharmacy in Hamilton, New Jersey, said that pharmacists—with their 6 to 8 years of education in a pharmacy school program in addition to clinical knowledge and skills—are uniquely prepared to provide clinical services. Despite this education and experience, though, pharmacists are “extremely underutilized,” he said.

Eklavya Lalwani, PharmD, pharmacist-in-charge at Olden Pharmacy in Hamilton, New Jersey

Lalwani, who is also a preceptor for Fairleigh Dickinson University School of Pharmacy and Health Sciences, said a good way to start collaborating with physician practices is to focus more closely on patients with diabetes. For example, when a patient says their insulin is too expensive, the pharmacist can call the physician and suggest the patient switch to a less expensive biosimilar with a lower co-pay. Most of the time, the pharmacist is talking to the receptionist, a medical assistant, or a nurse in these conversations. Over time, these team members start to remember the pharmacist and look to them as an expert. Lalwani also steals a page from the pharmaceutical sales rep’s book by occasionally showing up for quick in-person meetings at practices.

The ever-present challenge, though, is getting paid for chronic condition management, Lalwani noted. The American Society of Health-System Pharmacists (ASHP) provides guidance to pharmacies on billing Medicare for diabetes self-management. First, the pharmacy needs to set up a diabetes self-management training/education program that has been accredited or recognized by the American Diabetes Association or Association of Diabetes Care & Education Specialists. The program can be run and managed by a registered dietician, nurse, or pharmacist.

For billing, the pharmacy must use the practice’s or pharmacy’s National Provider Identifier (NPI) rather than the pharmacist’s NPI. Payment can range from $15 per patient for a group-based diabetes self-management training education session to $51 for a 30-minute session for an individual patient, according to ASHP.

“Ultimately...the primary role of the pharmacist is ensuring that medications are utilized in the safest, most effective, most efficient manner,” said Tom Kalista, PharmD, a lecturer at the University of Rhode Island College of Pharmacy. “Facilitating communication is only going to enhance that.”

Tom Kalista, PharmD, lecturer at the University of Rhode Island College of Pharmacy

Frequently, the biggest pitfalls are difficulties that occur between prescribing and dispensing, he said. Reviewing drug use and insurance coverage and addressing questions about cost and dosing concerns can take weeks, which introduces delays in patients’ receiving therapy, Kalista explained. “Any delays have an impact in terms of long-term outcomes.”

Kalista recalled a time over the Christmas holidays when a family of 5 came to the pharmacy unsure if they all had COVID-19 or strep throat. As a result of the pharmacy’s collaboration with a local physician, the family was able to access a diagnosis and treatment within 25 minutes. In addition, they were advised against going to a New Year’s Eve party to avoid spreading the strep infection.

“Picking up the phone or walking into the physician’s office is probably the biggest hurdle to [collaboration] because all the parties have the same intention, [which is caring for patients],” Kalista said.

1. Current cigarette smoking among adults in the United States. CDC. Updated March 17, 2022. Accessed May 16, 2022. 

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

2. Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco product use among adults – United States, 2020. 

. 2022;71(11):397-405. doi:10.15585/mmwr. mm7111a1

3. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress. CDC; 2014. Accessed May 16, 2022. 

https://www.ncbi.nlm.nih.gov/books/NBK179276/

4. FAQ: alternatives to “incident-to” billing for revenue generation in non-facility (physician-based) ambulatory clinics for pharmacists. American Society of Health-System Pharmacists. March 2019. Accessed May 16, 2022. 

https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/alternatives-to-incident-to-billing-2019.pdf

As a pharmacist, embedding yourself in a primary care practice can have positive outcomes for both patients and your business.

Empowering Pharmacist-Physician Collaboration

Elizabeth Gooking Greenleaf blazed a trail as the first female pharmacist in the United States, opening a Boston apothecary shop in 1727—the only one helmed by a woman in the entirety of the New England colonies.

Since then, many thousands of women have joined the same ranks as Greenleaf. According to the US Bureau of Labor Statistics, 57.8% of all practicing pharmacists in 2020 were women,

 and data from that same year from the American Association of Colleges of Pharmacy showed that women made up 64.6% of the total number of pharmacy students enrolled in their first professional degree program.

 shares the story of 3 women making their own mark on the industry.

For Zarina Jalal, PharmD, community pharmacy runs in the family. Her earliest role model was her father, who owned Lincoln Pharmacy in Albany, New York, when she was growing up.

“I was always surrounded by pharmacy,” said Jalal, who is now supervising pharmacist at Lincoln Pharmacy, which has served the Albany community since 1935 and has been owned by her family since 1988. “I’m the youngest of 3 [siblings]. When my mom needed a break, she’d drop me off at the pharmacy,” she joked.

