Who are you? Who are We? Professional Identity in Experiential Learning

The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

Discovering what it means to be a good healthcare provider goes beyond knowledge acquisition and education for pharmacy students; it demands a transformative journey of professional identity formation (PIF). The pharmacy profession, through its professional organizations, has identified a number of core values, but as the profession changes, new core values are emerging. PIF occurs over a trajectory, starting in pharmacy school (or even before) and continuing throughout life. Preceptors can use a number of techniques to help pharmacy students with PIF, assuring that our future pharmacists hold the same values ats the profession at large. Exposing students to a variety of situations, asking open-ended questions, using teach-back methods, and introducing students to professional organizations are a few.

INTRODUCTION

Let’s begin this continuing education activity with some questions. What makes a nurse a nurse? What makes a nurse a good or exceptional nurse? What makes an electrician an electrician? What makes an electrician a good or exceptional electrician? What makes a pharmacist a pharmacist? What makes a pharmacist a good or exceptional pharmacist? Those questions are no doubt difficult to answer. Preceptors may be making a list mentally of the qualities that the ideal nurse, electrician, or pharmacist should possess. Certainly, for each of these professions, education will be the foundation. Here’s a harder question: Is it possible to be a good or exceptional nurse, electrician, or pharmacist but a terrible person? And is it possible to be a good and loyal pharmacy employee, but not such a good pharmacist? All these questions speak to the concept discussed here: professional identity.

Discovering what it truly means to be a healthcare provider goes beyond knowledge acquisition and education for pharmacy students; it demands a transformative journey of professional identity formation (PIF) starting even before introductory pharmacy practice experiences (IPPE) (perhaps with acceptance into a pharmacy program or during professionalism ceremonies) and continuing past graduation and over an entire career. As the introduction hints, preceptors must distinguish between education, professionalism, and professional identity. A quick way to differentiate between the latter two is that a student’s professionalism is outwardly observable. Professional identity, however, is defined by a student’s internal thinking, feeling, and acting like a member of the pharmacy profession and its community.¹

Pharmacistscan use their extensive, science-based education to assume many professional identities; they may work in community, hospital, health-system, research, information technology, marketing, or a vast number of other positions. Viewing the history of the profession in just the last century, various identities have accumulated (rather than shifted) over time.² The typical pharmacist’s main responsibility was once compounding. As the industrial revolution made it possible to produce dosage forms en masse, compounding fell out of favor and dispensing manufactured products became the primary focus of a typical pharmacist. Within just the last 20 years, pharmacists have made major inroads into establishing their role as necessary health care professionals rather than just retailers.³ Pharmacists have been shown to be key in improving therapeutic outcomes with a new focus on patient focused intervention.⁴ Pharmacists’ employment opportunities are growing and adapting to a changing field but the profession’s fundamental or core values are somewhat fixed. Table 1 lists the pharmacy profession’s current core values as promulgate by the American Pharmacists Association.

Table 1. The Pharmacist’s Core Values^5,6

Commitment to the patient’s well-being	· Engage in shared decision making and respect patients’ right to self determination · Protect patient life and aim for best outcomes
Pharmaceutical expertise	· Maintain competence in knowledge and abilities to ensure the safe and effective use of medication
Reliability and care	· Find balance between risk and benefit in treatments · Maintain trust and confidentiality with patients · Collaborate reliably with other healthcare professionals to ensure best health outcomes
Social responsibility	· Act with honesty and integrity in professional relationships · Avoid discrimination and seek healthcare equity in society

PAUSE AND PONDER: Look at Table 1. What other values would you add to the table?

As the profession’s identity evolves, pharmacists’ identities and their core values must follow suit. While pharmacists must be lifelong learners and adapt over time to new conditions, change is most readily achieved in the initial learning process as pharmacy students. In other words, you can teach old dogs new tricks, but it’s easier to teach puppies. In class, faculty teach students information a pharmacist should know and address how to outwardly act like a professional, but the profession demands something more: the development of a professional identity. We rely on our community of pharmacist preceptors to augment the various didactic courses to cultivate new pharmacist graduates who identify strongly with our core values.

PIF is a crucial aspect of pharmacy experiential education. Students require experiential learning and immersion into the profession to assimilate the qualities that make pharmacists unique and different from other healthcare providers. The Accreditation Council for Pharmacy Education (ACPE)-required IPPE rotations provide students with important opportunities to influence PIF, and the PIF process continues during a student’s advanced pharmacy practice experiences (APPE).⁷

The Pharmacy Student’s IPPE Rotation

IPPE rotations serve a much broader purpose than students fulfilling educational requirements and completing dreaded 50-page workbooks that some schools use that aim to help them reflect on or consolidate learning. IPPE rotations should introduce students to the way front line pharmacists navigate real-world pharmacy practice situations. Students primarily relegated to counting pills and organizing stock in the back of a pharmacy are unlikely to develop professional identities. If students perceive that preceptors think of them as free labor or burdensome obligations, they will not engage in the deeper discussions about the preceptor as a person fulfilling professional obligations. Students should observe and actively take part in various aspects of the profession, applying theoretical knowledge acquired in classrooms to real-world situations. Practical knowledge gained through these experiences helps students to develop essential professional skills and test their learning.

Experiential learning rotations should also expose students to different types of pharmacist positions and responsibilities. By observing different practice settings and interacting with pharmacists, patients, and other healthcare professionals, students can explore their interests, while realizing their strengths and developing professional values.

Step-by-Step to Professional Identity

Throughout pharmacy education, faculty members encourage students to exhibit professionalism; they may

suggest more productive ways to present ideas
prompt students to elevate or refine language or speak in ways patients will understand, or
suggest that certain clothing choices can diminish peoples’ view of them and their credibility

While classroom faculty can teach and model the concept of professionalism, preceptors have the responsibility of supporting students in their PIF journey. Teaching starts the learning process; ultimately, students will need to “create their own adventures.” In other words, they must learn to apply aspects of specific material and explore different experiences to develop a professional identity. Relating to the definition of PIF, a pharmacy student’s PIF process must involve thinking, feeling, and acting like a pharmacist.

To discuss professional identity, preceptors and all pharmacists who influence the student’s learning process must acknowledge the steps inherent in PIF. Personal identity is based on an individual’s concept of who they are and how others perceive them.⁷Individuals develop personal identity in stages starting at birth but personal identity begins at birth and continues throughout life. Professional identity develops in a similar but slightly different way.

Robert Kegan, a Harvard psychologist, developed a framework for longitudinal development of the self into a moral meaning-making entity that has had lasting impact on PIF in education of professionals.^3,8-10His framework includes six stages with stage 0 beginning at birth. Stages 0 and 1 concern young children’s development of basic motor function and sensing the physical world around them (and are not discussed here).⁸

In relation to PIF, the health professional must pass through at least stages 2 through 4 of the framework: imperial, interpersonal, and institutional.¹⁰ This framework, with steps 2 through 5 shown in Table 2, defines the personal characteristics and related professional context of an individual in continuous stages of development. Individuals who reach the final stage, stage 5, or the inter-individual self-transforming stage, open themselves to multiple identities and other value systems, achieving full personal autonomy.⁸ Research shows that not all individuals reach stage 5.^10,11 However, with effective socialization partnered with experience in the pharmacist’s potential identities, students may reach this level during their careers.

Table 2. Kegan’s Stages of Personal and Professional Identity Development^8,10

Stage	Personal characteristics	Professional context
2. Imperial	Individuals put their own needs and interests first but consider other people’s views.	Individuals fill their professional roles but do so with a primary motivation of following rules. Individuals exhibit low self-reflection and may struggle to balance emotions with reason.
3. Interpersonal	Individuals are concerned with others’ perceptions of them and able to reduce focus on self-interest. Individuals balance multiple perspectives simultaneously.	Individuals are idealistic and self-reflective, seeking others to guide them. Individuals manage emotions acceptably and generally understand right and wrong.
4. Institutional	Individuals assess relationships with a focus on self-defined principles and standards. Individuals define themself independently of others.	Individuals can understand relationships by appreciating different values and expectations. They internalize professional values and do not allow emotion relating to needs, desires, and passion to gain control over reason.
5. Self-transforming	Individuals reconcile contradictory or paradoxical ways of constructing meaning. They can recognize the interdependencies of different systems or ways of thinking.	The self-transforming professional has a strong sense of self but also relies upon others knowledge and opinion in professional development. The professional integrates other identities into the total professional identity.

