Up close and personal: Is this the face of pharmacy’s future?
Nearly three hours into this day’s post-op patient clinic — following early morning review of lab work, then inpatient rounds and a quick stop in the research department he directs — noon is nearing. So far, Greg Smallwood, RPh, has sneaked a cup of coffee, a glass of cider, and a piece of chocolate. And lunch is still an hour away.
As the lone clinical pharmacy specialist with the liver transplant surgical team at Emory University Hospital in Atlanta, the only facility undertaking liver transplants in Georgia, Smallwood is much in demand by patients and other team members.
Today, 40 patients are in the clinic. Some underwent a transplant as many as five years ago; others just several months ago. Together, a team made up of Smallwood, two surgeon-physicians, a chief and junior resident, and a transplant team nurse coordinator divide up the patients, though there is much overlapping. Every patient sees a physician. Nearly every one sees Smallwood, either alone, with or without a physician, or before or after a physician visit.
Several times, he is pulled away from his tasks by physicians seeking medication advice. Alternately offering medical and personal counseling or just small talk to patients he has come to know fairly well, Smallwood is clearly in his element. Seeing the relative success stories in the clinic, he says, outweighs his other duties of medication research and seeing patients hospitalized and in need of a transplant. "Otherwise, you’d just get depressed. You’d get a real skewed view of what you’re doing."
Emory hospital averages more than 80 liver transplants a year and reports a success rate of about 80%. The average patient age is 47, and the average length of stay after transplant is 18 days. Part of a 600-bed teaching hospital within the university’s web of health care facilities, the hospital’s pharmacy, like many around the country, is going through some changes.
Having followed the trend of establishing a decentralized pharmacy system (some five satellite pharmacies have been set up throughout the hospital), plans are under way to return to a centralized setup, based in part on new automation being brought in. This spring, a McKesson Robot-Rx system is scheduled for installation for daily medication dose dispensing.
Staff reorganization is under way and includes placing pharmacy managers over specific pharmacy services. An assistant director of clinical services, for example, will oversee all of the clinical pharmacists, for example, who in turn will report to the director of pharmacy.
Currently, staff pharmacists rotate between clinical and dispensing duties, a basic structure that reorganization won’t change. Lead pharmacists are matched with different disease states, and they must oversee the pharmacokinetics involved while working in a pharmacy satellite. Before joining the liver transplant team, for example, Smallwood served as lead pharmacist with the hematology oncology satellite.
On the down side, Emory’s pharmacy department, again like many others, is suffering staff cuts by attrition. Positions are not being refilled, and new ones are not forthcoming, which is playing a role in the reorganization effort.
An indispensable pharmacist
In his role as liver transplant specialist, Smallwood, 43, is largely above the reorganization fray and far removed from the constant dispensing coming out of the satellites.
One key to the financial survival of his position at Emory is his role as director of research for the hospital’s liver transplant program. Secured largely through drug company-sponsored research, grants coming into the hospital account for 40% of Smallwood’s salary. "That really does help by freeing up the FTE for the hospital to use somewhere else, and the hospital is only paying for six-tenths of the FTE to have a clinical pharmacist, so it makes it affordable," he explains. "There’s always a big question in the profession: If you have clinical services, who’s going to pay for it? At least in part, we’re answering that in innovative ways such as using research grants to subsidize my salary."
Since joining the transplant team in 1994, Smallwood has written or co-written numerous papers published in journals, including Trans planta tion, Liver Transplantation and Surgery, the American Journal of Gastroenterology, and Hepatol ogy, among others. He has addressed conferences from Chicago to New Orleans to Rome, Italy, hosted by the International Transplant Nurses Association, the American Society of Transplant Physicians, and the American Society of Health-System Pharmacists.
When Drug Utilization Review visited Small wood, he was involved in several ongoing clinical trials at Emory Hospital. The subject matter ranged from hepatitis C recurrence and steroid withdrawal to an investigation of the indications of daclizumab (Zenapax), an anti-rejection monoclonal antibody that hit the market in January 1998.
On top of that, Smallwood and his colleagues collaborate on a bimonthly in-house newsletter, and he teaches the hospital’s pharmacokinetics certification to staff pharmacists.
In addition, he is pursuing his PharmD degree through a home-study Internet program offered by the University of Georgia College of Pharm acy, an undertaking he says is becoming more vital for aspiring clinical pharmacists. "When I graduated [BS in pharmacy, University of Georgia, 1979] I thought the PharmD was not going to be the practice degree; it was going to be the graduate degree, which is not the way it has turned out to be," he says.
The course offers exams, discussion, and bulletin boards over the Internet, with actual classroom time held once a month on weekends at the Athens, GA, campus. "Now if you’re coming from an accredited school of pharmacy, you have to have the PharmD," he says, "and I think the schools are recognizing the problem so they are going to the nontraditional PharmD program."