She remembers taking countless naps in her dad’s office at the pharmacy. Today, however, her days are spent managing the team of pharmacists and pharmacy technicians.

“I always loved coming to the pharmacy and seeing what my Dad did,” she said. “I didn’t like the hours; he was always at work. Growing up, he didn’t have a backup pharmacist—he was always running the entire show.”

Although that experience gave Jalal pause when pursuing a career
as a community pharmacist, she has relief help from the other pharmacists on her team. That help enabled her to spend a day recently serving as a luminary for the Community Pharmacy Enhanced Services Network (CPESN)—a clinically integrated, nationwide organization of local networks made up of individual community-based pharmacies working to empower community pharmacy practice—and helping with the Flip the Pharmacy initiative. This practice transformation initiative “aims to ‘flip’ community-based pharmacies away from point-in-time, prescription-level care processes and business models to longitudinal and patient-level care processes and business models through the use of hands-on coaching.”

That same day, Jalal also popped back into the pharmacy to give the pharmacist “a bit of a break,” coached a pharmacy technician on her team, and ended the day at a fundraiser for a local assemblyman who is also
a pharmacist.

Jalal is no stranger to advocating for community pharmacy. In October 2020, she wrote an opinion piece published in Albany’s 

 urging the New York Legislature to sign a bill regulating pharmacy benefit managers (PBMs).

“Like [then–New York Governor Andrew] Cuomo, I have followed in
my father’s footsteps to a profession where I proudly serve my community,” she wrote, referring to Cuomo’s father, Mario Cuomo, who served as New York governor from 1983 to 1994. “I also grew up in my father’s shadow and take great pride in upholding my father’s legacy. I want the same for my children. I want them to have the option of upholding the legacy of Lincoln Pharmacy and serving the community that has supported us for so many years.” 

New York Governor Kathy Hochul announced in January 2022 that
she had signed a bill requiring the licensure and registration of PBMs.

 “This landmark law creates the most comprehensive regulatory framework in the country for [PBMs], increasing transparency for consumers and shedding light on the cost of prescription drugs,” Hochul said in a news release. “Navigating costs associated with medications and insurance can be difficult, so I am proud to sign this legislation to make it that much easier.”

Looking back on her life and career so far, Jalal said she understands the “virtue of patience.”

“I’m someone who likes to see results for my actions—I want to see my results instantly,” she noted.“But you have to lay a foundation and do the groundwork. You won’t see the results immediately. It may be a year or two later.”

Michelle Farrell, PharmD, BCACP, grew up on a dairy farm in a small town in Wisconsin. She credits the now-retired Connie Kraus, PharmD, of University of Wisconsin Hospitals and Clinics in Madison, with inspiring her to become a pharmacist.

Today, Farrell is a pharmacist and owner of Boscobel Pharmacy in Boscobel, Wisconsin, and Center Pharmacy in Richland Center, Wisconsin. Within her practices, smoking cessation programs are one of her passions, she explained. Farrell’s mother, who was a smoker, passed away in 2006 due to lung cancer.

Farrell describes herself as a “strong tobacco-cessation advocate. ”That means she actively engages in conversations with patients to get them to quit smoking. That conversation might take place when a patient shows up at her pharmacy with a prescription to address bronchitis or for chronic obstructive pulmonary disease brought on by smoking.“ The copays and the drugs are adding up. The pill burden is adding up. They’re really amenable to accepting recommendations for change,” said Farrell, who’s a CPESN luminary for Wisconsin.

Her approach with patients is simple: Farrell asks, “Have you considered quitting smoking?” Often, the question prompts a longer conversation about the cost of quitting and the patient’s inability to tolerate smoking-cessation medication in the past, she explained. “That’s a great opportunity to have a conversation and immediately adjudicate a claim with their health insurer to see what’s covered and [to] get them set up for that ‘quit event,’” Farrell said.

Her advice for early-career pharmacists? “Be a sponge; soak in all the information around you,” she said. “Identify what you enjoy and what you don’t enjoy.”

Brooke Kulusich followed her older sister into the pharmacist profession.“I was very inspired by her journey,” she said. “I remember how much she studied and how hard she worked— the initial semesters that she was
in school and how hard they were. I really saw her persevere and grind through it.” 

Kulusich is a PharmD candidate at the University of Pittsburgh School of Pharmacy in Pennsylvania, graduating in 2022. She also serves as the 2021
to 2022 American Pharmacy Association–Academy of Student Pharmacists speaker of the house.

