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Hospital Pharmacology: An Alternative Model for Practice and Training in Clinical Pharmacology

From SUNY Upstate Medical University, Syracuse, New York.

	ABSTRACT

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External pressures continue to be exerted on hospitals to prioritize programs that minimize costs and improve the safety of medication use. Clinical pharmacologists are in an ideal position to provide leadership for such programs. At academic health centers, an added dimension is the exposure of physicians-in-training to the practical application of clinical pharmacology principles. At SUNY Upstate Medical University, the approach is led by a physician with clinical pharmacists and pharmacy practice residents. To align the clinical pharmacists with the overall goals of the program, a faculty promotions track system designed specifically for them has been enacted within the college of medicine. This report summarizes the "hospital pharmacology" program that provides funding for an academic physician-clinical pharmacologist. With this report, the authors hope to outline an alternative practice and training paradigm to potentially address the decline in physicians being trained in and practicing clinical pharmacology since the late 1970s.

Key Words: Clinical • hospital • pharmacology • practice • training • general

Clinical pharmacologists are in an ideal position to provide a central leadership role in hospitals by coordinating the necessary initiatives to achieve key institutional goals related to medication-use.⁴ For academic health centers (AHCs), an added dimension is the daily exposure of physician-trainees to the practical application of clinical pharmacology principles. Such exposure could be an important component of an overall strategy to promote the longevity and viability of the field.

A program in "hospital pharmacology," directed by a board-certified clinical pharmacologist-physician with support derived from the affiliated university hospital, has been in place at SUNY Upstate Medical University since 1999. This report summarizes the activities of the clinical pharmacologist to justify ongoing support that, in turn, may provide a basis for a new practice and training paradigm for our discipline.

	SCOPE OF PRACTICE FOR THE HOSPITAL PHARMACOLOGIST

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Figure 1 outlines the scope of practice for the hospital pharmacologist at SUNY Upstate Medical University. The hospital pharmacologist's role is to provide administrative team leadership in the processes of formulary management, quality improvement, and consultative services. All program outputs that affect patient care and medication-use are integrated through the pharmacy and therapeutics committee, reporting through the quality council to the hospital's medical executive committee.

View larger version (16K): [in this window] [in a new window]   Figure 1. Institutional roles and scope of practice for hospital pharmacologist. Organizational chart delineates the institutional infrastructure concerning the roles of the hospital pharmacologist (see also Lehmann, Medicis, Page, et al, unpublished data, July 2006; Lehmann, Page, Hirschman, Guharoy, Ploutz-Snyder, unpublished data, July 2006).

As chair of the pharmacy and therapeutics committee, the hospital pharmacologist directs formulary management programs to decrease the rise in expenditures through cost minimization strategies. These strategies target high-cost/high-volume drug classes for therapeutic interchange and prescribing protocols where appropriate while simplifying the formulary by avoiding duplication within drug classes. Specifically, since program establishment, approximately $600 000 per year has been minimized by strategies targeting serotonin antagonist antiemetics, bone marrow growth factors, proton pump inhibitors, low–molecular weight heparins, and antimicrobial dosing.

As the physician adviser on drug therapy to the hospital's clinical quality improvement committee, the hospital pharmacologist fosters drug safety through systematic monitoring programs. In that capacity, the hospital pharmacologist leads a multidisciplinary team that manages a database with inputs from a comprehensive nonpunitive adverse drug event (ADE)/error reporting system. This system targets high-use/narrow-therapeutic index drugs for opportunities to develop systematic process improvements using human factors principles (Lehmann, Medicis, Page, et al, unpublished data, July 2006; Lehmann, Page, Hirschman, Guharoy, Ploutz-Snyder, unpublished data, July 2006).⁵

As director of the clinical pharmacology consult service, the hospital pharmacologist leads a team of clinical pharmacists and pharmacy practice residents. In addition to requests for consults on drug-related issues from the inpatient teams, patient subgroups at high risk for drug toxicity are identified for prospective intervention by pharmacy-laboratory computer interfacing.

Each programmatic component of this scope of practice provides daily teaching/training and mentoring opportunities for college of medicine undergraduate and postgraduate learners. Specific formulary management issues and cases developed from the ADE monitoring system provide source data for the therapeutics curriculum used for teaching purposes. This curriculum and the consult service provide the daily infrastructure exposure for teaching fourth-year medical students and residents.

The hospital-based clinical pharmacists play an integral role in maintaining and supporting the activities of the service. To motivate and use them to strategically align the missions of the hospital and medical school, a faculty appointment and promotion track was specifically designed for eligible clinical pharmacists (Table I). This track modifies existing criteria to emphasize the medical school's teaching mission and links it with the clinical activity of hospital-based clinical pharmacists. In this way, the central goal of medication-use oversight for the hospital was linked to the teaching mission of the medical school, using clinical pharmacists as key personnel to achieve excellence for both. Using these criteria, eligible individuals are provided with volunteer faculty appointments in the appropriate clinical department of the medical college (eg, pediatrics, internal medicine, emergency medicine). A listserv e-mail query to the faculty deans of US medical schools did not indicate any program that involves a similar systematic approach to the utilization of clinical pharmacists employed at their affiliated university hospital/academic health center. Therefore, our approach appears to be unique in this regard.

