The first time I met Ida, an outgoing, warm-hearted woman in her mid-80s, she shuffled into my office for a comprehensive medication review (CMR). She ambulated stooped over on a rolling walker, her husband dutifully tagging behind her with her purse and paperwork. 

Ida, a pseudonym, was the kind of person who smiled as much with her eyes she did with her mouth. As soon as we locked eyes, the walker and her stoop-and Ida’s agony-melted away. We had an instant patient-provider connection.

During the CMR, Ida told me that her ambulatory challenges resulted from an adverse drug reaction that had left her bedridden and in the hospital for months. Her long road to recovery included arduous physical therapy. Although she eventually regained the ability to walk, she required assistance. 

Over the next few months, I became Ida’s personal pharmacist. She called me for drug information and even requested that I serve as her advocate when her insurance company asked her to change to cheaper medications.

I was a recent graduate at the time, and earning Ida’s trust boosted my confidence as a new pharmacist. 

A few months after Ida’s CMR, I saw her husband standing in line at the pharmacy.

“I wonder how Ms. Ida is doing,” I said to Dan, also a pseudonym, the other pharmacist on duty.

After a brief pause, Dan said: “She died.” 

I froze. Overcome with a sudden wave of grief and shame, I left the counter and hid between the pharmacy shelves like a scolded puppy licking its wounds. 

“Frieda, it wasn’t your fault,” Dan tried to console me. “Her husband thinks the world of you.”

Ida wasn’t a relative or a close friend, but neither of these factors softened the sudden blow of her passing. Toxic thoughts began to flood my brain: What could I have done differently? Was it even appropriate for me to feel sad? Is it acceptable to ask my colleagues about how they cope when they lose a patient? I felt too ashamed-and stupid-to ask. 

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It was truly an awkward moment in my career: questioning whether my feelings were appropriate and not knowing how to process them. I would eventually learn that the emotions I experienced that day were OK, and that they are normal. 

When a patient dies under the normal provision of care, healthcare workers may struggle with strong emotions including grief and self-blame, according to Brady Shuert, project manager with Christiana Care Health System’s Center for Provider Wellbeing, where he directs their peer support program, Care for the Caregiver.

For Andrea Seitzman-Siegel, PharmD, a clinician whose experience includes various hospital settings as well as telemedicine, circumstances and the type of practice setting sometimes amplifies the emotional toll on the pharmacist.

“I have attended codes with family present and when the patient dies, I have a much harder time dealing with that than if the family was not present,” says Seitzman-Siegel, a clinical advisor at Optum. “There is something about having the family there in the room that reminds me that this is not just a patient, but someone’s loved one.”

Seitzman-Siegel also says the impact of patient death intensifies when a child dies. She recounted an incident that involved a child who drowned and who was about the same age as her own son. Witnessing the medical team exhaust all options to save the child’s life, coupled with the parents’ reactions, devastated her.

“It changed the way I viewed my own child,” says Seitzman-Siegel. She signed her son up for swim lessons that week. While she took measures to help ensure the future safety of her own child, she didn’t take action to address her emotions.

“The people at the code were given the option of counseling. While I didn’t attend due to scheduling, I think it would have been helpful,” she says in retrospect. 

“Pharmacists risk burnout if they bury their feelings and don’t acknowledge them,” warns Judith A. Smith, PharmD, BCOP, FCCP, an associate professor at the University of Texas Science Center at Houston Medical School. 

As an oncology pharmacist who frequently works with dying patients, Smith says expecting practitioners to become desensitized is unrealistic. “It’s hard to completely detach yourself from a patient emotionally because you develop relationships with them,” she explains. “Acknowledging sad feelings after a patient dies is both normal and human.”

Stories about how patient death impacts physicians are not uncommon, and they touch on grief and post-traumatic stress disorder. But articles about the impact of patient death on other healthcare professionals-such as pharmacists and nurses, many of whom tend to have more frequent and intimate patient contact-are not as common.

A study from 1987 found that 68% of pharmacy programs included some form of death education in their curricula; [Beall J, Broeseker A. Pharmacy students’ attitudes toward death and end-of-life care. Am J Pharm Educ. 2010 Aug 10;74(6):104]. However, that statistic pales in comparison to 95% and 96% of nursing and medical schools that included death training, respectively. 

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Daniel Hays, PharmD, BCPS, FASHP, a clinical pharmacy specialist in emergency medicine at the University Medical Center of Southern Nevada, attributes the sparsity of dialogue surrounding the impact of patient death on pharmacists to the lack of training they receive as students. 

However, he also believes the lack of death education in pharmacy training reflects the fluid climate of pharmacy practice and the industry dynamic shifting to more patient-centered care.

“As pharmacists, our roles have been evolving over the last 20 or so years to more bedside engagement,” Hays observes. “The traditional pharmacist didn’t do much bedside care.” 

While current Accreditation Council for Pharmacy Education (ACPE) standards encourage patient-centered care and interdisciplinary practice, ACPE offers no explicit guidance regarding training in palliative care and the emotions surrounding patient death. 

Hays says pharmacy schools should expose students to palliative care and end-of-life issues as early as possible in their curricula. Similarly, pharmacy residents can also benefit from training about death to learn coping skills for themselves and also to deal with bereaved  family and friends.

Shuert recommends that practicing pharmacists take a moment to assess their emotional health following the loss of a patient. Some clinicians may find that exercising extra self-care or taking a day off can be cathartic.