The constantly evolving pharmacy profession and the lack of a specific list of steps for PIF makes it challenging for students to define an identity (and preceptors to help them). As the profession continues to develop to offer a wide range of opportunities for pharmacists, preceptors will observe students finding varying paths of PIF. Different pharmacists will define the profession differently depending on their experiences. Pharmacy students might generally navigate this list of steps, common among many young people developing professionally^12-15:

Exploration: In any career path, exploration is the first step in PIF. In pharmacy, the American Pharmacists Association offers the Career Pathway Evaluation (https://www.pharmacist.com/Career/Career-Pathways) to help aspiring pharmacists find a path forward. IPPE and APPE rotations should ideally provide students with opportunities to explore various pharmacy practice settings and work with pharmacists with a range of responsibilities. Students need to augment their existing identities—formed by their upbringing and personal beliefs—as they begin their pharmacy education and careers. Students come from diverse backgrounds with varying past experiences, cultural values, learning styles, and personal characteristics.
Reflection and integration: Educators should encourage students to reflect on their experiences, strengths, values, and areas for improvement. Reflection helps students align personal and professional values, shaping their professional identities. Self-reflection and reflection from preceptors during IPPE rotations is necessary for growth. For example, a technician told Jayne, a pharmacist for a chain pharmacy, that a patient was in the counseling room and ready for an immunization. Jayne took her student with her to observe. Jayne asked the student to review the necessary paperwork and make sure the patient, a 17-year-old adolescent, met all the criteria for the human papilloma virus vaccine. The student said he did. When Jayne reviewed the paperwork, she found one problem. She asked the patient, “Which of your parents is here with you today?” In Jayne’s state, the legal age of consent was 18. When contacted by phone, the parent agreed to come in immediately and Jayne administered the vaccination. After all was done, she spent just a few minutes talking to the student about the duty to protect and comply with the law, describing a couple of other instances when she encountered similar situations.
Commitment and advocacy: Commitment to the pharmacy profession and dedication to lifelong learning are essential elements in the development of a professional identity. Pharmacy students will become spokespeople for the profession and advocate for the inevitable change from retail-based to clinically- or service-based work. Pharmacists with solid professional identities will be lifelong learners and educators.

Students who have never worked in a pharmacy or observed a pharmacist at work (and some who have) may have inaccurate ideas about the profession. Preceptor Eddie encountered a curious situation when Adam, a P2 student, reported for an IPPE rotation. Adam was more than self-assured; Adam had an exaggerated sense of self-worth. He was bumptious (self-important or smug), so Eddie needed to work around Adam’s personal identity. Adam told Eddie that his older brother was a pharmacist who had told him that pharmacy schooling is pretty worthless. Adam said, “All you need to do is pass and you’re on your way to a darned good salary.” Eddie was astounded. Adam needed help reaching Step 2 of the PIF model—he was putting his own needs and beliefs first and disregarding others’ views. Eddie created a plan to help Adam develop more insight.

Each day when Adam came to work, Eddie presented two or three situations from his work experience that required more than just a body behind a computer. He would ask Adam to work through the problems and present the answers by the end of the day. In this way, he educated Adam about professional responsibility and clarified the difference between a person with a pharmacy degree and an exceptional pharmacist. PIF’s goal is for students to move from playing or imagining the pharmacist’s role to internalizing the pharmacist’s identity and acting as pharmacists at the unconscious level. The process shifts emphasis from ‘doing’ to ‘being.’ While professionalism can be put on and taken off like a white coat, professional identity stays with the healthcare professional at all times. Eddie was able to improve Adam’s professionalism, which was poor at the rotations start, and contribute to Adam’s professional identity.

PAUSE AND PONDER: When you were a student, which preceptors influenced your core values and how did you internalize them?

Activities that Develop Professional Identity

Preceptors who work in different types of positions need to acknowledge their personal and professional strengths and limitations to determine what they can realistically offer to students. Before taking on the preceptor’s or mentor’s responsibilities, professionals must be familiar with their own skillsets.^7,14

The first step preceptors should take is to embrace self-reflection. Just as preceptors should encourage students to engage in reflective practice, pharmacy is a profession in which preceptors must be lifelong learners. Established pharmacists will continue to accumulate PIF-related experiences over time to aid their effectiveness in guiding others.
Preceptors will then need to plan intentionally and commit to helping students develop professional identity. A reluctant or unprepared preceptor usually cannot teach students effectively. Sometimes pharmacists with extensive work experience on the frontlines might feel that students come with a more contemporary knowledge base and therefore, they have nothing to teach them. However, that pharmacist could be well-positioned to support the student’s PIF by embracing how their professional experiences led to a deeper understanding of their profession and the pharmacist’s role in supporting patient outcomes.

PAUSE AND PONDER: What are the most efficient ways to help your students develop professional identity in your practice location? What are the most important ideas you can teach? Are they the same?

PIF is a gradual process that revolves around socialization, not classroom lecture. IPPE rotations provide an ideal platform for students to engage in activities that promote professional development. Preceptors can work with students to facilitate PIF during an IPPE rotation in several ways.^7,16,17

Patient interactions: Direct patient interaction during IPPE can help students apply theoretical learning and develop communication skills, empathy, and a patient-centered approach to care. These experiences help students internalize a sense of responsibility toward patient well-being and strengthen trust in the caregiver-patient relationship.

Preceptors should expose students to patient counseling sessions as observers as often as possible. Consider Leonard, a preceptor who frequently tells students, “I am not going to bring you into this counseling session because it is too complicated. You won’t understand what’s going on.” This is a mistake. IPPE is an opportunity for students to be exposed to difficult real-life examples before they have to handle them alone. These experiences help develop professional identity and may even stimulate an “ah-HA!” moment about pharmacist responsibility for the student. Preceptors who ask students a few open-ended questions (e.g., What did you see that surprised you? What three points did I emphasize? What counseling techniques will you remember from this?) prompt students to engage. Inviting students to see a situation that requires pharmacists to work at the top of their license introduces step 4 (institutional) and epitomizes PIF. Leonard has the opportunity to show his version of an independent and talented pharmacist who contributes to healthcare positively.

PIF opportunities need not be complicated. Sometimes PIF occurs concurrent with simple everyday tasks. Preceptors who walk students through their thought process when processing an order (i.e., Why does this document go here in the electronic medical record? Why am I looking at that lab before processing the order?) introduce students to the necessity of questioning routinely as a professional function. They can also ask students to find or calculate doses, explore drug interactions, and then provide the information to another interdisciplinary team member.

Not all patient interactions are pleasant or welcome, but they may be professionally necessary. Alex, the pharmacist, was dismayed when a technician came to him and said, “Mrs. Royce is here and wants to talk to you,” while rolling her eyes. Mrs. Royce was notorious for being loud, disrespectful, and a know-it-all. Alex didn’t answer immediately. The technician said, “Shall I tell her you are busy?” Alex said he would talk to her and briefed the IPPE student on Mrs. Royce’s personality. He said he was concerned because Mrs. Royce had recently had surgery, had a reaction to the opioid that was prescribed, and was switched to tramadol. He explained that regardless of his personal feelings, he needed to deal with the situation. When he asked Mrs. Royce how he could help her, she said, “The oxycodone made me sick as a dog. My friend up the street who is a nurse says the tramadol I am taking now is not worth anything. I am taking it and it is super mild but at least it’s something. I have an anti-inflammatory, too. I know this is a first-world problem since this was an elective surgery, so I should not complain. I am just a whiner with pain.” Alex reassured her that no one deserves pain, even if the surgery was elective. Alex counseled the patient with these points^18-20:

Tramadol is a funny drug. People with certain genetic variations called CYP2D6 deficiencies get less relief from it. It gets a bad reputation because many clinicians don't know that. Take it if it helps. And it sounds like it helps a bit.
Schedule your anti-inflammatory around the clock. Don't wait until the pain is horrible. Take it every four to six hours for a few days. Eat a little something when you take it.
Use warm or cold compresses if they help but use them only for 10 minutes at a time once every hour. (You don't want to fry or freeze your skin.) If warm helps, use warm. If cold helps, use cold.
Move around as much as you can. It increases blood flow to the area.
Have you tried some acetaminophen? Some people find that taking a couple of acetaminophen once or twice a day for a couple of days helps--it won't address the inflammation but it may help with pain.
Consider finding an acupuncturist and/or a massage therapist who specializes in pain.

After the session, Alex explained that dealing with patients like Mrs. Royce is an obligation, as is not showing whether he likes her. This attitude aligns with the “interpersonal” step of PIF (step 3)—balancing multiple perspectives and putting others’ needs first. He said that all pharmacists encounter difficult patients. He also said that he planned to check in on her by phone the next day. He asked the student if anything surprised her, and she said, “Yes. You didn’t say anything about the nurse’s bad advice!” Alex explained that professionals don’t speak badly of each other, especially when the information from Mrs. Royce was hearsay. He said he trusts that Mrs. Royce, the consummate know-it-all, will talk to the nurse and the nurse will call if she wants more information. The student was able to teach-back the key points of professional identity:

Treat all patients with respect, even when they don’t return the favor
Counsel carefully
Do not disparage other healthcare providers (talk to them directly if you have a concern about their advice)
Follow-up.

When the student asked this preceptor for a letter of reference several months later, the preceptor said, “Remember Mrs. Royce? Her attitude is entirely different now. She’s kind and respectful when she comes in.”

Collaborative Practice: Preceptors can highlight interdisciplinary healthcare experiences, demonstrating teamwork, collaboration, and the ability to contribute effectively within a healthcare setting. In a health system setting, for example, many different pharmacists work in the same organization with varying responsibilities. A health system may include an inpatient and outpatient, specialized clinical, emergency department, investigational drug service, and oncology pharmacy. Each position requires modified professional identities and collaboration with different healthcare professionals. A preceptor can join forces with other pharmacists—a model that is increasingly popular and often called team precepting—to ensure students receive a well-rounded education in the short period of time provided.