“We had quite a bit of illness in our family,” said Kulusich about her decision to go to pharmacy school. “I watched our grandparents get sick and be in the hospital, [and] I remember how my parents would struggle to play doctor or pharmacist. I wanted to play that role as a pharmacist and help families.”

Next up for Kulusich is a job at a management consulting firm in Chicago, where she’ll be “putting the white coat away.” Kulusich will work on a team that provides strategic business advice to health plans and biotechnology companies to help them improve their sales and marketing efforts.

As she prepares to embark on that journey, Kulusich has one piece of advice for her younger self: “Step outside your comfort zone. That’s where you’ll find the most growth and meaning.”

Eilders C. Celebrating women in pharmacy. Pharmacy Quality Solutions. October 12, 2021. Accessed April 6, 2022. 

https://www.pharmacyquality.com/2020/10/12/celebrating-women-in-pharmacy/#_ftn1

Labor force statistics from the current population survey. US Bureau of Labor Statistics. Updated January 20, 2022. Accessed April 6, 2022. 

Academic pharmacy’s vital statistics. American Association of Colleges of Pharmacy. Accessed April 6, 2022. 

https://www.aacp.org/article/academic-pharmacys-vital-statistics

What is Flip the Pharmacy? Flip the Pharmacy. Accessed April 7, 2022. 

Jalal Z. Sign bill to regulate pharmacy benefit managers. 

. October 6, 2020. Accessed April 6, 2022. 

https://www.timesunion.com/opinion/article/Sign-bill-to-regulate-pharmacy-benefit-managers-15626579.php

Governor Hochul signs landmark legislation bringing transparency and a comprehensive regulatory structure to otherwise unregulated pharmacy benefit managers. News release. Office of the Governor. January 2, 2022. Accessed April 6, 2022. 

https://www.governor.ny.gov/news/governor-hochul-signs-landmark-legislation-bringing-transparency-and-comprehensive-regulatory

Three pharmacists share their stories, challenges, and lessons learned.

Women in Pharmacy Make Their Mark on the Profession

In 2011, nearly half of the 6.1 million pregnancies—or 45%—in the United States were unintended.

 The highest rates of unintended pregnancy are among women with low incomes earning less than 200% of the federal poverty level, women aged 18 to 24 years, cohabitating women, and women of color.

Contraceptive access just is one area in which pharmacists can help women, said Veronica Vernon, PharmD, assistant professor of pharmacy practice at Butler University College of Pharmacy & Health Sciences in Indianapolis, Indiana. Access to a pharmacist can also help women who experience menstrual disorders, including menstrual pain, irregular periods, and heavy or unusual bleeding.

Access to care for women with menstrual disorders was particularly acute during the COVID-19 pandemic, noted Vernon, who is also a clinical pharmacy specialist in ambu- latory care for gynecology and primary care at Richard L. Roudebush Veterans Affairs Medical Center in Indianapolis. More women than men missed recommended preventive services, including yearly checkups and routine tests, and women with low incomes were more likely to have missed these preventive health services.

A variety of factors make care access challenging for women with lower incomes, including inconsistent transportation, lack of childcare, limited insurance coverage, and a work schedule that prevents them from going to medical appointments, according to a commentary published in Pharmacy.

“Equipping community pharmacies with specialized skills in family planning will increase their ability to meet patient and community needs and subsequently reduce barriers to access. Newly developed learning resources...are a bridge to successfully implementing practices [that] reduce stigma, increase patient satisfaction, and improve health outcomes,” wrote the authors, one of whom was Sally Rafie, PharmD, BCPS, APH, founder of Birth Control Pharmacist and a pharmacist specialist at University of California San Diego.

Because 91% of Americans live within 5 miles of a community pharmacy, pharmacists are in a unique position to fill these health care gaps.

 “[Pharmacies] can be a public health hub in their communities,” Vernon said.

Pharmacists also play a meaningful role in the inpatient environment. Kayla Popova, PharmD, a clinical pharmacist specialist in obstetrics and gynecology at Michigan Medicine in Ann Arbor, spends her days rounding with obstetrics specialists who see women with high-risk pregnancies. “It’s very important to have a pharmacist on the women’s service,” Popova said.“When a woman is pregnant, there are certain medications that can’t be taken. They’re not safe in the first trimester, [but] they may be safe in the second or third trimester.” And because of some women’s past medical history, taking birth control with a lot of estrogen isn’t an option because it can lead to thrombosis, added Popova, who is also an adjunct clinical instructor in pharmacy at University of Michigan.

Pharmacists face hurdles in providing access to contraception. Without a collaborative practice agreement, pharmacists can only prescribe con- traceptives in 20 states.

 Pharmacists, however, are aware that women experience challenges accessing birth control. “We’ve all received those panic[ed] phone calls,” Rafie said.