“Above all, the pharmacist should reach out for support, whether from friends, coworkers, and family, or from a professional, if necessary,” Shuert says. 

Hays took advantage of employer-provided counseling early on in his career-a service he has used regularly. 

After taking time to work through their emotions, Shuert advises pharmacists to resume their routines and a sense of normalcy as soon as possible

Another critical element is setting healthy boundaries that allow pharmacists to grieve without becoming so emotionally invested that it limits their ability to practice. Seitzman-Siegel says pharmacists can find closure while setting boundaries so they can continue serving other patients. 

For example, one of her colleagues sends sympathy cards to the patient’s family-an act that the pharmacist finds both courteous and therapeutic without being emotionally overwhelming. Saying a prayer or having sympathetic thoughts towards the patient and the family also allow pharmacists to manage their emotions in a healthy way. 

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In the oncology setting, Smith frequently uses humor to lighten the mood. Her team also makes a concerted effort to encourage a positive work culture by giving grieving colleagues small gifts such as pastries. Additionally, she finds keeping the goal of helping patients at front-of-mind makes the coping process less painful.

“Peer support is crucial to normalizing the experience for the affected team member, and reaffirming the individual’s competencies,” Shuert says. “This emotional support is a critical element to coping with the loss of a patient.”

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My Dad was a top welder at a paper mill. He had an amazing work ethic and was one of the many tough guys from America’s greatest generation. He served his country for four years in World War II. In May of 1986, he performed his toughest job, giving his only daughter, my sister Mary, away in marriage. One of his nephews asked him, “How do you feel about this day?” My Dad smiled and said, “It is like a hemorrhoidectomy-uncomfortable at first, but after a while, it will feel so good”

Change is an inevitable part of life. Our jobs change, our families change, our kids change, and whether we realize it or not, we change. Thirty-seven years of working with patients and staff has given me a different outlook. The kids are all successful, the house is paid for, and when we get our paychecks deposited into the bank, the money actually stays there! Some changes are very good.

Our profession has changed; it didn’t happen all at once, but there are definitely some highlights that have driven the changes I’ve experienced since 1981. The computerization of the pharmacy in the ’80s, electronic claims submissions of the ’90s, Medicare D in 2006, and then the Affordable Care Act. Early in my career the drudgery was filling out triplicate claim forms for insurance companies. One of my old pharmacist colleagues said back in 1990, “Young man, when you let those black boxes [modems] in your pharmacy, you can kiss your profession good-bye.” Could you possibly imagine running a pharmacy without internet access? Insurance companies bring their own challenges, and our profession had to adapt back in the 1990s. We do a whole lot more with a whole lot less.

The biggest change I’ve seen in my career is the almost exponential growth in salaries. In 1981, I started at $12.35 an hour, which was $2 an hour more than my dad. Today, my dad would be making $25 an hour. Do we know any pharmacists making $27 an hour? The “golden handcuffs” have kept many of us in less-than-optimal jobs because the paycheck is fabulous.

After 25 years in the same local chain, my wife, Denise, was offered an opportunity to open and manage a retail pharmacy in a health system. There was great comfort in what she had been doing for 25 years; she knew her patients and staff well, but didn’t want to pass on this opportunity. To the amazement of everyone (including her husband) she signed on with the health system and did an excellent job. Four years ago, Denise was asked if she knew a pharmacist who might be interested in a clinical opportunity: a paid position with Center Volunteers in Medicine (CVIM), which takes care of the underserved.

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Denise took that job and now works 18 hours a week with CVIM and one day a week at the health system. She does intense patient counseling at CVIM, where she got life-sustaining drugs for a patient from oversees, started a patient who only spoke Russian on Lantus, and has helped several Hispanic people with minimal English-speaking abilities. She coordinates hospital discharge med lists with drugs she can get free for patients. She makes a huge impact on every patient who walks into that clinic, along with the physicians who volunteer there. She has one of the most rewarding careers of any pharmacist I know. She has taken in stride the changes in this profession much to her benefit. 

Today, everyone worries about market saturation of pharmacists and the availability of jobs. Talking to health system pharmacist managers, I’ve learned there are plenty of pharmacist positions they have trouble filling. 

Remember: Your license hangs on the wall by a nail. Go find a nail that will make you and your license happy. It will be “uncomfortable at first, but after a while, it will feel so good.”

"Our jobs change, our families change, our kids change, and whether we realize it or not, we change."

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The typical pharmacist gets to spend just 10% of their working day with patients, but they want to spend exponentially more time with them; up to 74% of their time for chain pharmacists and 60% for health system and specialty pharmacists. 

That is the key take away from the first-ever Pharmacy Check-Up survey sponsored by AmerisourceBergen. This nationwide survey across practice settings found that all pharmacists expect to spend significantly more time on patient-focused activities in the next five years. 

Patients visit a pharmacy an average 35 times per year compared to just four visits to see medical providers. The potential is there to expand pharmacists’ role in providing direct patient care, but turning that potential into practice will take major changes in healthcare delivery systems.

“We are at a pivotal place in our profession,” says Matthew Wolf, PharmD, Group Vice President, Consulting Practice, at AmerisourceBergen’s Pharmacy Healthcare Solutions. “We have got to get better at getting a seat at the table in the C suite so leaders understand the importance of who we are and what we do. We have to help other players in healthcare understand the importance of who we are and what we can do. Pharmacy is shifting away from being a cost center, especially in the health system and specialty worlds, to becoming a revenue center. The closer we get to the patient, the more time we can spend with patients, the more we can affect their health outcomes. That is particularly important as we move away from fee for service to fee for value.”