Exposure to eustress (healthy, stimulating kind and level of stress): A preceptor should take the time to facilitate a learning environment that optimizes the likelihood that PIF will occur. Preceptors can discuss situations that present ethical dilemmas during IPPE rotations, prompting critical thinking, ethical decision-making, and the development of moral reasoning. As students are exposed to common ethical dilemmas, they will begin to develop problem solving skills; build confidence; and think, act, and feel like pharmacists. Students who have not yet assimilated the second step of PIF—the imperial—may be more concerned with packing up to leave at their assigned quitting time than finishing a task. Helping students learn that sometimes the clock should not dictate decisions also develops professional identity.

Exposure to unanticipated, stressful misadventure. Marguerite was precepting a student when a technician came behind the bench with arms raised and a robber holding a gun behind her. The four other employees and the student froze, and Marguerite handled the situation, emptying the vault into the robber’s duffel bag. After the robbery, everyone was shaken but no one was hurt. Although the store manager’s opinion was to send the student home, Marguerite insisted on a post-incident stress debriefing. It gave everyone the opportunity to vent and identify what they did well and what they could do better, and reduced the likelihood of post-incident stress.²¹ As they met, the police returned and said they had apprehended the robber because Marguerite had placed a tracking device in the duffel bag. Marguerite has traversed all the steps of PIF. She considered others in her decisions, balanced multiple perspectives, and maintained her standards.

Although this is an extreme example that underscores the meaning of “unanticipated,” the student reported feeling better and understanding more about the pharmacist’s responsibilities. Other unanticipated events that can convey PIF include dealing with irrationally irate customers, diffusing the situation with a vaccine refuser who wants to espouse her opinion loudly to other patients, or dealing with a patient or employee medical emergency in the workplace. Appropriate and deliberate use of emotion can also focus learners and enhance learning, especially when the material is moving or highlights the patient’s perspective. Preceptors should employ emotion as a teaching tool carefully, since negative emotion (e.g., anger, embarrassment) erodes trust and can disenfranchise students.

Professional involvement: If time allows, preceptors can encourage students to engage with professional organizations. Attending conferences, workshops, state pharmacy board meetings, or seminars that promote professional growth, networking, and exposure to current trends in the pharmacy field builds professional identity. Preceptor Eddie, discussed previously, took Adam to a Board of Pharmacy meeting. Adam seemed uninterested until the Board discussed disciplinary action against a pharmacist who had failed to perform due diligence, leading to a patient’s death and a pharmacist with a drug abuse problem. Adam was less bumptious in the car on the way back to work, and Eddie took time to ask open-ended questions to mold Adam’s professional identity. He asked, “What questions do you have for me?” Adam said, “What is the chance they will get their licenses back?” It created a chance to talk about professional responsibilities and how state boards monitor and ensure public safety. Eddie asked a question of his own “What do you think the patients who experienced poor care or unprofessional behavior from those pharmacists think about the profession of pharmacy? In the world of social media, how far do you think those negative sentiments about pharmacists can spread?" This discussion moved Adam further through Step 2, and away from a preoccupation with self-interest.

Formative feedback (feedback that helps students recognize knowledge gaps and molds the student’s beliefs and values; see the SIDEBAR) and encourage reflection. Preceptors should⁷

Provide students with regular feedback, but also schedule time for check-ins and reviews mid-rotation. As students’ professional identities develop, they will become their own sources of feedback.
Employ teaching methods such as using teach-back and open-ended questions.
Schedule time for students to work on workbooks or other tools for reflection and encourage discussion and questions.
Assign meaningful work to help students integrate ethical principles, evidence-based practice, effective communication, and patient-centered care.

SIDEBAR: Formative Feedback^22,23

Formative feedback

refers to informal constructive feedback provided throughout a learning process
is ongoing and proactive
is specific and actionable
helps to develop self-awareness and independence
gives students the opportunity to reflect and adjust without being graded
and is not summative feedback (a method of assessment where students are evaluated and/or graded on their overall performance usually at the end of a learning period)

Open ended questions are important in formative feedback. Just as healthcare professionals are encouraged to ask patients open-ended questions, preceptors should do the same with their students. Open-ended questions

give students the opportunity to participate in discussion actively and gain a deeper understanding of a topic or situation
can help the preceptor identify gaps in a student’s understanding
develop students’ critical thinking skills and autonomy to further their PIF
are especially useful after patient counseling or other interaction.

Teach-back, or the "show-me" method, confirms whether a person—a patient or in this case, a student—understands the topic being explained. Pharmacists and other healthcare providers use the teach-back in patient counseling to facilitate better communication between patient and provider. This tool allows a healthcare provider to assess patient understanding by having a patient explain, or teach-back, what they took away from the counseling session. The healthcare provider can gently correct misunderstandings. Using teach-back with students is especially effective when

Students observe a complicated counseling session or process
Students are learning about a new medical device or a medication with an unusual administration route or schedule
Students need to research a topic that is new to them and may have missed some critical information
Students witness a situation that is emotionally charged or creates a safety concern

Demonstrating vulnerability. Preceptors often want to hide their deficiencies, limitations, or weaknesses from students so students will have greater confidence in the preceptor’s expertise. Students need to see how mistakes happen and lead to improvement. They also need to see the ethical challenges that are inherent in pharmacy practice. Preceptor Terry received a phone call from a pharmacist who worked at another of her chain’s locations. She knew the pharmacist quite well, and the pharmacist said she had received a prescription for a patient well known to them for hydromorphone 8 milligrams. They were out of hydromorphone and the pharmacist asked if Terry had any 8 milligram tablets. Terry said she did, and the pharmacist said she would send the patient over and to expect him within 30 minutes. When the patient arrived, Terry filled the prescription and being alone with just the IPPE student, prepared to dispense it at the cash register. As required by law, she asked the patient for identification. Much to her surprise, the person presented his driver’s license and he was not the patient. In fact, the identification card was for the prescriber who had written the prescription, a medical resident at a local hospital. She asked the prescriber why he was picking up the prescription and he said that he was helping out the patient who was in terrible pain. It was late in the day, and Terry had received this referral from a colleague who she trusted. She dispensed the prescription despite her misgivings.

The next day when the IPPE student arrived, Terry explained the immediacy of the situation and conflicting professional interests led to dispensing the prescription yesterday, but she still had some nagging doubts. With the prescription volume a bit slower now, she decided to do some follow up. She found that the “patient” had a number of prescriptions filled over months, most of which were filled at her colleague’s pharmacy. However, the initial prescriptions were filled in a town 40 miles away. She eventually called the hospital, found the name of the residents’ supervising physician, and contacted him. After brief discussion, he indicated that he would handle it going forward and that he appreciated the information. Although the supervising physician did not say outright that he suspected this resident of wrongdoing, the implication was that was the case. The supervising physician did follow through and eventually, the state requested documentation. Terry was able to talk through the situation with the student and explain the pharmacist's responsibility in cases like this. Terry exemplifies Step 4 of PIF. She was secure in her identity and despite the way others had handled this situation, she was concerned and confident enough to do the right thing.

Teach-back is useful in many situations, but especially when processes are involved. In one busy pharmacy, a man approached the pharmacy student at counter. He said, “Can I get a shingles vaccine today?” The student, having no prior experience in a community pharmacy, politely asked the patient to wait while she asked the pharmacist. Her preceptor said quickly, “Get the patient’s insurance information and enter him into the system.” With the patient’s insurance card in hand, she began to enter his information. Unsure how to proceed, she asked the pharmacist for assistance again. A line began to form behind the man, so the pharmacist said, “Don’t worry, I’ll do it and you can watch.” The intern watched and thought the process looked easy enough. The pharmacist asked if she understands (a close-ended question), and she said yes. Later in the day, a new patient came in and the student began to enter the patient’s insurance information. She hit a point where she was unsure how to continue. But earlier she told her preceptor that she understood how to do it! She really thought she did know how! The student, becoming flustered, was embarrassed to ask for help again on something she had just learned. How could this situation have been avoided? If the preceptor had asked the student to describe the process, correcting any inaccuracies in recollection, and explained why pharmacies need to provide accurate information, the student would have been in a better position to help.

Overall, preceptors need to provide students with the best experience possible with available time and resources. For example, a student may be in a health systems rotation in a department that has little patient interaction and plenty of down time. The preceptor may worry he cannot give the student the experience she deserves. This preceptor could assign the student to review a journal article on a relevant subject and present it to an interprofessional team of nurses, pharmacists, and doctors. Subsequently, the student may realize the pharmacist’s potential impact and help the student internalize what it means to be a pharmacist.

PAUSE AND PONDER: Can you recall a time when you were taught how to do something, told your teacher you understood it, then could not perform the action on your own? As a preceptor, how would you avoid this situation with your own student?

Finally, let's return to the questions asked at the beginning of this continuing education activity. In particular, the question of whether a pharmacist can be a good employee, but a bad pharmacist, is of tremendous interest right now. The situation it brings to mind is that of the good employee pharmacist whose supervisors urge him to dispense opioid prescriptions as written and avoid asking too many questions. Doing so makes customers happy, increases prescription volume, and reflects positively in the store’s metrics. Many pharmacists conducted themselves this way for many years, despite the fact that they probably had an inkling that they should be checking more closely or perhaps turning some prescriptions away. These pharmacists were not necessarily bad pharmacists, but their employers considered them good employees because they followed directions and turned a blind eye to a developing opioid epidemic.