Making the rounds
By 8:30 in the morning, Smallwood begins "clinic day" by scanning the IntelliHealth Online Web site, looking for new drug approvals and related medication topics relevant to liver function. "You must be ready to answer questions," he says, from patients who really keep up with their care.
Then he reviews the most recent lab reports of the transplant patients currently admitted. For this, he uses his own Palm Pilot, which he constantly keeps with him. Plugged in is a database on each patient, including his or her medications, assigned physician, and demographics. Here, Smallwood is looking for trends and red flags concerning platelet counts or liver enzyme levels to note prior to inpatient rounds, set to begin at 9 a.m. Among the patients is a woman in her early 50s being treated for thrombosis of the liver, who, he says, is unfortunately "not a candidate for another transplant."
Another patient is being treated for an abscess and is receiving gentamicin and the third-generation cephalosporin ceftazidime (Fortaz), along with antifungals and steroids. Fortaz is used to counter any pseudomonas coverage, which can complicate liver transplants. Therapy with gentamicin, a nephrotoxic aminoglycoside, is watched closely for reactions in patients being given other nephrotoxins such as Prograf or Cyclosporin. And, Smallwood notes, the drug is cleared less than normal in liver transplant patients due to hepatorenal syndrome, which translates into a risk of overdose.
Another patient is suffering from hepatic disease and lung disorders, admitted for a second transplant because rejection occurred after the first surgery.
During the inpatient rounds, Smallwood consults with the physician on one patient’s need for a permanent catheter to replace the line currently being run. Based on the patient’s lab results, Smallwood recommends no change, and the physician agrees. The consultation is not one of testing, like that between a doctor and residents, but is a genuine consultation, one of several to come.
Other brief consults include whether a patient should receive a solid or oral medication, and for another patient suffering from hepatitis C and cirrhosis, a discussion centers on the right dosage of the commonly used infection-fighting prophylaxis ciprofloxacin.
In the case of another patient, who is in his third day of post-op, medication-use guidelines come into play after the team notices low albumin levels on the chart. They suspect albumin is leaking into the patient’s stomach and discuss whether to replace it with the diuretic furosemide (Lasix) as the guidelines suggest.
The team completes inpatient rounds in about 40 minutes, and Smallwood briefly stops in the research office before joining the team in clinic. Here, another problem awaits. His assistant recently left the position, and on top of his clinical duties and his studies, Smallwood is taking resumes and conducting a search for a new research assistant.
He notes that there are several entrees for pharmacists looking to get involved in sponsored research. "Pharmacists in general have not become involved enough with case report forms. Pharmacists are well-versed in the protocols, but you need to either be in good with a surgeon or pursue pharmacokinetics or outcome studies," he offers. And with that, it’s off to the outpatient clinic, stopping briefly along the way to return a page from the team’s nurse coordinator concerning a prescription. It’s a question Smallwood easily handles by reviewing patient records stored in his Palm Pilot.
Patients in Emory Hospital’s liver transplant outpatient clinic are seen once a week for the first month after discharge, then every two weeks for three months, then once a month for six months. After that, patients come about once every three months, depending how they are faring medically.
With patients coming from as far away as North Carolina, Florida, or Louisiana, Emory sets up communication with each patient’s hometown, Department of Veterans Affairs, insurance plan doctor, or hepatologist to get blood samples regularly sent to the hospital.
Smallwood and the team conduct clinics two days a week. On clinic days, patients arrive at 8 a.m. for a blood draw, then meet in group therapy while the lab results are documented. The team sees patients beginning about 10 a.m.
This day, there are 40 patients for the five-member team, and the atmosphere is largely one of grab a chart and hit a room, though Small wood makes sure to visit patients with whom he has struck up a relationship.
For one such patient, who is on a regimen of eight drugs, Smallwood begins by asking if he’s suffered any recent chills, fever, diarrhea, or pain that either shoots through or travels around the patient’s trunk. He goes on to discuss any problems the patient may be having based on possible interactions specifically from the use of ciprofloxacin and tacrolimus (Prograf). The combination is commonly given to liver transplant patients, showing good results in staving off Candida infection or when patients show biliary problems.
He tells the patient he will talk to the doctor about stopping a magnesium supplement because related lab work shows positive levels. The patient asks Smallwood about an over-the-counter sinus medicine he’s taking, which Smallwood says he also will clear with the doctor.
Getting to the next patient room takes some time. First, a physician stops Smallwood to discuss whether an antihypertensive a patient is taking is safe for transplant patients. Then a nurse stops by to talk about blood draw records she’s pulling for a clinical study within the hospital. Smallwood remembers that the doctor conducting the study is no longer with the hospital, and he directs her to halt the protocol.