The move toward pay for performance is an important opportunity for pharmacists, Wolf says. While he focuses on the evolving role of pharmacists and pharmacy services in health systems, the same need to demonstrate value and improved outcomes is also playing out in chain and independent pharmacy. 

The barriers to expanding patient contact time depend on the practice setting. Chain pharmacists must deal with staffing limitations and insurance reimbursement issues. They need more time to deliver the level of care they have been trained to provide and want to provide.

“The metrics imposed by many retail corporations are not conducive to quality patient care,” one chain pharmacist said in the survey. “Too much focus is being placed on number and patient care is suffering. Staffing is being decreased while the workload is increasing.

Independent pharmacists must deal with reimbursement issues as well as with payer and manufacturer contracting complications.

“As reimbursement declines and cost continues to increase, the only thing we can do to stay afloat is reduce labor. And when you reduce labor, it affects patient care,” said one independent pharmacist. 

On the health system side, pharmacy has long been viewed as a cost center. That began to change a decade ago as changes in reimbursement across different care settings encouraged hospitals to focus on ambulatory clinics and ambulatory pharmacy. More recently, the focus has shifted to specialty pharmacy. What hasn’t changed is the potential impact pharmacists can have on metrics such as readmissions as well as on the bottom line.

Take discharge planning and counseling: In an era when more than half of hospital readmissions are linked to some sort of adverse drug event, the need for pharmacist involvement in discharge planning is greater than ever. Where the financial rewards of healthcare were once focused on dealing with acute events through physician visits, hospital admissions, and urgent prescriptions, financial rewards going forward are focused on preventing acute events: fewer admissions, fewer readmissions, fewer acute scripts, more preventative care, more chronic medications. 

“We need, as a profession, to stop looking at ourselves as inpatient pharmacists or outpatient pharmacists,” Wolf said. “We are pharmacists. As care is shifting from the inpatient hospital to ambulatory, we are all shifting to more of a quality-driven perspective, keeping the patient out of the hospital by keeping them well. That changes the paradigm for pharmacists. We have to care for the whole patient continuum rather than just ‘I’m a pharmacist who supports a patient while they are in the hospital’ or ‘I support patients in the ambulatory setting.’ Our new paradigm is ‘I support the patient, period.’ ”

Survey shows pharmacists are eager to provide care for the whole patient continuum. 

Pharmacists Want More Time with Patients

Working at a health system pharmacy has its perks when compared to working in a community setting. For one, health systems are where pharmacists tend to make the most money, according to the Drug Topics 2018 Salary and Job Satisfaction Study. The survey found that 82% of hospital pharmacists make more than $120,000 annually compared to 71% of all pharmacists, and 25% make at least $150,000. This means health system pharmacists are almost twice as likely to earn salaries in the top range for the profession than pharmacists as a whole.

But it is health system pharmacists’ responsibilities and opportunities that make their jobs most rewarding. In fact, the annual salary survey reported that only 15% of health system pharmacists were dissatisfied in their work compared to 27% of all pharmacists.

Health system pharmacists cite a variety of reasons for making the switch from community pharmacy. Emily Griesbach, PharmD, BCPS, at University of Wisconsin Health, Madison, Wisconsin, decided to pursue being a health systems pharmacist to grow her clinical knowledge and become involved with managing more acute disease states. “I can use what I learned in pharmacy school more fully,” she says.

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“A huge benefit of working as a health systems pharmacist is being directly involved in the patient’s healthcare team,” Griesbach says. “I work alongside physicians and advanced practice providers to develop care plans and make medication recommendations during daily rounds. Being visible to these providers helps foster relationships, which in turn leads to clinicians asking pharmacists for their opinions and recommendations.” 

Besides having more time to spend with patients, Panteha Kelly, RPh, BCACP, CDE, clinical pharmacist specialist and assistant clinical professor of pharmacy, University of California San Diego Health, La Jolla, says her work hours are also better. “At the community pharmacy, I worked until 9 or 10 p.m. some nights and every other weekend. Now, as I gain seniority, I can choose from variable shifts and transition to shifts that are more desirable.” 

And with more technicians and clerks assisting with prescription processing, Kelly has more time to focus on patient care rather than being more involved in the business side of the practice and completing tasks such as prior authorization approvals from insurance companies or prescription order entry. 

When she worked as a community pharmacist, Susan Alsaras, PharmD, pharmacist at the Hospital for Special Surgery in Manhattan, says the focus was entirely on selling prescriptions, refills, offering 90-day prescriptions, and verifying orders fast enough to keep up with demands of statistical requirements.

Working as a health system pharmacist differs from community pharmacy in other ways, according to pharmacists who made the change.

In a community pharmacy, patient interaction was abundant, but rushed, Alsaras says. “Patients didn’t want to be bothered with discussing their new medications,” she says. “And they often targeted me for insurance mishaps. Patients at HSS usually listen, ask questions, and seem satisfied with pharmacist responses when counseled.”

With access to each patient’s electronic medical record at a health system, it is much easier to determine if the selected therapy is appropriate for the patient, Kelly says. At a community pharmacy, this access is not always readily available.