In November 2021, a federal jury in Ohio found three of the nation's largest pharmacy chains liable for contributing to the U.S. opioid crisis.^24,25 The jury found that the prosecution provided ample evidence that some medications dispensed at chain pharmacies legally were sold on the black market. That finding has resonated nationally as state after state filed similar lawsuits. In December of 2022, two chain pharmacies agreed to share a $10.7 billion fine to settle allegations that they failed to oversee opioid analgesic prescriptions adequately. These funds are being distributed to states, local governments, and federally recognized tribes to improve opioid crisis abatement and remediation programs. Both chains agreed to improve their controlled substance compliance programs and provide mandatory training to pharmacists. Expediency in the short term and compliance with procedures that are unethical seldom avoid long term consequences.

Other states have also secured settlements from pharmacies, and independent pharmacies have also been prosecuted. Discussing situations related to pharmacy that appear in the media is another way that preceptors can introduce discussion of our professional values. The nation is hopeful that pharmacists everywhere have learned that part of our professional identity is the necessity to speak up and to challenge our employers when they ask us to do things that walk the line of professionally ethical behaviors. Starting discussions with students about newsworthy events like this in which preceptors talk about self-interest, other people’s perception of pharmacy and pharmacists, and maintaining standards can advance our profession. Pharmacists are part of a complex system of drug distribution. We need to establish our core values and uphold them to keep society’s respect.

CONCLUSION

Pharmacy educators, preceptors, and mentors must realize the significance of IPPE and APPE rotations and their influence in shaping future pharmacists’ professional identities. Professional identity formation is essential for students’ transformation into successful and compassionate pharmacists. IPPE rotations with effective preceptors enable students to observe, participate, and reflect on various aspects of pharmacy practice. Often these exercises take very little time, and small actions can have tremendous impact. Through exploration, reflection, and commitment to the profession, students can develop professional identities that align with the core values and beliefs of the pharmacy profession and their own personal values.

As students grow throughout their educational and professional careers, they will internalize what it means to be a pharmacist. Changes may not be apparent in the short amount of time a preceptor is with a student. If students are comfortable with the idea, preceptors can connect with them on LinkedIn, stay in contact through email, and be open to being a mentor to the student after the rotation ends. Pharmacy is a profession of many interconnected individuals with unique and valuable professional identities.

Who are you? Who are We? Professional Identity in Experiential Learning

Post-test

After competing this continuing education activity, preceptors will be able to
● Describe professional identify formation
● Apply the steps in development of a professional identity
● Identify activities that develop professional identity appropriately

1. Lyle is a preceptor whose student arrives to work wearing a tee shirt with a silly slogan on it, a ball cap, and brightly colored foam clogs. The student puts on a wrinkled and somewhat dirty white coat and steps out behind the register to start helping patients in the line. What is Lyle’s main concern with regard to this student?
A. Professionalism
B. Cleanliness
C. Professional identity

2. As the end of the day approaches, a prescriber calls in a set of prescriptions for a child who has a serious infection. Lyle assigns his student to check the dosing. The student asks if he can do the task tomorrow morning, as it's late and he'd like to head home for dinner. He also says that the prescriber probably double checked her own work. What is the BEST way for Lyle to explain the importance of completing the task today?
A. Explaining that one never knows when a patient will arrive to pick up prescriptions and how that reflects on the pharmacy staff. He is trying to help develop the student’s professionalism.
B. Explaining that most prescribers rarely double check their own work so the pharmacy needs to do it before the prescriber leaves for the day. This encourages professional identity formation.
C. Explaining that pharmacists have a duty to be diligent about medication doses, especially in pediatric patients. This should contribute to the student’s professional identity formation.

3. Mr. Walker, a patient who has successfully overcome an addiction to heroin, presents a prescription for oxycodone after having dental work. He wants to talk to the pharmacist, and you invite your student to join you. Mr. Walker asks if the prescription is for an addictive substance and says that the dentist never asked if he had a current or previous addiction problem. He would like you to call the dentist and have the prescription changed. You agree, and when you return to the pharmacy, your student asks, “Why don't you have him call the dentist himself? We're really busy.” What part of the pharmacist core values should you discuss with this student?
A. Pharmaceutical expertise
B. Commitment to the patient’s well-being
C. Social responsibility

4. Which of the following describes Step 2 in Kegan’s Stages of Personal and Professional Identity Development?
A. A student's primary concern is understanding others’ values and expectations.
B. A student's primary concern is ensuring the team approves of her work.
C. A student’s primary concern is in learning and following the rules of dispensing.

5. Which of the following accurately represents the sequence in which students can be expected to develop professional identity?
A. Learning the rules of pharmacy; learning to differentiate between right and wrong and working with other team members; removing emotion and using reason to make decisions
B. Learning to differentiate between right and wrong and work with other team members; removing emotion and using reason to make decisions; learning the rules of pharmacy
C. Removing emotion and using reason to make decisions; learning the rules of pharmacy; learning to differentiate between right and wrong and work with other team members

6. Which of the following accurately describes PIF opportunities in the pharmacy?
A. Preceptors who take IPPE students should use the simplest of examples to help students with PIF because students have little experience.
B. Preceptors should concentrate on situations that are complex so that students see pharmacists practicing at the top of their licenses.
C. Preceptors can use simple everyday tasks to help students understand the pharmacist's role and develop their professional identities.

7. Which of the following activities would be MOST appropriate for an IPPE student who has never worked in a pharmacy with regard to professional identity formation?
A. Having the student observe a controlled substance inventory and asking questions like, “Why do you think we conduct an inventory every day? What would we do if we found a discrepancy?”
B. Having the student observe a technician who is running the cash register and coaching the technician to ask questions like, “Do you have any experience running a cash register or dealing with customers?”
C. Having the student restock the OTC section of the pharmacy and make a list of OTCs that need to be ordered, and asking the student to justify her reasons for ordering the various drugs and the quantity she designates.

8. Which of the following activities is MORE appropriate for an APPE student than an IPPE student to develop professional identity?
A. Reviewing the case of a patient with drug resistant tuberculosis and several drug allergies and presenting the case on medical rounds with physicians and nurses
B. Checking that the dose of amoxicillin for a 5-year-old child who weighs 36 pounds is correct and that the child has no allergy to penicillin antibiotics
C. Asking the student to shadow you while you provide counseling to a patient who has a question about OTC cough and cold formulations

9. A new IPPE student has a casual attitude about pharmacy and expresses opinions that indicate that she knows very little about professional responsibilities. Several times and despite gentle correction, she has counted controlled substances incorrectly and returned control substance bottles to the regular shelves, not the vault. Which of the following activities might increase her awareness of the pharmacist’s responsibilities and legal obligations?
A. Having the student accompany you to your state’s Board of Pharmacy meeting
B. Abandoning formative feedback and pointing out the student’s errors forcefully
C. Restricting this student’s activity to handling the front end of the store only

10. Your state announces that it will now impose significant restrictions on all prescriptions for a certain drug because of a growing number of patient deaths related to its abuse. During the morning huddle, your staff discusses the increased paperwork burden and the potential that patients will be upset. After the huddle, the student asks, “Why is this our problem? Shouldn't this be handled by the drug’s manufacturer?” What is the best answer?
A. Technically pharmacists are nothing more than the medication police. Our job is to enforce the rules other create strictly and unemotionally.
B. In an ideal world, pharmaceutical companies would take complete responsibility for the damage their drugs do. This is not an ideal world.
C. Pharmacists are part of a complex system of drug distribution. We need to establish our core values and uphold them to keep society’s respect.

REFERENCES
1. Larose-Pierre M, Cleven AJ, Renaud A, et al. Reevaluating core elements of emotional intelligence in professional identity formation for inclusion in Pharmacy Education. American Journal of Pharmaceutical Education. 2023;87(6):100082. doi:10.1016/j.ajpe.2023.100082
2. Kellar J, Paradis E, van der Vleuten CPM, oude Egbrink MGA, Austin Z. A historical discourse analysis of Pharmacist Identity in Pharmacy Education. American Journal of Pharmaceutical Education. 2020;84(9). doi:10.5688/ajpe7864
3. Jarvis‐Selinger, S., Pratt, D.D., and Regehr, G. (2012). Competency is not enough: integrating identity formation into the medical education discourse. Academic Medicine 87: 1185
4. Toklu HZ, Hussain A. The changing face of pharmacy practice and the need for a new model of pharmacy education. J Young Pharm. 2013;5(2):38-40. doi:10.1016/j.jyp.2012.09.001
5. Kruijtbosch M, Göttgens-Jansen W, Floor-Schreudering A, van Leeuwen E, Bouvy ML. Moral dilemmas reflect professional core values of pharmacists in community pharmacy. Int J Pharm Pract. 2019;27(2):140-148. doi:10.1111/ijpp.12490
6. https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/code-of-ethics-for-pharmacists.ashx
7. Johnson JL, Arif S, Bloom TJ, Isaacs AN, Moseley LE, Janke KK. Preparing pharmacy educators as expedition guides to support professional identity formation in Pharmacy Education. American Journal of Pharmaceutical Education. 2023;87(1). doi:10.5688/ajpe8944
8. Kegan, R. (1982). The Evolving Self: Problem and Process in Human Development. Cambridge, MA: Harvard University Press
9. Irby, D.M. and Hamstra, S.J. (2016). Parting the clouds: three professionalism frameworks in medical education. Academic Medicine 91: 1606–1611
10. Swanwick T, Forrest K, O’Brien BC, Cruess RL, Cruess SR. The Development of Professional Identity. In: Understanding Medical Education: Evidence, Theory and Practice. Wiley-Blackwell; 2019:239-254.
11. Hafferty, F.W. (2016). Professionalism and the socialization of medical students. In: Teaching Medical Professionalism (ed. R.L. Cruess, S.R. Cruess and Y. Steinert), 54–68. Cambridge: Cambridge University Press.
12. Briceland LL, Martinez T. Exploring the impact of reflecting upon pharmacy experts’ written career guidance on Student Professional Identity Formation. INNOVATIONS in pharmacy. 2022;13(3):5. doi:10.24926/iip.v13i3.4778
13. Arnoldi J, Kempland M, Newman K. Assessing student reflections of significant professional identity experiences. Currents in Pharmacy Teaching and Learning. 2022;14(12):1478-1486. doi:10.1016/j.cptl.2022.10.003
14. Janke KK, Bloom TJ, Boyce EG, et al. A pathway to professional identity formation: Report of the 2020-2021 AACP student affairs standing committee. American Journal of Pharmaceutical Education. 2021;85(10). doi:10.5688/ajpe8714
15. Luyckx K, Goossens L, Soenens B, Beyers W. Unpacking commitment and exploration: Preliminary validation of an integrative model of late adolescent identity formation. Journal of Adolescence. 2005;29(3):361-378. doi:10.1016/j.adolescence.2005.03.008