The next patient, whom a physician has just visited, goes over everything he and the doctor talked about, eager to hear Smallwood’s opinions on his blood pressure and an OTC cough medicine he’s taking. The pharmacist is worried about the effects of an antihistamine on the patient’s post-op regimen. He prescribes lots of water and an immediate call if any fever or itching occurs. Later, he says, "Interactions are one of the most important things I do, and that’s part of the educational process we give [patients] to make sure they tell us all the medications they are taking from all over the place. Because of their immunosuppression, a lot of interactions can occur. A lot of the drugs we use are nephrotoxic, and if their immunosuppression goes too high, they could wind up with a lot of side effects or their kidneys could shut down. Likewise, if they are taking medications that induce enzymes, they may clear immunosuppression quicker so they wouldn’t have enough in their body to prevent rejection," he explains.
Working with doctors long-distance
It’s a fine medication line many of the patients walk, made more difficult by the long-distance medicine often practiced, though Smallwood says for the most part the patients’ local doctors will consult before prescribing. "The point is, maybe there’s some better choices than what [a physician] is accustomed to giving their general population."
The size of the second patient’s belly causes Smallwood to speak to a team surgeon about scheduling a biopsy. Smallwood is worried about post-op fibrosis and about conducting serology tests based on a low white-cell count. The physician agrees.
Heading back to the main clinic area, he is stopped twice by team doctors, once to consult on a particular patient’s diet and then on a question of interactions.
On the way to see another patient, Smallwood remarks that he asks patients to take their own blood pressure at home before coming to the clinic, which he believes counters the "white-coat" effect that blood pressure readings could take on if done in the clinic environment.
In a third patient room, Smallwood begins with basic questions of itching or pain. When told itching has been occurring, he reacts by observing the patient’s surgery scar, which runs from sternum to waist and around the entire stomach. The patient says he’s been experiencing some heartburn and offers a look at a heart medicine prescription he was given. Smallwood doesn’t recognize the medication, so he takes one pill from the bottle so he can research it. Noting that the patient works in construction and wears heavy clothes, Smallwood suggests baby powder, though he’ll bring in the physician to talk about it.
The patient then asks him about the possibility of exposing his wife to hepatitis C via sex. (This patient needed a transplant after contracting hepatitis C.) Smallwood discusses some basic contraception with the patient and notes that his biliru - bin levels have increased, which could mean a flare-up of hepatitis C. He tells the patient he also will bring the doctor in to talk about this.
The patient says the skin on his hands has become tender and shows Smallwood some cuts and scabs. That, Smallwood replies, is the likely result of the prednisone the patient is on. "We try to get people off it quickly," Smallwood tells him, because the drug also carries the risk of causing bones to become brittle.
Side effects to steroids cause concern
The patient also is concerned because he’s been having difficulty controlling his temper, sleeping, and keeping his weight down. That information signals a possible problem with the steroids and furosemide the patient is taking.
"Now, steroids can get on your nerves, and you’re also getting used to your new liver. You’re a different person now, and you’re not as dependent on [your wife] as when you were sick," he says, moving from medical to a little psychological counseling.
When the physician comes in, Smallwood suggests stopping the patient’s Lasix. The physician agrees that eliminating drugs is an overall treatment goal; in this case, the Lasix and the prednisone. For now, the physician decides to lower the prednisone dosage and continue the Lasix because the patient also is experiencing shortness of breath. The physician ends by prescribing more vegetables in the patient’s diet and scheduling a blood test in a month’s time.
Smallwood takes the heart pill to the floor’s computer station and looks the medication up on a MicroMedex database system. He finds the drug profile and determines it’s not harmful for the patient to continue taking it.
The clinic continues for a little more than three hours before all of the patients are seen, and the team begins to disassemble for lunch. On the way, though, he is asked to confirm a prescription for a hepatitis B patient who is cramping.
Finally, he sits down to eat at about 2 p.m., only to be interrupted by several pages.
Research and career-building
The rest of Smallwood’s day, he says, will be spent in research mode. Specifically, he has just received a FedEx package in the mail with questions and comments from a peer review panel that is evaluating some research papers Small wood has submitted for publication. Answers need to go back as soon as possible.
Overall, it’s a career path Smallwood says he’s satisfied with, but he’s not taking it for granted, evidenced by his pursuit of a PharmD. "I’m looking toward survivability. I want to practice 20 more years, and I’m not guaranteed we’re going to have a liver transplant program for the rest of my working career."
He relates that when his predecessor on the transplant team left the hospital, he responded by voicing an interest. He was given a chance to test for the position and make a presentation, after which he was given the position.
"Even though I’ve got some publications and have done the work in the liver transplants, if you have someone to stack up against side by side, and they’ve done all that but one has a doctorate degree and a residency, who are you going to hire?"