Consulting with physicians, nurses, and other professionals: 

Health system pharmacists work more frequently with other care team members, says Ryan Foster, PharmD, MBA, senior director of pharmacy at Spectrum Health, Grand Rapids, MI. They bring a specialized set of skills and knowledge to the team and can integrate it into decision making much earlier in the process.

Griesbach says it’s easier to consult and work with other healthcare providers, especially physicians, when working as a health systems pharmacist because they often work with the same people each day and can build rapport.

In community pharmacy, you are a “jack of all trades,” you know a little bit about a lot of medications, Griesbach says. As a health systems pharmacist, you can carve out a niche in an area of great interest. However, additional training may be required such as a second or third year of residency.

Kelly says a health system offers the opportunity to work in a variety of specialties such as geriatrics, internal medicine, oncology, diabetes, and administration, and provides many career opportunities. “At UC San Diego Health, my interest in diabetes led me to start a diabetes self-management program, which the pharmacy department supported,” Kelly says. “Our accredited program allows us to bill for services and not only garner additional revenue but also practice at the top of my pharmacy license. Our organization has employed numerous clinical pharmacists who are involved in different specialties and work side by side with other healthcare providers.”

By working at a hospital that deals solely with surgery and orthopedics, anti-coagulation and infectious disease are topics that Alsaras largely provides information on to physicians, prescribers, and nurses. In addition, she compounds medications, often for intravenous use, which she rarely did as a community pharmacist.

Health system pharmacists have many opportunities to participate in research as well as quality improvement, especially at larger academic institutions, says Griesbach, who championed a bariatric quality improvement project.

For pharmacists considering which path to take, Foster recommends they reflect on whether they prefer to work with patients more longitudinally, which community pharmacists do, or if they would rather be more involved with acute episodic care, which health system pharmacists do.

In order to build a successful career in health system pharmacy, pharmacists need to first establish a high degree of trust with their pharmacy peers and other members of the healthcare team, Foster says.

Along these lines Alsaras adds, “Work together with your colleagues, ask each other for advice and maintain a cordial, professional relationship.”

Pharmacists who are interested in a career change should research their path of interest, learn what it takes to get there, and not be afraid to take risks to make a change, Kelly says.

Griesbach says it’s critical to know your resources. “Not a day goes by without being asked a question for which I don’t have the answer,” she says. “It’s fine to say, ‘I don’t know the answer,’ but then I go and find it in a timely manner.”

When offering a recommendation to a physician, word it thoughtfully and concisely. “Physicians are constantly busy and are appreciative (and will more likely listen) if you’re short and to the point,” Griesbach says. “Also, don’t be discouraged or take it personally if your recommendation isn’t accepted.” 

Flexibility is another key. “Drug shortages, clinical guideline changes, and formulary changes are just a few challenges that you encounter every day as a health system pharmacist,” Griesbach says. 

When reflecting on making the change, Alsaras says, “Learning something new each day, working together with a team to provide the best possible care for patients, and being someone who everyone relies on for drug information gives me a sense of pride and success that I never felt when working in community pharmacy. Although I enjoyed the frequent interaction with patients that was prevalent in community pharmacy, I had much more to offer patients and physicians. Switching to a health system pharmacy was one of the best decisions I have made.”

Health systems offer a wider use of pharmacy training, but more readily succumb to drug shortages and frequent formulary changes. 

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Retirement is the welcome and well deserved finish line for many pharmacists after a successful career. But the milestone requires careful consideration-and years of planning-to fully realize the best financial and mental benefits retirement can bring.

Before a pharmacy owner can walk out the door for the last time, there are legal, financial, emotional, and pharmacy management considerations that should be addressed and specific steps that should be taken to promote a smooth transition from one owner to another.

“There’s a lot of pharmacists near retirement age who don’t necessarily have a retirement plan or succession strategy,” says Charlie Le Bon, Director of Pharmacy Ownership Services for AmerisourceBergen.

The biggest mistake most pharmacists make is underestimating the amount of time it will take to prepare their pharmacy for succession or a sale.

Experts recommend that pharmacists begin preparing for retirement three to five years before they plan to leave. By preparing in advance, pharmacists are able to find a suitable successor if they desire, identify areas of weakness within the business and optimize operations to improve their profits during a sale.

Succession Planning Versus Replacement Planning

One of the first steps out-going pharmacists need to consider is how they want to exit the industry. According to Ben Coakley, director of business development for Waypoint Rx, there is a significant difference between succession planning and replacement planning. 

Succession planning is a comprehensive exit strategy that allows a pharmacist to make sure his or her values are still incorporated into the pharmacy after departure. “Succession planning is when you are preparing your successor, preparing the pharmacy,” Coakley says. “You are doing employee retention and you are doing a lot of these things because the owner says ‘I want a little bit of say in how this goes.’” 

Replacement planning, on the other hand, is simply selling a pharmacy, which focuses more on preparing for the actual transaction rather than working in collaboration with the new owner to smooth the transition before the sale.

True succession planning, Coakley says, is a way for the selling pharmacist to ensure his or her values are maintained in the new ownership. 

“It’s like dating,” he says. “You have to go through the dating process to learn the new successor and whether he or she has the values that you share. That’s the most important part when it comes to succession planning.”

According to Coakley, most pharmacists typically want succession planning, but it can be a difficult and timely process, leading many to end up with replacement planning instead.