	DISCUSSION

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We applied the administrative strategy of physician-championing used successfully in initiatives at other institutions as an adjunct to our existing traditional hospital pharmacist-based medication-use programs.^6-8 This approach provided the potential for a clinical pharmacologist physician to create a niche for a hospital-based practice. Programmatic longevity and continued salary support have been ensured through strategic goal alignment between the various institutional stakeholders, tracking cumulative cost minimization outcomes, documenting the specific drug-related quality improvements, and developing a continued teaching focus (Lehmann, Medicis, Page, et al, unpublished data, July 2006; Lehmann, Page, Hirschman, Guharoy, Ploutz-Snyder, unpublished data, July 2006).

View larger version (7K): [in this window] [in a new window]   Figure 2. Annual assessment of National Institutes of Health–sponsored clinical pharmacology training programs. Data not assessed for number of MDs in programs prior to 2005. Figure derived from personal communication with Dr. Allison Cole, NIGMS, program directors of individual training programs, and Benowitz.10

Figure 2 shows the number of clinical pharmacology training programs in the United States affiliated with the National Institute of General Medical Sciences (NIGMS) from 1978 to 2005. The number of training programs has decreased from 16 in 1978 to 8 for the academic year 2005-2006, corresponding to a decrease in trainee slots from 55 to 28, respectively, with 22 currently held by physicians.¹⁰ Because the curriculum in each of these programs is spread over 2 to 3 years, the number of graduating physicians each year varies between 7 and 11. The primary emphasis of these programs continues to be on the development of independent, laboratory-based investigators who are able to successfully garner federal funding. Although this goal remains valuable, this paradigm may attract trainees with little passion for the application of clinical pharmacology and therapeutics to the daily care of patients. This tendency is exacerbated by the limited hospital ward time of faculty and trainees in these programs that minimizes their exposure and influence on potential new recruits to the field of clinical pharmacology.

Indeed, less than 10% of allopathic medical schools provide formal courses in clinical pharmacology and therapeutics after the second year of medical training (personal communication, Dr Neal Benowitz, March 1, 2004). Although the percentage of medical schools that have physicians actively practicing clinical pharmacology is likely higher than the number providing coursework, this figure provides a surrogate to underscore the limited exposure that medical students have to academic clinical pharmacologists. This exposure is further hampered by pressures on academic clinical pharmacologists to generate extramural funding and a lack of a definable patient population, unlike organ-based subspecialties. The hospital pharmacology model described in this report addresses both issues because funding is provided and all hospitalized patients could come under the scope of practice for the clinical pharmacologist.

A national need exists to identify well-trained leaders who apply the principles of clinical pharmacology to the practical decisions favoring rational and cost-effective drug therapy. Despite this need, our field remains focused on a single training and practice standard. A persistent focus on this exclusive model may simply secure the fate of our field as an interesting historical footnote in medical science that made a brief appearance in the late 20th century and became extinct in the early part of the 21st century.

	REFERENCES

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1. Hoffman JM, Shah ND, Vermeulen LC, Hunkler RJ, Hontz KM. Projecting future drug expenditures—2004. Am J Health-System Pharm. 2004;61: 145-158.[Abstract/Free Full Text]

2. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

3. Nadzam DM. A systems approach to medication use. In: Cousins DM, ed. Medication Use. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1998: 5.

4. Anonymous. American College of Clinical Pharmacology response to the Institute of Medicine report "To err is human: building a safer health system." J Clin Pharmacol. 2000;40: 1075-1078.[Web of Science][Medline] [Order article via Infotrieve]

5. Reason J. The contribution of latent human failures to the breakdown of complex systems. Phil Trans R Soc London B. 1990;327: 475-484.[Web of Science][Medline] [Order article via Infotrieve]

6. Anonymous. Improving care for acute myocardial infarction: experience from the Cooperative Cardiovascular Project. The Cooperative Cardiovascular Project Best Practices Working Group. Joint Commission J Quality Improvement. 1998;24: 480-490.

7. Cooper GS, Armitage KB, Ashar B, et al. Design and implementation of an inpatient disease management program. Am J Managed Care. 2000;6: 793-801.

8. Middleton DB, Fox DE, Nowalk MP, et al. Overcoming barriers to establishing an inpatient vaccination program for pneumonoccus using standing orders. Infect Control Hosp Epidemiol. 2005;26: 874-881.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]

9. http://www.abcp.net/diplomat.htm (updated with 2005 board certification figures).

10. Benowitz NL. Birthing of clinical pharmacologists. Clin Pharmacol Ther. 1997;62: 587-591.[CrossRef][Web of Science][Medline] [Order article via Infotrieve]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Request Reprints Citing Articles Citing Articles via ISI Web of Science (2) Citing Articles via Google Scholar Google Scholar Articles by Lehmann, D. F. Articles by Guharoy, R. Search for Related Content PubMed PubMed Citation Articles by Lehmann, D. F. Articles by Guharoy, R. Social Bookmarking                   What's this?