If you asked me where I saw myself working after graduation any time throughout pharmacy school, I wouldn't hesitate in saying that a community/family/retail store was the place I wanted to be. Since I did my first hospital rotation last month, though, I see that as only a fall-back option. My only hospital exposure before last month was the introductory experience at UWMC a couple years ago. While I was there, I really only saw the factory-like dispensing/order entry pharmacist duties. Sure, there were questions from doctors and a couple times they would talk to a patient, but it seemed like the part of retail I'm not as fond of, just in a basement with almost no outside contact. After a month at a rural hospital and a couple weeks into a critical care rotation at a larger hospital, though, I have been exposed to and given the opportunity to do some of the many clinical things that pharmacists do in a hospital setting.
A clinical pharmacist plays an integral role in the healthcare team. Doctors have a lot of things to think about when treating a patient and it's simply not feasible to expect them to do or know everything; thus, the total care of the patient depends on people from many different healthcare disciplines. A few examples of things pharmacists do as part of this team are daily monitoring of end-organ function and re-dosing of drugs accordingly, management of drugs (antibiotics and anticoagulants mostly) that require very individualized dosing and need frequent monitoring, recommendation of anticoagulants to prevent clots while in the hospital, and regular evaluation of antibiotic choice for indications, susceptibility results from cultures, cost, toxicity, etc. Pharmacists are also heavily relied upon for drug dosing, recommendation, and preparation in situations like cardiac/respiratory arrest, blood pressure support, and intubation.
In today's hospitals, the pharmacist is part of the "team," not just a voice on the phone coming from the basement pharmacy. We can make recommendations to doctors about possible changes when we see something that can be changed or adjusted, and for many things there are protocols that allow pharmacists to make the changes themselves (e.g. changing an antibiotic dose when renal function changes). Most doctors are glad to have someone focused on the drugs specifically and we often get asked for input on decisions about drug choice or dosing. (Of course, there are pharmacists that take this too far and assume the position of telling the doctor what needs to happen or what was done wrong. They're shut down pretty quickly, though, and that's a whole different topic…)
What a lot of the difference between retail and hospital comes down to, from my perspective, is the need for professional/clinical judgment and decision-making. There are some aspects of retail where the pharmacist has to make these types of decisions, but unless a prescriber calls for advice or something is so out-of-whack that you call them to clarify, there often isn't enough information to form an opinion. All you have is the list of things they've had filled at your pharmacy, the prescription in front of you, and sometimes the patient's word (which can be variable, especially in elderly patients who didn't understand what their doctor told them). Sure, you catch big issues sometimes, but the little intricacies of drug therapy that a pharmacist is trained to evaluate usually slip by because you don't have the patient's history or lab results and you aren't physically there with the prescriber (and face-to-face interaction with doctors really does make a difference).
Don't get me wrong, I really do enjoy the "heart" of retail pharmacy. Talking to customers that have been coming in to your store for years, being a trusted person to come to with ailments that don't warrant a trip to the doctor, teaching people about their glucose meters and compression hose, and many other things are what drew me to pharmacy in the first place. However, with the amount of time you have to spend dealing with insurance companies, steadily declining reimbursement rates, and ever-expanding big box stores are crushing the small pharmacies, the only ones that provide these services. Sure, I could find a job at one of the few independent stores and be very happy for a while, but who know how long before that totally dies out and either factory/production-line or mail-order pharmacies take over completely. I think the monotony of filling and checking prescriptions would quickly take over the attractive aspects of customer service, too, especially with the need to process more prescriptions just to remain profitable. Being a clinical pharmacist will have its monotonous tasks too (entering orders, going through reports), but it is a growing field that I find much more mentally stimulating. And every pharmacist I've talked to so far has said that you can easily switch from hospital to retail at any point in your life, but it's rare and much more difficult to do the opposite. So if I want to have a clinical position, the time to act is now.
So how do I go about this? Unfortunately, it's not as easy as just applying to a hospital instead of a store. Inpatient pharmacy managers are looking, almost exclusively, for candidates with post-graduate training. Since I had this revelation within the last couple months and not a year ago, I've missed the whole application process for residencies starting after graduation. The plus side of that is I won't be starting a residency during the summer and can work at Camp Parsons. But that also means that I'll have to figure out some sort of plan for the upcoming year that I hadn't ever thought to consider until now. To be continued…
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