Waypoint Rx has developed a tailored program known as Transitions Rx to guide owners and new buyers through the succession process, including the pharmacy, legal, financial, and emotional aspects of the transition.

Le Bon says the overall selling process for pharmacies can take anywhere from six months to five years and can be hindered by any number of challenges, including geographic, financial, or business operation issues.

“It varies substantially. Part of it is you have to find a buyer that’s a right fit,” he says.

Many retiring pharmacists may have a certain dollar figure in mind that they hope to sell their business for, but just like in a home sale, a business is only worth what a buyer will pay. 

To optimize the profits from a sale, pharmacists need to spend time and resources before selling a pharmacy to streamline operations, maximize profits, and make cosmetic improvements to the store. 

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“It’s kind of like curb appeal with your house. It’s curb appeal as it relates to your pharmacy and you want to pretty it up if you can,” says Bill Popomaronis, BSPharm, vice president of professional affairs for NCPA. 

As part his responsibilities, Popomaronis helps buyers and sellers arrive at a fair and responsible price for a business. He recommends sellers make themselves more valuable to the bank handling the sale by creating a lean inventory, making sure the pharmacy is buying at the best price by partnering with an aggressive wholesaler, and making the payroll as efficient as possible. 

Le Bon says the best way for pharmacies to gain a better understanding of their current operations is to undergo an outside business evaluation that can help the pharmacy create an individualized set of recommendations to maximize both efficiency and profitability.

“If they are able to plan ahead accordingly, and work to increase the efficiency of a business, ultimately, we help increase the sales price when it is time to retire,” he says.

Popomaronis also recommends pharmacies “normalize the books” by looking at NCPA benchmarks, assessing what is a fair and reasonable price, and assessing the one-time nonrecurring extraordinary expenses that a seller may have put in, but that won’t be expected by the new owner. These expenses are typically found on the expense side of the ledger and are added back into the profit, he says.

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“The greater the profit, the greater the price for the business,” Popomaronis says. “A $3-million store that has a 5% normalized net profit will not be as expensive as one that is at 8%.” 

One factor working in favor of sellers is that community independent pharmacies continue to be a sought-after commodity. 

“I would say, in terms of a ratio, it’s probably two to one buyers to sellers,” Le Bon says. “There’s definitely an appetite and a hunger for pharmacists to own their own business and to play that role as a critical part of a patient’s journey.”

Experts say pharmacists can also employ strategies to help ease the transition from one owner to another to help increase the probability that the pharmacy will continue to succeed under new ownership.

Some pharmacy owners choose to continue to work at the store in a part-time capacity to not only help answer any lingering questions but also to assist with customer retention. 

Coakley says there are typically two types of responsibilities in any business: ownership responsibility and management responsibility. Most owners looking to sell a business are tired of the management responsibility, including payroll, billing, and scheduling. 

“A lot of times in succession plans, we transfer [management responsibilities] first,” he says. “We need to make sure the new owner can run the business and that mentally they are capable of handling this before we give them the ownership control.” 

Other owners prefer to exit on a set date. 

One of the biggest obstacles facing pharmacists reaching the end of their career is reaching burnout before they are able to put the steps or pieces in place to hand off the pharmacy in the way they had hoped. 

Experts say by planning early and relying on experts to help, pharmacy owners can ensure their life’s work is able to continue under new ownership and leave a lasting legacy.

It's a seller's market for those looking to transition or divest; buyers must consider profit and continuity in addition to price. 

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Dietary supplement use continues to grow in popularity. In 2017, 76% of U.S. adults reportedly used dietary supplements-a 5% increase from the previous year and an all-time high, according to a survey conducted by the Council for Responsible Nutrition. WHO estimates that 80% of the global population uses some form of herbal medicine. Domestically, the nutraceutical industry has also enjoyed a surge in popularity, partly spawned by growing public discontent with traditional Western medicine. In addition, some patients view OTC products and dietary supplements as a more convenient and/or affordable alternative to seeking medical treatment or as a suitable treatment for minor conditions. 

The uptrend in dietary supplement use creates unprecedented opportunities for pharmacists working in many practice settings where they can alter the patient experience by ensuring appropriate use of these products. While pharmacy students receive education on OTC products, training varies greatly among schools of pharmacy, and pharmacists might lack sufficient knowledge about OTCs.

The Accreditation Council for Pharmacy Education (ACPE) requires that pharmacy students receive training in what it refers to as “natural products and alternative and complementary therapies.” ACPE defines this training as the “evidence-based evaluation of the therapeutic value, safety, and regulation of pharmacologically active natural products and dietary supplements,” while also acknowledging cultural practices of  providers and their patients to encourage healthy habits and practice. 

While the ACPE mandates that pharmacy schools provide education on OTC products, it does not require a certain number of hours for OTC education. The amount of nonprescription dietary supplement education varies tremendously between schools and remains a difficult undertaking given the myriad of dietary supplements on the market. “There are an estimated 70,000 supplements worldwide from which consumers may choose, so it’s hard for healthcare professionals to figure out which group of supplements to focus on for clinical indication, side effects, and place in therapy,” says Cathy Rosenbaum, PharmD,   MBA, CHC, a holistic clinical pharmacist and founder/CEO of Rx Integrative Solutions in Blue Ash, OH. “There’s a vast difference among clinical research related to American, Chinese, and Ayurvedic herbs, in addition to homeopathy and other nonvitamin supplements that are used for condition management or wellness/prevention.”

