The Consultant Pharmacist is published by the
American Society of Consultant Pharmacists.

ASCP Research and Education Foundation Traineeships: Life-Changing Experiences

The nurses were at wit's end. The resident had been up and down between the nursing station and her room all day, for days at a time, complaining of extreme back pain. No pain medication or treatment seemed to placate her. At times, she would even lay on the floor in the hall and roll back and forth to get their attention. She was anxious and tearful all the time. Her physician admitted he didn't know what else to do with her. Her family was bewildered. Her behavior finally culminated in an episode of unresponsiveness that sent her to the emergency room.

The consultant pharmacist in her facility observed her behavior and assessed her symptoms. The pharmacist felt she was manifesting signs of extreme depression. Upon the pharmacist's recommendation, an antidepressant was started. Within a few weeks, all her behavioral symptoms ceased. She began to participate in activities and leave the facility for lunch with family members. She had no further complaints of pain, and all her pain medications were discontinued without incident.

Whether you're looking to hone your skills in HIV/AIDS treatment, disease management, or geriatric psychiatry, or eager to learn about the latest strategies for Alzheimer's, Parkinson's, and wound care, the ASCP Foundation has a traineeship program to fit the bill.

Gianna Bryan

Paths to Clinical Proficiency

The experience described above, which actually occurred at a nursing facility I serve, illustrates how an astute pharmacist with the right training can make a tremendous difference in the lives of patients.

We all want to be the pharmacist that makes a tangible difference for our patients. For many years, the profession of pharmacy has been evolving from that of "lick and stick, count and pour" to a model where the pharmacist is a vital part of the health care team. In order to bridge the gap between a dispenser of pills and a dispenser of information, consultant pharmacists have recognized the need to become more proficient at participating in the clinical environment.

Realizing the need for postgraduate education that is intensive, patient-focused, and interdisciplinary, the ASCP Foundation sought to develop programs that would allow consultant pharmacists the opportunity for both didactic and "hands-on," or experiential, learning. This concept came to fruition in 1993, when the Parkinson's Disease Pharmacotherapy Traineeship was started. Encouraged by the favorable response to that first endeavor, the Foundation branched out into other clinical areas and now offers six traineeship programs covering topics ranging from congestive heart failure and osteoporosis to Alzheimer's disease and wound care.

ASCP Research and Education Foundation traineeships provide unique opportunities for consultant pharmacists to hone their clinical assessment skills and focus on disease management strategies to improve or maintain patient function and health. The traineeships empower pharmacists with the knowledge and skills to play a more active role in clinical care teams.

The primary goals of the traineeship programs are to create pharmacist advocates for the care and treatment of their patients and to positively impact the way pharmacists perceive their role in caring for their patients.

Alzheimer's/Dementia Traineeship

Participants in this traineeship are provided with extensive information on the diagnosis, symptoms, evaluation, treatment, monitoring, and management of patients with Alzheimer's disease. Patients with various stages of dementia are evaluated to illustrate the range of presentations of the disease process. Experiential instruction with physicians, nurses, and social workers is given in evaluating and monitoring the symptoms and progression of the disease and effects of drug therapy.

Even experienced consultant pharmacists such as Patricia Cash, PharmD, of Holliday Healthcare in North Carolina, have found much to learn from the experience.


Patricia Cash		"While I have for years visited residents, especially those taking antipsychotic medications who have Alzheimer's disease, I was introduced to assessment tools in a new way. I personally performed several assessments, which gave me a much better understanding of patients compared to my past assessments during an informal visit."

1998 traineeship participant Rich Learned, PharmD, formerly with NeighorCare in Naperville, Illinois, says, "The traineeship was one of the most gratifying experiences of my professional career. The knowledge I gained will certainly allow me to contribute to the [care of] Alzheimer's patients."

