Friday, April 13, 2012

Community versus hospital versus grab bag pharmacy

One of my professional mentors was asking me the other week about whether I want to keep working in community pharmacy when I'm the pharmacist.  My response was that I have no idea.  This is actually not totally true.

First, for you non-pharmacists in the audience, pharmacists are the medication experts in your healthcare team.  Doctors are the diagnosis experts in the healthcare team. Nurses are the people management experts in your healthcare team. Physical and occupational therapists are the muscle experts, and so forth.  In a good system, everyone works together and does a good job and no patient falls through the cracks.  No system is perfect, and there are some big gaps in the U.S. healthcare system (obviously, hence the "healthcare reform" law and subsequent shenanigans in the legal system). 

The very short of what pharmacists do: check what a doctor prescribes and make sure it's all right for the patient to take.

You've probably seen a pharmacist fetching your antibiotic when you have strep throat or something at a community pharmacy (think Walgreens or CVS or grocery store chain).  Pharmacists in community practice are kind of like islands in the healthcare island chain, with patients going by boat from one island to another (hospital, nursing home, various doctors who may or may not talk to/know about one another).  That well-defined healthcare team is not so plain in community pharmacy as it is in a hospital.  The island nature means the patient-prescriber-pharmacist triad is less stable as well with patients seeing many doctors but also maybe using several pharmacies depending on their mood or discounts or what have you.  More gaps in community pharmacy in patient care as well because information from one place to another isn't so smooth.

You probably never considered who checks all the medications people get in hospitals, but it's still the pharmacist.  Many hospital pharmacies are located in the basement so there's almost no chance of running into a pharmacist if you visit a hospital, and you probably missed that there was a pharmacist there at all.  Hospital pharmacists are moving toward a stronger role as a part of the healthcare team, strolling around with doctors on rounds to visit patients in person and assess their medications or assigning specific patients to the pharmacist to tweak doses based on labs following a diagnosis.  Here you've usually got pretty decent continuity of care (meaning you know a reasonably complete patient history, and the patient's doctors probably are available to answer questions easily and without playing phone tag) and if the hospital is part of a health system that includes clinics as well, you might have all kinds of helpful information.

The post title talks about "grab bag pharmacy" and I lump together everything else and all the interesting and strange places pharmacists get paid to work in this category.  There are jobs working for insurance plans or their pharmacy-specific branches, there are jobs working in universities teaching future pharmacists, there are jobs running employee wellness programs for corporations, all kinds of interesting and very unique settings. There are places where you see the pharmacist first, then the doctor (or the two together) when you're sick.

So me and career plans: I know I like the big picture, I prefer words and research to experiments, I like talking to old people well enough, I like systems and how they work, and I'm a super big information technology dork and I'm still geeking out about getting to watch a new electronic health record system work the other day.  I want to do something where I get to use these skills, but I can see where this stuff would be useful in any practice setting.  The numbers say that 60-65% of pharmacist graduates get jobs in community pharmacy, and 20-30% get jobs in hospitals, with everyone else ending up in the grab bag jobs.  I presume therefore that I'll get a job working in a community pharmacy.  I'm not so worried about it.  I like it well enough to do it for the rest of my career.  My life is boring, so I can just get rid of my sweatpants and be "on duty" all of the time.  I think one reason why in the profession it's more desirable to work in a hospital is that because nobody sees you working as a pharmacist (since you're either in your office or the depths of the hospital sending techs out to deliver stuff) you don't have that same level of public scrutiny.

But I also think I'm cautious about deciding I know what I want from life since up to this point I've been absolutely wrong about what is good for me.  If I got to pick a perfect job, I'd want to do clinical and IT stuff for a hospital system, or drug information (basically a librarian but looking at the literature and making sense out of it for somebody else).  I just try to remember that some years ago when picking a major I was almost this certain that I wanted to teach English to high schoolers, and I was extremely wrong then.  I could be just as wrong now about where I'm meant to end up, so I'm trusting that I'll get there when I get there.

I always liked that Shaker hymn "Tis the gift to be simple" and I think the part that means the most to me is "Tis the gift to come down where we ought to be."  My idea of my higher power (you can say G-d if it makes you happy, as I do sometimes) includes some bigger plan for me and my life, and I'm just bumbling around to figure out what that plan is, so it's very comforting to know that somewhere I have a place and when it presents itself, it will be where I ought to be.

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