16. AFPC Educational Outcomes for First Professional Degree Programs in Pharmacy in Canada 2017. Association of Faculties of Pharmacy of Canada. Accessed August 26, 2023. http://www.afpc.info/system/files/public/AFPC-educational%20Outcomes%202017_final%20Jun2017.pdf
17. Elnicki DM. Learning with emotion: which emotions and learning what? Acad Med 2010;85:1111.
18. Poulsen L, Brosen K, Arendt-Nielsen L, et al. Codeine and morphine in extensive and poor metabolizers of sparteine:pharmacokinetics, analgesic effect and side effects. Eur J Clin Pharmacol. 1996. 51(3-4): 289-295.
19. Caraco Y, Sheller J, and Wood AJ. Pharmacogenetic determination of the effects of codeine and prediction of drug interactions. J Pharmacol Exp Ther. 1996. 278: 1165-1174.
20. Lalovic B, Phillips B, Resler LL, et al. Quantitative contribution of CYP2D6 & CYP3A4 to oxycodone metabolism in human liver and intestinal microsomes. Drug Metab Dispos. 2004. 32: 447-454.
21. Campfield KM, Hills AM. Effect of timing of critical incident stress debriefing (CISD) on posttraumatic symptoms. J Trauma Stress. 2001;14(2):327-340. doi:10.1023/A:1011117018705
22. Formative Assessment and Feedback. Stanford | Teaching Commons. Accessed August 16, 2023. https://teachingcommons.stanford.edu/teaching-guides/foundations-course-design/feedback-and-assessment/formative-assessment-and-feedback#:~:text=Formative%20feedback%20helps%20students%20recognize,to%20meet%20the%20course%20outcomes.
23. Formative and Summative Feedback. Teaching@Tufts. Accessed August 6, 2023. https://sites.tufts.edu/teaching/assessment/assessment-approaches/formative-and-summative-feedback/.
24. Mann B. 3 of America's biggest pharmacy chains have been found liable for the opioid crisis. November 23, 2023. Accessed August 16, 2023. Ohio jury holds CVS, Walgreens and Walmart liable for opioid crisis : NPR
25. Wile R. CVS and Walgreens to pay a combined $10.7 billion settlement for alleged opioid prescription lapses. December 12, 2022. Accessed August 16, 2023. CVS, Walgreens to pay $10.7 billion for alleged opioid prescription lapses (nbcnews.com)

Risk Management in Anticoagulation 2025 Revision

UConn has developed web-based continuing pharmacy education activities to enhance the practice of pharmacists and assist pharmacists in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve. There are a total of 17.25 hours of CPE credit available. Successful completion of these 17.25 hours (13 activities) or equivalent training will prepare the pharmacist for the Anticoagulation Traineeship, which described below in the Additional Information Box.

The activities below are available separately for $17/hr or as a bundle price of $199 for all 13 activities (17.25 hours). These are the pre-requisites for the anticoagulation traineeship. Any pharmacist who wishes to increase their knowledge of anticoagulation may take any of the programs below.

When you are ready to submit quiz answers, go to the Blue "Take Test/Evaluation" Button.

If desired, “bundle” pricing can be obtained by registering for the activities in groups. It consists of thirteen anticoagulation activities in our online selection.

You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(18.25 hours of CE) $199.00

In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

The University of Connecticut School of Pharmacy and The UConn Health Center Outpatient Anticoagulation Clinic have developed 2-day practice-based ACPE certificate continuing education activity for registered pharmacists and nurses who are interested in the clinical management of patients on anticoagulant therapy and/or who are looking to expand their practice to involve patient management of outpatient anticoagulation therapy. This traineeship will provide you with both the clinical and administrative aspects of a pharmacist-managed outpatient anticoagulation clinic. The activity features ample time to individualize your learning experience. A “Certificate of Completion” will be awarded upon successful completion of the traineeship.

More Information About Traineeship

1. What are the four most important ways to reduce risk?
A. Education, strong policy development, complete documentation, and continuous quality improvement
B. Physician involvement, light workload, time management, and malpractice insurance
C. The newest anticoagulation management software, coworker education, and quality improvement

2. How can pharmaists BEST teach application, analysis and synthesis of new knowledge particularly of situational cases?
A. Lecture and post-lecture reading assignments
B. Case presentation and practice-based learning
C. Observation of the student;s in-clinic skills

3. When should Continuous Quality Improvement activities should be completed?
A. Regularly at cadence of stewardship committee
B. No less often than every five years
C. Annually in the month designated by your accreditor

4. What happens when a physician reviews and approves a pharmacist’s recommendations?
A. The physician assumes all the risk
B. The pharmacist still carries risk
C. The pharmacist can only bill for the lab test

5. Why does provider education initially take precedence over patient education?
A. Patients can twist provider education in a malpractice claim if they realize the provider lacks confidence
B. The health system is only responsible for provider educationunder current accreditation standas
C. Effective provider education is the foundation for standardized, effective patient education

6. When is a Decision Pathway BEST used to minimize risk?
A. With a low-risk DVT protocol for anticoagulation management
B. As you complete coding and billing for various clinic visits
C. With a collaborative practice agreement or policy for DOAC dose-adjustment

7. Which of the following lists include ALL of the elements of provider education?
A. Disease state management, malpractice risk defense, thrombolytic administration
B. Medication management, malpractice risk defense, IV administration technique
C. Disease state management, medication management, patient care management

Developing an Anticoagulation Clinic 2025 Revision

When you are ready to submit quiz answers, go to the Blue "Take Test/Evaluation" Button.

If desired, “bundle” pricing can be obtained by registering for the activities in groups. It consists of thirteen anticoagulation activities in our online selection.

You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(17.25 hours of CE) $199.00

In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

More Information About Traineeship

Post-Test Questions:
1. Which of the following reasons best denotes the benefits of initiating a pharmacist-run anticoagulation clinic?
a. Improved outcomes for patients
b. Less need for space and resources
c. Patient willingness to come to clinic

2. As you run reports for the first year of service of your anticoagulation clinic, what results do you expect to see based on previous literature?
a. Decreased patient satisfaction scores
b. Increased frequency of bleeding
c. Improved time in therapeutic range

3. Which of the following establishes the greatest need for a pharmacist-run anticoagulation clinic from a regulatory standpoint?
a. Ensuring compliance with National Patient Safety Goals
b. Legally pharmacists are required to manage warfarin
c. National guidelines recommend pharmacist management

4. Identify which of the following is a crucial step in establishing an anticoagulation clinic
a. Finding rental space in the region to create clinic space
b. Identifying stakeholders to provide institutional backing
c. Obtaining an NPI certificate to allow for reimbursement

5. In a low budget, low resource pharmacist-run clinic, which staff member would be most important other than the pharmacist?
a. Medical director
b. Registered nurse
c. Receptionist

6. Identify the most important resource to acquire ahead of starting patient visits:
a. A fax machine
b. A private space
c. A white coat

7. What poses the biggest financial challenge for establishing a pharmacist-run anticoagulation clinic?
a. Cost of supplies is significant
b. Lack of pharmacist reimbursement
c. Services are free for patients

8. Which of the following strategies could be utilized to minimize overall clinic costs?
a. Reduce clinic hours
b. Streamline staff
c. Utilize an iSTAT meter

9. Which of the following processes will ensure standardized, legal autonomous care by a pharmacist?
a. Development and approval of a collaborative practice agreement with 1 or more providers
b. Purchase and attainment of an NPI and DEA number by each employed pharmacist
c. Requiring a PGY2 residency completed in ambulatory care by all employed pharmacists

10. Which of the following strategies will allow for sustained function and improvement of the clinic once established?
a. Reducing hours once less time is needed for appointments
b. Routine evaluation and reporting of clinical outcomes
c. Transitioning majority of patients to a DOAC

Pharmacist Reimbursement for Anticoagulation Services 2025 Revision

When you are ready to submit quiz answers, go to the Blue "Take Test/Evaluation" Button.