Alzheimer's/Dementia Traineeship Preceptor Vicki Berchou, RN, notes "The U.S. medical system is so large that a team approach is key to appropriate care and treatment of patients. Pharmacists are essential in making these teams work. The Alzheimer's/ Dementia Traineeship participants brought a different perspective to our practice at Oakwood Healthcare System, Dearborn, Michigan. The traineeship has been a two-way learning street: Not only have the traineeship participants gained new knowledge and skills, but the physicians, nurses, and caregivers have also benefited tremendously from the traineeship experience." Adds preceptor Stephen Aronson, MD, "The traineeship breaks the mold of old ways of thinking about predefined roles for health care professionals. It models a true interdisciplinary approach to care, which translates into improved quality of care." In addition, Aronson notes, "the traineeship experience empowers participants to approach physicians and feel more comfortable working with them."

'A Truly Outstanding Experience'

Dear ASCP:

Once again your efforts have produced a truly outstanding educational and experiential program. It will be most difficult to provide a two-page evaluation, since you would most likely get tired of the continued use of so many adjectives.

It was most gratifying to be in the company of so many people who were willing to share their knowledge, expertise, and experience so unselfishly during my participation in the Disease Pharmacotherapy Traineeship. The quality of the program and the medical staff was remarkable. Dennis Chapron has been at the top of my list since I first met him professionally only a couple of years ago, and I was not in any way disappointed in his role this past week. His depth is to be envied. His efforts were supplemented handsomely by Jon Folstad. Jon's presentations were succinct, timely, well documented from the literature, and given in a practical way that was understood.

Dr. Henry Schneiderman is one of a kind, in so many ways. His gentle attitude toward the patients, coupled with his no-nonsense approach to problems, further enhanced by his vast intellect and tempered by his love of poetry applied to his daily philosophy, all mesh to make him one of the best teachers of geriatric medicine I have ever met

All of the "team" presented outstanding material. Gail Dalsky is to be particularly remembered for the unselfish sharing of her time late in the day to perform bone density testing on several "willing subjects." We all learned a lot from being able to see firsthand how this is done, and to be able to observe the results.

In summary, just a few suggestions: Both Dr. Schneiderman and Dennis Chapron would be welcome additions as presenters at any of the ASCP conventions. I was in attendance at Nashville when Dennis presented, but he has some "new" topics that would be enjoyed by all and certainly would benefit the membership. His presentation on estrogens would be most beneficial. Dr. Schneiderman could "wow" the crowd with numerous physical assessment techniques, a topic most of us need but are fearful of. Quite frankly, I can't think of any topic that Dr. Schneiderman could not present!

Finally, thank you for this opportunity. It was one of the best learning experiences I have had. I look forward to participating in other traineeships, especially the Alzheimer's and Parkinson's Disease Traineeships. Interestingly enough, I became very excited about the Parkinson's traineeship while talking with Mickey Glasco during our evening discussions, which, by the way, was an added benefit of the program. I now count among my friends some new consultant pharmacists from across the country. It was a great week.

Sincerely,
Van D. Weaver

Disease Pharmacotherapy Traineeship

Patients with complex treatment regimens and concomitant disease states are the norm in nursing facilities. The Disease Pharmacotherapy Traineeship prepares consultant pharmacists to provide a high level of pharmaceutical care to these residents through patient-centered experiential training at the Hebrew Home and Hospital in West Hartford, Connecticut. While the experience focuses on heart failure and osteoporosis, many other disease states and conditions are encountered.

Trainees work on teams with geriatricians and geriatrics fellows, actively participating in all aspects of clinical decision making. "This was truly my most memorable experience as a consultant pharmacist," says 1998 trainee Paul Hecht, RPh, of Specialized Pharmacy Services in Livonia, Michigan.


Henry Schneiderman
"Going on rounds with Dr. Henry Schneiderman taught me that there is much more to consulting than just doing chart reviews. It is important to relate the patient to the chart in order to actually see the signs and symptoms of different disease states. Through this experience," Hecht continues, "I have developed more compassion for the elderly patient."


Evelyn Buchholtz
Evelyn Buchholtz, RPh, of NCS Healthcare in Ohio, another traineeship participant, notes that "rounds with the medical director of the facility was not something we did when I was in school, but I had the opportunity to do it in this traineeship. It really helped me feel more confident in my recommendations since my assessments were in agreement with those of other members of the team."

Mark Rhoads, RPh, of Sunscript Pharmacy in Tucson, Arizona, characterizes the traineeship as "one of the finest educational experiences" of his life. "The knowledge and experience I gained have already had a tremendous impact on my consulting practice."