Traditional Indian medicine, or Ayurveda, and traditional Chinese medicine are among the oldest forms of medicine, and their popularity has transcended their Asian origins, with global market growth predicted at a rate of 5% to 10% annually, according to the peer-review journal “Evidence-Based Complementary and Alternative Medicine.” 

Recognizing the market potential, the FDA passed the Dietary Supplement Health and Education Act of 1994 (DSHEA), designed to prevent mislabeling and misbranding, and published regulatory documentation guidance in efforts to address quality challenges stemming from the use of herbal medicine. While DSHEA expanded the market of dietary supplements by including vitamins in its classification, the FDA does not evaluate these nonprescription products for safety, but charges the manufacturers with ensuring the products are safe.

“From a practical perspective, dietary supplements are considered safe until they’re proven unsafe under DSHEA, which is just the reverse with prescription medications,” Rosenbaum cautions. Due to potential quality/safety risks with supplements, “buyer, pharmacist, physician, and healthcare provider beware before purchasing or recommending supplements for yourself or your patients,” she says. 

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John Ayo, a naturopath and CEO of Travel Balance, emphasizes the importance of healthcare professionals exercising their due diligence when reviewing product quality-especially when evaluating the potency and purity of herbal products. “Selecting quality herbal products can be tricky because you have to consider many factors, including whether the product has been standardized, how it was processed, the growing conditions, and when the plant was harvested,” Ayo says. 

To help overcome these hurdles, Rosenbaum recommends pharmacists use three steps to ensure the potency and purity of a product:

Determine if the product has undergone quality or potency and purity testing by an independent third party.

 Rosenbaum says the product labels should bear seals from either the United States Pharmacopeia (USP), NSF International, or ConsumerLab.com.

Request a quality specification sheet for potency and purity from the manufacturer, called a Certificate of Analysis (CoA).

 “Most people don’t realize that we as pharmacists have the ability to get a CoA,” says Rosenbaum. 

To answer any questions not provided in the CoA, Rosenbaum recommends calling the manufacturer to gather information about its product testing. Ask what testing methods are used, such as chromatography, mass spectrometry, gas chromatography, or titrimetry? What additional levels of testing are done? In early 2018, the NSF International began offering DNA verification of raw ingredients, known as a DNA-authenticated mark, to help reduce concerns regarding fraudulent products infiltrating the market.

3. Review published human clinical studies.

 For supplement indication, side effects, and drug/supplement interactions for the supplement formulations that have been standardized in the industry.

“Pharmacists play a tremendous role in helping to communicate when patients are on something that doctors don’t know about,” Andrew Freeman, MD, FACC, FACP, a cardiologist, co-chair of the Nutrition and Lifestyle Workgroup of the American College of Cardiology (ACC) and director of cardiovascular prevention and wellness at National Jewish Health in Denver.

The intimate patient-pharmacist relationship coupled with pharmacists’ educational training empower them to evaluate the potential for herbal-drug and nutrient-drug interactions, but determining interactions is only one part of the puzzle, says Rosenbaum. According to ACPE standards, pharmacists must make prudent recommendations for supplement use based on evidence, which often is not as easy to find or as thorough as that for prescription pharmaceuticals. Because herbal-drug interactions have not been studied as widely as drug-drug interactions, the best available evidence might be a case report. 

Rosenbaum points out that pharmacists’ training in evaluating clinical research studies for supplements, the patient’s laboratory results, and recommending dosing adjustments and/or cost-effective alternatives are a value-added professional service. Advice from pharmacists can fill the gap among health food store clerks, nurses, dietitians, chiropractors, and physicians. Pharmacists have another layer of professional responsibility when determining whether supplementation is necessary. For example, patients who take metformin should not take vitamin B12 without having levels of this vitamin tested first. Similarly, CoQ10 supplementation may not be appropriate for every patient taking statins. If a patient has muscle pain while on statin therapy, Rosenbaum recommends evaluating other potential sources of the patient’s pain and/or requesting the primary care physician write an order for a CoQ10 blood level before automatically recommending the supplement. 

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Another complication in managing medication-related nutrient deficiencies is the need to evaluate the patient’s diet. “How does the pharmacist know if the patient truly needs CoQ10 supplementation?” Many foods such as broccoli, cauliflower, pork, beef, chicken, strawberries, and peanuts contain CoQ10, he notes.

Rosenbaum offers readers some final advice: “Your recommendations should be understandable, evidence-based, practical, and readily actionable for your patients.”

Some patients view supplements as more convienent and affordable than medical treatment. 

Dietary Supplements Need Evidence and Evaluation

Pharmacists and others who work in the pharmacy industry are a unique hybrid of caregiver and scientist. In their daily work, the science aspect is often emphasized, but the client or patient is the one that benefits from the caregiving role. 

Jan L. Bowen, a life coach and founder of Strategic Solutions Services, says the difficulty with that hybridization is that as a caregiver, the “well” from which one gives can often run dry. 

“It’s crucial to replenish yourself-to fill the well, so to speak-in order to continue successfully doing your job and keep giving,” she says. “Work is only one aspect of life. We need various aspects of life to stay mentally, physically, emotionally, and spiritually-however you define that-healthy.”

Mary Loverde, a work-life balance expert and author of 

I Used to Have a Handle on Life, But It Broke

, says if you think you have too much to do and not enough time to do it, this is not your imagination, and it doesn’t mean you have failed in some way. 