If desired, “bundle” pricing can be obtained by registering for the activities in groups. It consists of thirteen anticoagulation activities in our online selection.

You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(17.25 hours of CE) $199.00

In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

More Information About Traineeship

Post-Test Questions:
1. Which of the following challenges is most likely to affect a pharmacist’s ability to get reimbursed for anticoagulation visits?
a. Lack of provider status
b. Location proximity to the hospital
c. Small Medicare population

2. Your clinic is taking over a population of nursing home patients. Why may this negatively affect reimbursement?
a. Most patients in nursing homes do not have Medicare
b. Pharmacists may only care for patients in their organization
c. Telephone encounters are often not billable

3. Your clinic will begin seeing patients in person and administering a POCT to check INR and provide subsequent dosing instructions. Which of the following CPT code combinations would be appropriate for these visits?
a. 99211 and 93792
b. 99211 and 85610
c. 93793 and 85610

4. Which of the following is true regarding a pharmacist’s ability to bill?
a. ‘Incident to bill’ can only be done under direct supervision by a provider (MD or PA/APRN)
b. ‘Incident to bill’ can only be done under a medical doctor’s supervision (MD)
c. ‘Incident to bill’ can only be done under a PA or APRN specialized in anticoagulation

5. Which of the following strategies would be ideal for optimizing reimbursement?
a. Shift to a telephone only care to improve efficiency
b. Consider utilizing pharmacy students to offset costs
c. Develop a standardized note template for all clinicians

6. Which of the following stakeholders is crucial in ensuring ongoing billing and reimbursement is accurate?
a. The cosigning provider
b. The financial department
c. The receptionist

Anticoagulation Management Pearls 2025 Revision

When you are ready to submit quiz answers, go to the Blue "Take Test/Evaluation" Button.

If desired, “bundle” pricing can be obtained by registering for the activities in groups. This series consists of thirteen anticoagulation activities in our online selection.

You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(18.25 hours of CE) $199.00

In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

More Information About Traineeship

1. The Joint Commission revised National Patient Safety Goal is intended to:
a. Provide guidance on how to deal with providers and health systems who do not adhere to the standards
b. Set standards on provider’s level of knowledge of anticoagulant medications
c. Reduce the likelihood of patient harm associated with the use of anticoagulant therapy

2. Which of the following would be a key area where using a multidisciplinary approach to anticoagulation management is necessary?
a. Perioperative anticoagulation management
b. Dosing warfarin in an outpatient clinic
c. Identifying cost-barriers to DOAC management

3. What is a practical and efficient way to ensure that DOAC dosing errors are minimized upon initiation?
a. Implement a program where only pharmacists dose DOACs on discharge from the hospital
b. Ensure regular updates of dosing policies & protocols with a changing clinical landscape
c. Set an electronic medical record requirement for all DOAC discharge orders to be reviewed by the outpatient anticoagulation clinic

4. How are clinician decision support tools best used in the anticoagulation management clinical setting?
a. They should be leveraged to automate decision-making to reduce inter-provider variability
b. They should be leveraged to assist decision-making using standardized protocols and pathways to minimize errors
c. They should be leveraged to optimize decision-making and increase speed of discharges, clinic visits and decrease staff dependence

5. Which of the following is an evidence-based benefit of utilizing a population health model to optimize anticoagulation management?
a. Population health models have been linked to improved clinical outcomes and reduced times to intervention
b. Population health models have been linked to automating patient monitoring to decrease the need for clinician oversight
c. Population health models when combined with artificial intelligence will minimize the need for pharmacists in the future

6. Which of the strategies is best when managing patients with language barriers?
a. Ask patient to bring in family members who can help interpret
b. Ask bilingual coworker to help interpret
c. Use qualified interpreter

7. Which of the following would be the most appropriate depiction of transitions of care?
a. A transition of care anytime a patient’s clinical setting changes
b. A transition of care is handled solely by the hospital discharge staff
c. Provide transition of care assistance only to elderly patients who request it

8. Which of the following statements are true regarding transitioning between anticoagulants?
a. Transitions between anticoagulants should be done regularly to account for a patient’s changing clinical status, especially over time
b. Literature suggests that transitioning between anticoagulants inherently increases risk of bleeding and clotting, and should be done with care
c. All DOACs can be transitioned to and from warfarin and heparins using the same transition guidance

Information overload to action: Decoding academic concepts for pharmacy preceptors- RECORDED WEBINAR

The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

Pharmacists and Pharmacy Technicians are eligible to participate in this application-based activity and will receive 1.0 CE Hour for completing the activity (ACPE UAN 0009-0000-25-026-H04-P), passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

1. Joey is an IPPE student under your supervision this month. He observes as you meet with a patient who has a question about various options to treat psoriasis. You tell the patient you will get back to him about medications covered by his plan, out of pocket costs, the time burden associated with treatment, and potential adverse effects. Joey wants to help. What can Joey do?
A. Collect information, asking for help if or when he needs it
B. Observe how you collect information but assess independently
C. Collect information only under direct and proactive supervision

2. Phoebe is an APPE student in her first clinical rotation. She aspires to obtain an industry fellowship and hopes to receive the best grade possible on this rotation with the least work. She says, "I don't plan to work in a clinical position, so this is not a priority for me. What is the BEST answer?
A. The PPCP is not just applicable to clinical situations. It structures processes for all kinds of projects, not just clinical challenges.
B. Most students who aspire to work in industry do not get fellowships, and you need to know the PPCP if you land in an actual pharmacy.
C. Say nothing. Allow Phoebe to do minimal work.

3. Rachel is on her last APPE rotation before graduation. YAY! She works up a patient who has a cardiac issue. She collects a lot of appropriate information, and her assessment is almost perfect. She makes one statement that seems "off" to you. She recommends using a medication that is no longer first-line treatment. What is the MOST LIKELY cause for her omission?
A. She relied on only one guideline for evidence
B. She collects too much information and is confused
C. She is hyper-focused on cost, not effectiveness

4. Joey is now an APPE student on a general medicine rotation. You assign him a patient to review for your discussion this afternoon. When Joey joins you, he provides background information on the patient, reports on the physical notes, pertinent laboratory values and his conversation with the patient. What step of the Pharmacist Patient Care Process is Joey demonstrating?
A. Collect
B. Assess
C. Plan

5. Ross, an APPE student on your ambulatory care rotation, is writing up a SMART goal for his patient with diabetes. The goal reads “Reduce the patient’s blood glucose within six months. Patient will start metformin XL 500mg PO daily and follow up with the pharmacy team for titration every seven days. Reduction in the patient’s A1c will lead to better health outcomes and reduce the severity of complications from his diabetes.” What part of the SMART goal is Ross missing?
A. Specific
B. Measurable
C. Realistic

6. What is the performance goal for a “practice ready” APPE student in terms of level of entrustability on each of the entrustable professional activities (EPAs)?
A. Direct supervision
B. Reactive supervision
C. General Direction

AI: A New Way to Help Pharmacy Thrive!

The global adoption of artificial intelligence (AI) continues to expand, with AI systems providing essential functions in prediction, recommendation, and decision-making based on their underlying algorithms. Healthcare institutions are exploring how these resources may enhance workflows, improve patient outcomes, and allow clinicians to focus more time on direct patient care. Researchers are exploring AI implementation in numerous areas, including diabetes and heart failure management, medical imaging evaluation, acute kidney injury detection, medication adherence, and electronic health record integration. While AI holds immense potential for transforming healthcare, its implementation faces several challenges. Barriers to AI integration include resource allocation, legal consideration, and securing healthcare provider acceptance. Healthcare professionals must address these barriers for the successful application of AI into daily clinical practice.

INTRODUCTION

Dolly is a pharmacist in an independent pharmacy working 9 to 5 (what a way to make a living!). Her technician, Miley, calls her to the front to talk with Carol, a 60-year-old woman who consistently wears her smartwatch. Miley tells Dolly, “You have to hear this!” Carol reports that while walking her dog, she tripped and landed face down on the pavement. Carol says her smartwatch called out, “It looks like you’ve taken a hard fall,” and asked if it should call 911. Carol didn’t need emergency services, but she was grateful that the watch detected her fall and could help if necessary. If Carol had been unresponsive, the watch would have called 911 automatically. When Carol left, Miley said, “You know Dolly, I am really concerned that artificial intelligence (AI) is going to replace me.” Dolly nodded and said, “I know. I have some concerns, too. It's enough to drive you crazy if you let it.” Dolly realizes she needs to look into AI and its possibilities.

AI is a technology that learns, reasons, and performs tasks to mimic humans.¹ A 2022 Pew Institute survey of 11,004 Americans found that while 55% use AI frequently, awareness of its presence and capabilities varies.² Only 30% of participants demonstrated high AI awareness, with factors such as education level, income, and Internet use influencing their familiarity.² Despite growing adoption, public engagement is mixed, with concerns about AI’s impact fueling debate.