Dennis Chapron
Says preceptor Dennis Chapron, RPh, "One of the most important aspects of the traineeship is that the experience sensitizes pharmacists to the importance of actually seeing and personally interviewing patients to determine appropriate therapy. Patient charts, while important, simply don't give the whole picture."

Fellow preceptor Henry Schneiderman, MD, points out that the Disease Pharmacotherapy Traineeship "offers an altogether unprecedented and unique opportunity for extended, collegial, face-to-face contact between highly skilled and motivated adult-learner pharmacists and their counterparts in geriatric medicine. At the Hebrew Home, we are blessed with superb in-house pharmacists and a renowned teacher of pharmacy, Dennis Chapron. Yet, we and our patients benefit every time a group of trainees come through: Each day as they sit in on our morning report, they challenge us with sophisticated questions-respectful but rigorous-that make us rethink our patients' pharmacotherapy and revise it to their benefit. It's enormously pleasurable for us to work with them, for they are exceptionally insightful and hungry to make the best use of their time with us."

Judging by the feedback Schneiderman has received, traineeship participants find the experience equally enlightening and enriching. "We repeatedly hear comments praising the intensity and expertise of our patient care and our bedside manner-things every health care professional savors hearing. Perhaps more to the point, past trainees consistently report in their post-course evaluations and in verbal comments that our in-person interviews with patients and pharmacists, as well as the conduct of our medical faculty, confer a renewed sense of mission-a strong reminder of why they went into this helping profession to begin with.

"We've heard more than one wise and reflective consultant pharmacist say, 'I write DRRs and other forms of feedback to the nursing homes I serve from my computer at my desk, somewhat insulated from most of the patients. Now I'll be thinking more about the individual human being that they concern.'"

The sessions Schneiderman conducts on the value of poetry for pharmacists have caught some trainees off guard, but most have come to appreciate "poety's power to tap the deep emotions that are an integral part of life in the health care professions, and its power to articulate and soothe pain-to make one feel more human."

Pharmacists Making a Difference

Dear Ms Feinberg:

It is difficult for me to find the appropriate words to describe the most wonderful feeling in my career as a pharmacist. As a mother of three, there have been many of these inexpressible feelings; however, as a career woman, oftentimes it has fallen short on the gratification side. I would like to extend my gratitude to you for the opportunity to be one of the fortunate ones chosen to attend the Parkinson's Disease Pharmacotherapy Traineeship at Sinai Neuroscience Clinic in Detroit, Michigan. Without this experience I would not have been able to have had the following experience, which I would like to share with you.

Since my return from the Parkinson's traineeship I have been visiting Parkinson's patients in an attempt to assess the extent of their disease and their current drug therapy in an effort to evaluate and recommend changes. During one such visit I came upon a patient who was "catatonic-like", expressionless, motionless, and speechless. She was staring straight ahead as I entered the room, unaware of my presence (as it appeared to me) despite my greetings to her. She had with her in the room a wonderful sitter, who was able to speak to me on her behalf regarding her condition and her activities of daily living. I was able to ascertain through physical assessment, chart review, and the interview with the caregiver that my patient was in late Stage 4 with her activities of daily living about 30%. She was severely stiff, expressionless in her masked face and in her eyes, and highly unmotivated. She had been agitated in the afternoons and had a poor appetite, with choking episodes. I met with her medical doctor later that afternoon and was able to change her dosing schedule, add an additional dose of Sinemet, and discontinue Atarax.

I returned to the facility three weeks later to do my monthly consultation. I was sitting at a table outside of the nursing station working at my laptop, when I notice out of the corner of my eye a patient charging at me. Before I could look up, the patient had grabbed my hand and began rubbing it with the utmost of enthusiasm. I was faced with a pair of beautiful, bright blue eyes and a smile on the face of my Parkinson's patient, who I had just visited three weeks earlier. Tears immediately filled my eyes as chills ran down my body. She was smiling at me with complete recognition, her face glowing, her arms devoid of rigidity. I began to inquire as to how she was feeling. She answered me with sounds of joy. She continued to rub my hand and smile at me. As she left with her caregiver, completely unassisted, with a slight arm swing as she walked, I watched after her for several moments, unable to move, tears leaking out of my eyes and with a warm feeling all over. Later that evening, as I recalled the events of the day to my family, I expressed the complete feeling of making a difference in someone's life. This is why I became a pharmacist, and I realized my reason for being.