“It’s important to create a new definition of life balance,” she says. “Instead of trying to get it all done, adopt a new life balance motto: ‘When you can’t keep up, connect.’ Connection is what creates a balanced life: Connecting with yourself, your family, friends, community and your God.”

A great way to do this, she says, is to establish some rituals that connect you with what is most important to you. 

“For example, make the first Saturday of each month movie date night and be sure it put it on the calendar,” Loverde says. “Tell your kids that Wednesday nights are go-for-a-hike night. Figure out what feels good. Meaningful rituals give us the predictability and stability that make us feel safer and more connected in what feels like a very unpredictable and unstable world.”

Joe Robinson, a noted work-life balance speaker with Optimal Performance Strategies, says the life side of the work-life balance equation won’t happen by itself. People need to commit to making changes in their lives, including dipping their foot in the “life water,” and trying some new activities like dance or tai chi, he says. 

“You have to look at the areas at work that are draining you in terms of demand, stress, and productivity that you can’t keep up with, and make adjustments in your work style,” he says. “You also need to carve out time for work recovery, so when you go home at night, you have strategies to relieve the stress and recharge the brain.”

Robinson says some great ways to remove stress from the day are unplugging from email once you go home, dedicating time to a hobby or exercise, and spending time with loved ones doing things you enjoy.

“If there’s a passion that you take part in regularly, you can add eight hours of joy in your week, and that goes a long way to relieving stress,” he says.

Jeff Davidson, who holds the registered trademark "The Work-Life Balance Expert" from the U.S. Patent and Trademark Office, says it’s vital to periodically abandon the rat race and make time for yourself. He is author of 

“The typical professional sacrifices rest and reflection in the hope of getting more done. Those with work-life balance take time for rest and reflection throughout the day, and accomplish more as a result,” he says. “Ways to accomplish that include drawing upon self-calming rituals all day long, lingering a moment after lunch, centering yourself on the way to breaks, and even between tasks and sleeping eight hours a night.”

Change, especially for workaholics, isn’t easy, so taking small steps toward establishing clear priorities, supporting them, and assembling resources to accomplish objectives is the best way to go. Loverde suggests looking at your existing routine and modifying one element that would have the greatest impact for you.

Bowen recommends reflecting on all areas of life: fun/leisure, relationships (family/friends), home/physical environment, personal/spiritual development, finance/wealth, and career/work, and figuring out what feels complete and what areas are lacking.

“If you consider each of these areas a spoke in a circle, this can be a representation for a wheel of life. The wheel needs to be in balance in order to run smoothly,” she says. “Then focus on one area that will be the most impactful to change. And start by committing to a morning and evening routine for yourself. That routine will be designed according to your needs, so only you know the perfect routine that will suit.”

Some of Davidson’s tips for removing stress from one’s life include going a whole weekend without reading anything, scheduling a spa treatment, writing and calling friends you haven’t seen in a while, or visiting a botanical garden to enjoy the flowers, and letting your sense of smell, rather than your eyes and ears, dominate for a change.

“Another idea is to walk around your yard barefoot like you did when you were a kid. Feel the grass between your toes. Stick your feet in dirt or in a puddle,” he says. “Establish life priorities and pursue them daily. It will make a big difference.”

Relationships and planning will help bring balance to life. 

Reconnect to Reinvigorate

As the role of today’s pharmacists expands beyond the counter and takes its place in the changing landscape of healthcare, the question arises: How well are pharmacy schools meeting their responsibility to prepare the next generation of pharmacists for the latest trends in the profession and industry?

Drug Topics sought the insights of a diverse group of individuals representing professional organizations, industry observers, experienced pharmacists, recent pharmacy school grads, and current students to get their take on the situation. The result is a snapshot of where pharmacy schools are today, along with  some candid suggestions for ways they can better educate their students for the future.

How does a school of pharmacy guide its PharmD students in four short years to sufficiently help them find the areas of pharmacy that most interest them? Lucinda Maine, RPh, PhD, executive vice president and CEO of the American Association of Colleges of Pharmacy (AACP) says the challenge is one of both depth and breadth, due at least in part to the increasingly rapid pace of change in therapeutics.

“Schools of pharmacy can’t begin to believe that they can teach the students all the knowledge that they’re going to potentially access in their career,” Maine says. She adds that the complexity of many therapeutic areas-and the complexity of being a successful researcher, manager, or leader-requires students to choose the path for which they have the greatest passion and drill into it. 

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“Unequivocally, every school should have faculty who are equipped to teach 21st century skills like informatics and pharmacogenomics at some basic level of exposure. And yet we know that there are likely not sufficient faculty resources to effectively address this at the right level across every curriculum,” she adds. 

In 2013, AACP published the latest iteration of its Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes, which are intended to provide a target toward which pharmacy curricula should be aimed. The current CAPE Outcomes focus on four specific areas: foundational knowledge, practice and care essentials, practice and care approach, and personal and professional development.

AACP recently offered additional curriculum guidance for pharmacy schools with its entrustable professional activities (EPAs) for new pharmacy graduates. Released in 2017 and patterned after a similar document for medical students entering residency, it identifies practices, procedures, and guidelines to assist faculties in developing students to their maximum potential. Validation of the 15 EPA statements was published late last year in the American Journal of Health-System Pharmacy. 