Recently, many media outlets have published articles about AI, and many of those pieces have generated public debate and concern.^3-5 Public engagement in ethical debates about AI’s use and limitations is only reasonable and well advised if individuals understand its strengths and limitations. Despite the widespread adoption of AI technologies among Americans, another Pew Research Center survey reported that only 15% express more excitement than concern about its increased use in daily life, 38% express more concern than excitement, and 46% are mixed, containing both excitement and concern.⁶ Nonetheless, AI’s adoption and market value increases annually. Researchers estimated the AI market size at $40 billion in 2022 and expect it to grow to $1.3 trillion by 2032.⁷

Americans rely on AI in their everyday lives for web searches, task automation, and more—often without even realizing it. Engineers have seamlessly integrated AI into technologies like Siri, Alexa, and Google Home, making everyday tasks more convenient. With almost limitless possibilities, AI continues to evolve and grow, including in the healthcare field.

PAUSE AND PONDER: Take a moment and look at this list. Which of the following are AI powered? You can find the answers at the end of this activity (after the CONCLUSION).

Air conditioners
Automatic washing machines
Basic calculators
Customer service chatboxes
Email services
Facial recognition technology
Media/playlist recommendations
Purchase recommendations
Refrigerators
Social media
Television remote controls
Voice assistants
Wearable fitness trackers

Defining AI

AI systems predict, recommend, and make decisions using machine-based algorithms. Programmers design these systems with a set of rules and human-defined objectives to accomplish a variety of tasks.^8,9 As Table 1 implies, no single definition fully captures AI’s complexity, and its applications are broad.¹

Table 1. Definitions and Possibilities Associated with AI¹

An artificial system…

· performs tasks in predictable and unpredictable conditions with minimal human oversight

· learns and improves its performance from experience and data set exposure

· is developed in software or hardware

· works to complete tasks requiring human-like action, cognition, communication, learning, perception, or planning

· is developed to mimic human cognition and neural networks

· is made with techniques for approximating a cognitive task

· is designed to act rationally

AI Models

AI system designs vary based on the AI model used. Common algorithms include machine learning, neural network, deep learning, natural language processing, and rule-based expert systems. Neural network and deep learning fall under the broader category of machine learning. Table 2 describes how developers tailor each model to accomplish specific tasks in unique ways.¹⁰ It also captures common AI models used in healthcare with examples for their application.

Table 2. Explanations and Examples of AI Model Applications¹⁰^-15
Model	Explanation	Example(s)
Machine Learning	· Fits models to data · Trains models with data sets · Encompasses neural network and deep learning models	· Precision medicine: uses information about a person’s genes and lifestyle to prevent, diagnose, or treat disease · A breast cancer prediction algorithm: interpreted 38,444 mammograms from 9,611 women to predict biopsy malignancy and distinguish between normal and abnormal screenings
Neural Network	· Inspired by and mimics the human brain · Uses nodes that mimic human neurons to process and learn from data · Considers inputs, outputs, and weights of variables	· Google Photos: uses a neural network to categorize images based on face or object recognition
Deep Learning	· Complex model building off the neural network · Uses features and variables used to predict an outcome	· Facial recognition: uses deep learning for security purposes like unlocking smartphones or for tagging people on social media · Enables the identification of individuals as the same person, even with changes to physical appearance, lighting, or visual obstructions
Rule-Based Expert Systems	· If-then format for decision-making processes · Constructs rules in a knowledge domain	· Medical diagnosis: if the patient has a fever and a sore throat, then consider the possibility of strep throat

After some research, Dolly was ready to determine the model AI uses to detect falls. She found that smartwatches rely on machine learning models, including deep learning, to identify falls. Specifically, the technology uses accelerometer (an instrument that detects and measures speed and directional vibrations) and gyroscope (an instrument that detects and measures angular momentum) data from the watch to detect abrupt movements and shifts in motion that could signal a fall.¹⁶

PAUSE AND PONDER: How can healthcare professionals and leaders integrate AI models into healthcare?

AI IN DISEASE MANAGEMENT

Integrating AI into healthcare can transform patient care and streamline workflows.¹⁰ A recent survey reported that 80% to 90% of forecast panelists believe that AI will improve care, simplify patient referrals, and facilitate prior authorizations.⁸ Also, 63% of participants indicated that it is very or highly likely for health systems to adopt AI for pharmacist documentation. AI can specifically help document patient information in electronic health records (EHR).⁸ Some physicians and advanced practice providers are already using AI to improve patient documentation.⁸

Generative AI uses machine models to analyze data patterns and create content like images and text. In healthcare, it enhances patient care and supports whole-person health.⁸This technology can assist with medical image interpretation, inform disease diagnosis, identify care gaps, personalize treatment plans, enable remote patient monitoring, and support early intervention and preventive care.^8,17 In her research, Dolly found a number of applications that could improve patient care.

Diabetes Management

By 2050, statisticians expect that 1.31 billion Americans will have diabetes.¹⁸Diabetes management requires frequent follow-up and comprehensive examinations to monitor blood glucose levels and detect complications.¹⁹ Medical resources are unevenly distributed across the United States (U.S.). Physicians are often concentrated in wealthier and suburban areas, leaving rural regions with limited access to primary and specialty care. Yet, rural populations have a 16% higher prevalence of type 2 diabetes (T2DM) and a 20% higher T2DM-related hospital mortality rate compared to urban populations.²⁰

Effective diabetes management requires a collaborative approach involving endocrinology, nutrition, nephrology, ophthalmology, pharmacy, and podiatry. Since primary care alone is insufficient to handle this complex condition, rural areas face significant challenges in diabetes management.¹⁹By 2034, researchers estimate a shortage of 124,000 doctors in the U.S., with the majority of loss in primary care.²¹ If this prediction is accurate, individuals in rural areas will face growing challenges accessing healthcare. Given the uneven distribution of healthcare resources across various regions, AI advancements may enhance efficiency in diabetes care while diminishing overall health expenditures.^10,19

To achieve better care for all people, clinicians may use predictive models to assess disease progression in T2DM, forecast blood glucose levels, and detect diabetic retinopathy.²²

AI technology may prevent diabetes onset in high-risk patients by ensuring early medical intervention.¹⁹AI technologies may use non-invasive, cost-effective methods capable of early identification and classification of diabetes.

An emerging theory is that machine learning using facial texture features and tongue color analysis could predict diabetes onset and identify those at high risk. In patients with diabetes, skin manifestations are common.²³These manifestations range from acanthosis nigricans (demarcated plaques with grey to brown pigmentation), to dermopathy (spots on the front of lower legs), to skin thickening.²³The pathophysiology of these conditions is not entirely understood. However, aging and diabetes causes increased collagen interlinking. Consequentially, skin changes like thickening and hardening may occur.²³

In Chinese Medicine, practitioners believe face regions reflect the health of internal organs.²⁴ Asian researchers postulated that tongue discoloration, such as a yellow coating, is linked to diabetes, with studies showing a connection between tongue features and glucose metabolism.^25,26 In 2017, researchers conducted a study to determine which model analyzes facial texture and color to detect diabetes most accurately.²⁴ They took facial images, divided them into regions, characterized regions by textures, and analyzed them using eight different models.²⁴ In 2019, Chinese researchers collected tongue images from 570 patients and analyzed their color and texture using AI models. The results demonstrated that these models may effectively associate tongue images with diabetes, but these studies remain preliminary.²⁵

In 2024, 8.7 million Americans or 3.4% of all U.S. adults met laboratory criteria for diabetes but were not aware that they had this condition.²⁷ Delayed diagnosis is a common concern in diabetes, with about 45% of adults worldwide undiagnosed.¹⁸ Current diabetes diagnostic tests include hemoglobin A1C, fasting plasma glucose, 2-hour plasma glucose, and oral glucose tolerance test (OGTT). These four tests are invasive as they require venipuncture.²⁴ Non-invasive diagnostic methods, such as analyzing facial images and tongue color, could help identify diabetic patients who are unaware of their condition.

Dolly is fascinated by this information, but aware that these findings are very preliminary. Recently, one of her favorite patients, Lily, had gained weight rapidly in the early trimesters of pregnancy. Her obstetrician ordered an OGTT. Before the test, Lily fasted, then drank a sugary solution and had her blood sugar levels measured at specific intervals. This process was challenging for Lily, as the sight of blood and having her blood drawn nauseates her. Dolly wishes that non-invasive methods were currently available.