In closing, I would like to thank you and the ASCP Research and Education Foundation. What you do makes a difference.

Sincerely,
Sandi Bryant, RPh

GeroPsych/Behavioral Disorders Traineeship

Joseph Gruber, RPh, of Omnicare in Edwardsville, Illinois, who participated in the inaugural session of this traineeship, describes it as a "marvelous experience. This was my first traineeship, and I'm sold!" he says, noting that he has since strongly encouraged colleagues to follow suit.

This traineeship prepares consultant pharmacists to play an active role in interdisciplinary care teams for patients with various psychiatric and behavioral disorders common to the geriatric population. This is accomplished through opportunities to observe and participate in the development of pharmacologic and nonpharmacologic treatment plans for patients. Participants gain considerable knowledge of the diagnosis and assessment of psychiatric and behavioral disorders, recognition and appropriate treatment of common comorbid conditions, and the significant role of caregivers as members of the treatment team. Pharmacists are encouraged to become advocates for the appropriate care and treatment of persons with psychiatric and behavioral disorders in the settings where they practice.

"The assessment techniques were most valuable," reports Bill Kasper, PharmD, of NCS Healthcare in Ohio, an alumnus of the first GeroPsych/ Behavioral Disorders Traineeship. "I utilize what I learned every day in my practice. I already had a practice in place that dealt with patients with behavior problems, but the traineeship has allowed me to become a more effective clinician."

Gruber adds, "In addition to the traineeship materials and demonstrations, my most valuable experiences included the amount of direct patient contact we were able to have, and the amount of time the McLean Hospital staff gave us to give meaning to our patient care experiences." That sentiment is shared by Evelyn Buchholz,of NCS Healthcare in Columbus, Ohio, who adds, "Not even in college have I had such thought-provoking discussions with experts in the field who were so willing to take the time to make sure we understood the concepts presented."

Says preceptor Stephen Feldman, RPh, president of The ICPS Group, Boston: "As both a former traineeship participant and now a preceptor, I am really excited about the GeroPsych/Behavioral Disorders Traineeship! I wish I had this educational opportunity open to me 20 years ago when I started in the business. Consultant pharmacists deal with psychiatric issues many, many times every day but unfortunately don't get much training in this clinical area," Feldman continues. "In addition, a lot of attending physicians in nursing facilities are not well educated in psychiatry and may not be aware of the latest therapies and assessments. The traineeship allows consultant pharmacists to move to the next 'plateau' of their practice by providing trainees with the skills and confidence to do a better job in assessing their residents for problems and making recommendations to address these problems."

Parkinson's Disease Pharmacotherapy Traineeship

This traineeship offers an opportunity for consultant pharmacists to fine-tune their own skills and educate other members of the health care team to better meet the needs of this often neglected group of patients. Holliday Healthcare's Cash participated in a Parkinson's Disease Traineeship in addition to the Alzheimer's/ Dementia Traineeship. She notes that "many pharmacy schools don't dwell on chronic management of diseases, especially conditions such as Parkinsonism that are commonly found in the elderly population. Also, many physicians don't have this training either and avoid tinkering with therapy." Through direct patient interaction with physicians, trainees are given the opportunity to participate in the development of comprehensive treatment plans for Parkinson's disease patients. This is accomplished primarily through hands-on evaluations. Focuses of the experience include evaluation of alternative clinical diagnoses, control of medication adverse effects, drug interactions, dementia and depression, adjustment of therapy, and use of adjunctive medications.

Through the leadership of her traineeship preceptors, Cash found a new confidence in recommending therapy. She now believes that "in many instances, if the pharmacist doesn't recommend therapy changes for the Parkinson's patient, nothing changes. This leaves the resident undertreated, with a diminished ability to perform activities of daily living and a less-than-optimal quality of life."