The pharmacist’s role is to serve as a resource to patients who need birth control, Rafie explained. That includes counseling and helping patients pick the contraception method that works best for them. And in states where pharmacists can prescribe contraception, that role includes writing a prescription. “This is a public health challenge,” she said.“It’s critically important that women have autonomy over their own bodies and their own health.”

Rafie, founder of the San Diego–based Pharmacists Clinic, provides contraception and other clinical services in a community pharmacy environment. Educating patients about the pharmacist’s ability to prescribe birth control is important as well.“ I definitely encourage pharmacists to make it very apparent that they’re offering this service,” she said. Education opportunities include sharing posts on social media, wearing buttons that promote the service, and using counter tents. Rafie also recommended providing a private or semiprivate space—or at least a sound barrier—to support women speaking with a pharmacist about birth control options.

Pain, psychological complaints, and tiredness are the most common symptoms associated with menstruation, and during menstruation, 1 in 3 women refrain from daily activities due to these symptoms.

 When a pharmacist sees a woman browsing the menstrual pain–relief section of the pharmacy, it’s a great opportunity to approach and ask questions, Vernon said. She recommends using this conversation starter: “You’re here looking for menstrual pain relief. What are your symptoms? How long has this been occurring?”

“You’re not going to have 20 [or] 30 minutes for this conversation,” Vernon said.“But you can have a 2-minute conversation with a patient to ask a few questions and determine if there’s something more going on than menstruation...such as overlooked endometriosis.” She also recommends using this opportunity to connect the woman with a gynecologist if she doesn’t already have one. Of course, this requires doing some research in advance to develop a list of obstetricians-gynecologists.

In her talk at a 2014 TEDxProvidence event, Alyson McGregor, MD, now the associate dean of faculty affairs and development at the University of South Carolina School of Medicine Greenville, discussed the mistake of merely focusing on reproduction when it comes to women’s health.

“Women’s health became synonymous with reproduction: breasts, ovaries, uterus, pregnancy,” McGregor said in her talk. “It’s this term we now refer to as ‘bikini medicine.’ And [it] stayed this way until... the 1980s, when the concept was challenged by the medical community and the public health policymakers, when they realized that by excluding women from all medical research studies, we actually did them a disservice—in that apart from reproductive issues, nothing was known about the unique needs of the female patient.”

Vernon agrees. Women’s health should also focus on tobacco-cessation management, cardiovascular health, and osteoporosis. And crucially, pharmacists must also be prepared to provide women’s health services to patients who aren’t cisgender women;

 transgender individuals require these services as well.

Immunizations, preventive care, medication management, and life- style changes are all services that pharmacists can provide.“Starting with immunization is a great way to focus on women’s health,” Vernon said. Pharmacists can ensure that all patients get their yearly flu vaccine and are up-to-date on human papillomavirus immunization as well, which prevents multiple types of cervical cancer in cisgender women and genital warts, anal cancers, and cancers of the mouth, throat, neck, and head in both women and men.

“Everything we look at in medicine is centered on a male lens,” Vernon said. Increasing awareness of these issues, in the pharmacy and beyond, is the first step to more equitable health care for everyone.

1. Unintended pregnancy in the United States. Guttmacher Institute. January 2019. Accessed April 18, 2022. 

https://www.guttmacher.org/sites/default/files/factsheet/fb-unintended-pregnancy-us.pdf

2. Period problems. Office on Women's Health. Updated March 16, 2018. Accessed April 18, 2022. 

https://www.womenshealth.gov/menstrual-cycle/period-problems

3. Frederiksen B, Ranji U, Salganicoff A, Long M. Women's experiences with health care during the COVID-19 pandemic: findings from the KFF women’s health survey. Kaiser Family Foundation. March 22, 2021. Accessed April 18, 2022. 

https://www.kff.org/womens-health-policy/issue-brief/womens-experiences-with-health-care-during-the-covid-19-pandemic-findings-from-the-kff-womens-health-survey

4. Pfaff A, Rafie S. Expanding pharmacy capacity for patient-centered reproductive health services. 

. 2020;8(4):236. doi:10.3390/pharmacy8040236

5. Face-to-face with community pharmacies. National Association of Chain Drug Stores. Accessed April 18, 2022. 

https://www.nacds.org/pdfs/about/rximpact-leavebehind.pdf

6. Pharmacist prescribing: hormonal contraceptives. National Alliance of State Pharmacy Associations. December 1, 2021. Accessed April 18, 2022. 

https://naspa.us/resource/contraceptives/

Pharmacists can improve quality of life for the women they care for by offering advice, education, and other point-of-care services.