The CAPE Outcomes were subsequently adopted by the Accreditation Council for Pharmacy Education (ACPE) as an integral part of its Standards 2016, which established the minimum standards that professional PharmD degree programs must meet to achieve and maintain accreditation. The standards focus on the required educational outcomes and their assessment, structural, and process-related elements necessary to implement evidence-based outcome measures that document achievement of the standards, and areas where programs can experiment and innovate within their curricula to meet the required CAPE Outcomes.

ACPE Executive Director Peter Vlasses, PharmD, says input from a consensus conference of accredited stakeholders-including pharmacy colleges and schools, professional pharmacy organizations, and student pharmacist organizations-greatly influenced the new standards. Two messages that came through loud and clear were that graduating students should be practice ready (able to directly contribute to patient care) and team ready (able to work in collaboration with other healthcare providers).

Vlasses notes that today’s pharmacy students spend 300 hours during their first three years of pharmacy school gathering practical experience in community and hospital pharmacies or in other available opportunities, such as industry. 

“Basically, we heard that we need to make sure that students finish those three years and enter the fourth experiential year-the advanced pharmacy practice experience, or APPE-ready,” he explains. “They need to be actively engaged within the law and under the supervision of preceptors in the care of patients, and to apply the knowledge, skills, and abilities that they gained in the first three years in a controlled but active way so they get first-hand experience in doing the kinds of things they’ll be required to do on graduation.”

The 2016 standards specifically mandate that entrepreneurship be taught in all pharmacy school curricula by 2019. It’s a move that’s applauded by George Zorich, CEO of ZEDpharma, and author of Entrepreneurs in Pharmacy and Other Leaders. He believes that existing core courses need to be adapted to make students more marketable when they graduate.

“Let’s get more entrepreneurs out there. If we do, we have a good chance of building businesses that create jobs and could benefit healthcare and society,” he says enthusiastically. “Let’s realize that big box retail will not be creating the same number of jobs in 2030 as they do today.”

Erin Albert, PharmD, JD, MBA, and senior director of education at the American Society of Consultant Pharmacists (ASCP), also advocates for curriculum expansions that emphasize leadership, entrepreneurship, and self-awareness. 

“Most schools have electives in these areas, but few mandate these types of training,” she explains. “The irony is that we used to be almost all entrepreneurs, and we’ve done a 180 [degree turn] to being employees. But I’m starting to see the pendulum swing back the other way.”

Programs like the Master of Science in Pharmacy Business Administration (MSPBA) at the University of Pittsburgh School of Pharmacy are leading the way in that reversal. It offers core business fundamentals like financial accounting, financial management, and strategic management while also focusing on healthcare and the business of pharmacy. The program allows students to work full-time while going to school full-time. 

“We’re looking for anybody working in the pharmacy sector of healthcare with at least two years’ experience,” says Bridget Regan, RPh, MBA, director of pharmacy business programs at Pitt. “We’re looking for somebody who wants to take on leadership roles within the industry or their current organization, be entrepreneurial, or look at other opportunities within healthcare to take on those skills and lead the changes that are happening.”

Twenty-one students have completed Pitt’s year-long MSPBA program since 2016, including recent grad Mark Thomas. After earning his PharmD in 2013 from Lake Erie College of Osteopathic Medicine, he joined a major pharmacy healthcare provider where he now works as a clinical advisor helping employers identify patterns in their drug spending. His work experience and the Pitt program opened his eyes to the business side of pharmacy, which he says was not part of his PharmD curriculum.

“The biggest deficit that we have right now in our profession is understanding and following the healthcare dollar. We’ve really lost sight of that because it has become pretty complex,” says Thomas. “Doing due diligence to understand how the healthcare dollar works is critical.”

Today’s pharmacy school students are tomorrow’s industry leaders. So what can the schools do to ensure that the future is secure and bright for both pharmacy and its practitioners? 

Stephen J. Allen, RPh, MS, and retired CEO of the ASHP Research and Education Foundation, maintains that while schools do a solid job of preparing students to enter practice, their ability straight out of school is limited. He acknowledges that changing curriculum is a slow and deliberate process, particularly since the components are stipulated, evaluated, and accredited by ACPE. 

Allen points to other challenges facing pharmacy academia like the availability of faculty to teach new subjects and an overabundance of schools that he predicts could glut the market and result in many unemployed pharmacists inside a decade. He proposes several subject areas that need additional focus, including verbal and written communication, healthcare economics, and niche pharmacy. As an example of the latter, he points to three programs that his alma mater, the University of Maryland School of Pharmacy, is developing to expose students to the fields of THC, regulatory science, and leadership.

“Students who are getting a PharmD degree must understand healthcare economics, and they must be able to lead,” he concludes. “If they want to be in a practice that can establish patient care plans, follow up and monitor a care plan, and collaborate as part of the interprofessional team, they have to show their value.”

Schools increase focus on patients, outcomes, economics, and leadership.

Drug Topics March 2019

Coping with Patient Death

Opinion: Why Change Is Like a Hemorrhoidectomy

Pharmacists Want More Time with Patients

The Pros and Cons of Switching to a Health System

Early Planning is Key to Retirement and Succession

Dietary Supplements Need Evidence and Evaluation

Reconnect to Reinvigorate

Pharmacy Education for the 21st Century

How to Achieve Balance in Work and in Life

Case Studies in Stability

Opinion: Avoiding "White Coat Marketing" Accusations

Xofluza for Acute Uncomplicated Influenza