1998 traineeship participant Mary Syfrett, RPh, of American Pharmaceutical Services in Panama City, Florida, echoes Cash's sentiments: "The knowledge that I obtained and my experiences during the traineeship greatly increased my confidence and ability as a consultant pharmacist." Working directly with patients and their caregivers also was very beneficial, Syfrett notes.


Richard Berchou
"Preceptor Richard Berchou, PharmD, conducted very informative question and answer sessions with patients and family members, and the interaction with these groups, as well as with other patients in the clinic, made me more compassionate and increased my sensitivity to those who suffer with this progressive neurological disorder."

Wound Care Traineeship


Karen Parsons
Pressure sores are an all too common occurrence for the long-term care resident. This traineeship uses a multidisciplinary model to help consultant pharmacists acquire the knowledge and skills necessary to provide pharmaceutical care to patients with or at risk for pressure sores. "My participation in the Wound Care Traineeship has changed my life, both personally and professionally," says 1998 participant Karen Parsons, RPh, of NCS Healthcare in Ohio.
"Too often, pharmacists are trained in wound care through pictures and lectures. Much can be gained, however, from one-on-one experiences with patients. The opportunity to deliver hands-on care to the residents was not being done in my own practice," says Parsons, "but I found it an invaluable part of the learning experience."

Parsons found the experience changed her life, both personally and professionally. For Parsons, the traineeship offered a forum to blend both practical and intellectual experience in one setting.

Alan Winter, RPh, of Terrace Pharmacy in Ogden, Utah, who attended the traineeship with Parsons, notes, "We were taught so much more than wound care. The single most useful thing I took away with me from this traineeship was the feeling and conviction that I can really make a difference in my practice setting."

HIV/AIDS Pharmacotherapy Traineeship

The ASCP Foundation's newest traineeship offers extensive information on the diagnosis, evaluation, treatment, and management of HIV/AIDS and its complications. Training is provided to enable participants to evaluate and monitor the symptoms and progression of the disease, as well as the effects of drug therapy.


HIV/AIDS Pharmacotherapy Traineeship left to right: Gary deSimone (perceptor), Colleen Terriff (participant), Fay Ng (participant), Ellecya McCants (participant) and Alice Pau (perceptor).

Ellecya McCants, PharmD, an HIV clinical pharmacist and assistant professor of pharmacy practice at Texas Southern University, found this traineeship very beneficial. She especially appreciated participating in patient rounds with physicians from Whitman-Walker Clinic, Washington, D.C., and "debating the pros and cons of various regimens for immediate implementation or change, as compared to case consults after the patient has left the clinic."

The traineeship experience, particularly the day spent with persons living with HIV/AIDS at a Washington adult day center, made Dr. McCants more sensitive to the psychosocial needs of patients; she is now volunteering at an AIDS hospice in Houston, Texas.

Preceptor Alice Pau, PharmD, clinical pharmacy specialist with the National Institutes of Health Clinical Center Pharmacy, Bethesda, Maryland, believes that the HIV/AIDS Pharmacotherapy Traineeship is "an excellent avenue to provide practicing pharmacists with guidance in improving their clinical experience and knowledge to optimize medication therapy to achieve the best clinical, immunological, and virological outcomes." Most importantly, she notes, "the traineeship stresses the importance of lifelong learning, particularly in the area of HIV/AIDS, where new therapeutic information emerges daily."

How To Become a Traineeship Participant

Participants in the traineeship programs are selected on the basis of applications submitted to the ASCP Foundation. In addition to completing the application form, each applicant submits a résumé or curriculum vitae, as well as a letter of support from the applicant's employer confirming support for the applicant's participation and willingness to implement the results of the traineeship. Further, each applicant contributes an essay highlighting the reasons he or she is interested in participating in the traineeship and how the training will enhance their clinical practice. Finally, a proposal outlining a project the pharmacist will do upon completion of the traineeship experience is required. Experts in the field of study, prior traineeship participants, and the members of the planning committee then come together as a selection committee to review the applications and select the participants.

Misconceptions abound regarding the qualities a pharmacist must possess to be a traineeship participant. Although a pharmacist must have a minimum of three years of experience, it is not necessary to be in a management, academic, or a research-oriented position. Pharmacists do not need to have a long list of published articles or scores of presentations under their belt. ASCP Foundation Associate Executive Director Kathleen Cameron, RPh, MPH, stresses that "the traineeship selection committees are not looking for 'superpharmacists.' Rather, the emphasis is placed on the impact the applicant will have in their own practice setting once the traineeship is over. The goal is to create pharmacists who are confident in their skills and who can advocate for appropriate treatment of their patients."

At first glance, the application process may seem a bit daunting. Past participants emphasize, however, that the application process is not nearly as difficult as it may seem. Prospective applicants can take heart in the fact that past trainees are willing to mentor colleagues through the application process.

The Traineeship Experience

Once selected for a traineeship, participants are responsible for making travel arrangements and coordinating time off from their normal job requirements. Lodging is coordinated through the ASCP Foundation, with the week-long hotel stay provided at no cost to the trainees through the generous support of the sponsoring company. Their financial support also provides the reading and lecture materials for the traineeship.

Prior to the program, trainees are sent a collection of pretraineeship materials, including articles pertinent to the topics of the traineeship. By being familiar with the information in these materials, participants are able to enter into the traineeship experience with a strong foundation of working knowledge that enables them get right to work on developing their clinical skills.

While the traineeships are structured differently, based on specific subject and site requirements, there are some basic similarities. All traineeships are five days in length. Each day begins as participants are transported from their hotel to the traineeship site. Didactic and experiential experiences follow, including lectures, small group discussions, question and answer periods, hands-on patient assessment and interaction, disease-specific support groups, and rounds with medical teams. Depending on the traineeship, participants may move between different sites during the day. The group will leave the site for dinner. More discussion, lectures, or group meetings often follow in the evenings.

Following the traineeship, each participant is required to submit a project and two case consults within the next year. "We really want to encourage applicants to think creatively about their post-traineeship projects," says Cameron. Past projects include poster presentations, in-services, or involvement in community groups such as local Parkinson's or Alzheimer's disease support groups.

The case consults focus on the application of the skills gained during the traineeship. Past trainees agree they "hit their facilities running" towards the patients with the disease states they focused on during their traineeship, eager to apply their newfound knowledge with their own patients. The participant selects two of these patients to submit as case consults to the Foundation, and these consults are ultimately forwarded to the traineeship preceptors.

One benefit of the traineeship experience that should not be overlooked is the opportunity to spend time in the company of other pharmacists who are interested in optimizing quality care for their older patients. Many opportunities are available to discuss approaches to consulting, treatment options, and common concerns. This networking extends into membership in the traineeship network e-mail listserve after the traineeship is completed. This listserve is a service of the Foundation that allows members to share information on current issues in pharmacy practice. The Foundation also sponsors luncheons at both the ASCP annual and midyear meetings, where traineeship participants, preceptors, and representatives of the sponsoring companies discuss the traineeships.

On the Cutting Edge

As the role of pharmacy continues to evolve, we are continually challenged to develop new skills. The ASCP Foundation provides consultant pharmacists unique opportunities to be on the cutting edge of patient-focused clinical practice. "In a nutshell, the traineeships reinforce something that should be an integral part of our drug regimen review: the patient," says Cash. "It still amazes me how easy it is to get caught up in the data, regulations, and charts and forget the main ingredient to ensure proper drug therapy." Sumer Verma, MD, a psychiatrist with McLean Hospital and a preceptor for the GeroPsych/Behavioral Disorders Traineeship, feels the traineeship is a valuable experience for all concerned. He notes that "the introduction of the pharmacist into the clinical setting helps the medical team realize the worth of the pharmacist's contributions to patient care." This will be especially important for the consultant pharmacist as the population of this country ages. "The role of the consultant pharmacist must be redefined as that of a clinician on equal footing with other members of the medical team," in Verma's opinion. The traineeships are an important step towards beginning this process.

Editor's note: For more information on ASCP Research and Education Foundation traineeship programs or to request an application, visit the Foundation's Web site (www.ascpfoundation.org) or call Foundation Program Assistant Devin Lowe at 703-739-1316, ext. 167 (dlowe@ascp.com).



The Consultant Pharmacist is published by the
American Society of Consultant Pharmacists.