In primary care, AI technologies may create personalized diet and exercise plans for people with diabetes. These plans could align with clinician recommendations and contribute to effective diabetes management.¹⁸

Despite the promise of AI technology in diabetes management, predicting blood glucose levels remains challenging because food and subcutaneously administered insulin absorption rates vary. AI technologies are increasingly embedded into continuous glucose monitoring (CGM) systems to predict blood glucose levels. CGMs track patients’ blood glucose levels in real time and eliminate frequent finger pricks. CGMs provide regular and accurate blood glucose data, offering greater convenience than traditional finger sticks. Regardless, errors may still occur. CGM may report blood glucose levels that differ from actual values by roughly 9%. Differences in actual blood glucose level measurements may be an important consideration for individuals with diabetes and their healthcare providers. Soon, it’s likely that AI will also measure ketone levels; some systems will be integrated into CGMs.²⁹

Another obstacle is when clinicians’ recommendations differ from those generated using AI, as both may be correct. To resolve discrepancies, AI may serve as a tool to support human decision-making. Last, AI technology is designed based on the data it receives. Data quality is important for accurately predicting and managing diabetes.^19,22

Cardiac Care

Like diabetes, heart failure (HF)—the inability of an individual’s heart muscle to pump enough blood—is becoming more prevalent. Common symptoms include shortness of breath, fatigue, and swelling of the legs, ankles, or abdomen.³⁰ Worldwide, approximately 60 million individuals live with HF.³¹ Managing HF requires accurate diagnoses and treatments tailored to individual patients. AI technologies may help diagnose, predict outcomes, classify, and optimize treatment strategies in HF.³²

Researchers have published much information on HF, and information on the use of machine learning to analyze this data is increasing. AI algorithms address challenges like data noise (large amounts of unwanted data that make analysis difficult), false correlations (no relationship between two variables), and statistical power issues (a study’s inability to detect accurate results or effects). By streamlining data analysis, AI complements traditional statistical methods to gather insights into HF.³²

Researchers have created an AI-based diagnostic algorithm for HF. The study enrolled 600 patients with and without HF. The results demonstrated a diagnostic accuracy of 98% and surpassed non-specialist clinicians, who had an accuracy of 76%. In regions with limited access to HF specialists, these AI technologies could be beneficial.^32,33

Patients with HF also face high 30-day readmission rates. Decreasing HF hospital admissions and readmissions is important considering the financial penalties that the Centers for Medicare and Medicaid Services (CMS) impose. CMS reduces hospital payments by a percentage following unplanned 30-day readmissions for patients with HF.³⁴The hospitalization rate has improved from about 367 hospitalizations per 100,000 adults in 2016 to 350 hospitalizations in 2020. However, Healthy People 2030’s target is 330 per 100,000, meaning more improvement is needed.³⁵

Deep learning AI models may help lower hospital readmissions for patients with HF. In a 900-patient cohort study, these technologies outperformed traditional techniques in predicting readmission rates. This AI algorithm used heart sounds, respiratory rate, tidal volume (the amount of air that moves in and out of the lungs during a normal breath), heart rate, and patient activity to make predictions.³²

The rising use of remote monitoring and wearable devices is likely to expand AI’s effectiveness in managing HF. AI-powered smartwatches programmed with electrocardiography features demonstrate acceptable accuracy in detecting HF with reduced ejection fraction. These technologies allow continuous data streams, better prediction in hospital readmission rates, and earlier HF identification.^31,32

Dolly finds that smartwatches can also be useful for patients who have or are at risk for atrial fibrillation (AFib). Carol, the patient whose smartwatch detected a fall, has been worried that she might develop AFib, which causes irregular heartbeats. Last week, the watch detected an episode of AFib. When Carol visited her provider, she brought the printed electrocardiogram showing the episode. This enabled the provider to make informed decisions about next steps, supported by AI technologies.

Sepsis Identification

Globally, sepsis—a life-threatening response to an infection—is a leading cause of illness and death.³⁶ Patients with sepsis present with varying degrees of severity, ranging from mild sepsis to septic shock. It can lead to tissue damage, organ failure, and death. Sepsis’s variable presentation makes early detection challenging. However, prompt recognition of sepsis is critical, as every hour without treatment increases the risk of death.³⁶

AI technologies may predict sepsis hours before its onset. Through machine learning and predictive algorithms, AI improves the accuracy of sepsis detection in a clinical setting.^36-38Researchers conducted a prospective, multi-center study of 590,736 patients across five hospitals, with 6,877 included in the analysis.³⁸ During the study, researchers used the Targeted Real-time Early Warning System (TREWS) as a sepsis alert system for providers.³⁸ TREWS is a machine learning-based algorithm that notifies providers when a patient is at high risk for sepsis.

TREWS integration enabled early intervention from providers and reduced the hospital mortality rate by 5.1% when providers responded to the alert within three hours.³⁸ The TREWS intervention group also saw a 4.5% decrease in overall mortality compared to patients whose providers did not respond within three hours. Patients flagged as high risk also experienced reductions in organ failure severity.³⁸ A critical point is provider response time. It is possible that providers who responded more quickly simply had better resources or teams at their disposal.³⁹

This study’s major limitation was the predetermined alert settings, which may have influenced the alerts and their associations with clinical outcomes.³⁸ TREWS notified providers when patients exhibited significant findings related to sepsis. This constraint limits the study’s generalizability, as variations in alert settings may lead to significant differences in the timing of alerts and, potentially, patient outcomes. Future implementation may adopt a less restrictive model, allowing earlier warnings by identifying patients with fewer sepsis-related criteria.³⁸

Alert fatigue—healthcare provider desensitization to safety alerts—may also limit this study’s applicability to clinical practice.³⁸ Alert fatigue often causes individuals to not respond properly to safety alerts and warnings.⁴⁰ TREWS integration may contribute to the alert fatigue phenomenon that plagues the healthcare industry.

Despite this study’s promising results, few large, randomized controlled trials (RCTs) have evaluated AI-based alerts for patients with sepsis.³⁷

Acute Kidney Injury Alert

Acute kidney injury (AKI; a decline in the kidney filtrate rate) impacts approximately 18% of inpatients and greater than 50% of patients in intensive care units.⁴¹ Like managing HF and diabetes, early detection is critical.^41,42Two studies have examined AI in AKI.

Chinese researchers led a double-blind RCT to evaluate the impact of electronic alerts on adults with AKI.⁴¹ They randomized more than 2,000 hospitalized patients to determine whether an AKI alert combined with management strategies improves care and clinical outcomes. The data showed that alerts did not improve kidney function or overall patient outcomes. However, the alerts influenced treatment approaches. Patients in the alerts group received more intravenous fluids (82.6% vs 61.8%), fewer nonsteroidal anti-inflammatory drugs (5% vs 11%), and more AKI documentation at discharge (49.9% vs 27.3%).⁴¹

Another double-blinded, multicenter RCT enrolled more than 6,000 patients. Researchers concluded that the AKI alerts did not reduce the risk of AKI progression, dialysis initiation, or death within 14 days of randomization.⁴²

Both studies found that integrating their specific AKI alert algorithms into EHR did not improve patient outcomes.^41-43However, pairing these alerts with management strategies influenced providers’ treatment decisions. These findings suggest that while changes in treatment strategies may not directly benefit patients, they may help avoid medications that can contribute to AKI.^41,42

Image Interpretation

Beyond its use in facial recognition for social media and security, AI also has the proven potential to analyze medical images. Specifically, AI technologies show promise in oncology for identifying and categorizing cancers, and in managing diabetic retinopathy.

Oncology

Researchers are developing AI models for cancer imaging, aiming to improve tumor detection, characterization, and monitoring.^10,44 These tools identify various cancers and predict patient outcomes very accurately.⁴⁵ They can help minimize oversights and serve as an initial screen to reduce omission errors.

AI tumor characterization involves tumor segmentation (outlining and identifying boundaries of the tumor in images), diagnosis, and staging. AI-driven automated segmentation has the potential to enhance the efficiency, reproducibility, and quality of tumor measurements.⁴⁴ It may also improve the ability to monitor changes in tumors over time. Despite these promising advancements, challenges remain in ensuring accurate detection, characterization, and monitoring.⁴⁴

Diabetic Retinopathy

AI models can detect diabetic retinopathy, a complication of diabetes that progressively impairs vision over time. AI identification of diabetic retinopathy is facilitated through retinal fundus imaging, which has demonstrated high sensitivity and selectivity, as defined in the SIDEBAR.^22,46,47

SIDEBAR: Differentiating Sensitivity and Specificity⁴⁷

Sensitivity

Specificity

· A test’s ability to determine whether an individual with the disease is positive

· High sensitivity: limited false negative results—few cases where the disease is missed

· A test’s ability to determine if an individual who does not have the disease is negative

· High specificity: limited false positive results

· Using a test with low specificity causes many people without the disease to screen as positive and receive treatment

In 2017, researchers enrolled 521 participants across 10 U.S. centers. Each patient underwent a dilated ophthalmoscopy (an eye exam). The AI algorithm accurately identified 36 of 37 positive cases (97% sensitivity) and 162 of 184 negative cases (88% specificity).⁴⁶The researchers concluded thatthe AI system detects mild diabetic retinopathy more effectively than general ophthalmologists or retina specialists. This tool may offer a low-cost solution for diabetic retinopathy screening and help reduce the burden of diabetic eye screenings.⁴⁶

Electronic Health Records

Approximately 80% of clinically relevant healthcare information is unstructured data.⁴⁸Applying a natural language processing (NLP)-based algorithm to the EHR may help hospitals identify patients who need a clinical pharmacist’s review. NLP models possess the ability to engage in speech recognition, text analysis, and translation, with goals centered around language processing. One example of its use is transcribing patient interactions, which may be helpful for medication reconciliation. Similarly, NLP-based systems can prepare reports, such as patient notes within the EHR, and analyze these notes.¹⁰By analyzing notes, the system can also identify patients requiring extensive medication interventions and categorize them as high risk. This classification enables pharmacists to dedicate their efforts to patients most likely to benefit, ultimately enhancing their impact on patient care.⁴⁸

AI models may also detect and alert providers when an ordered medication deviates from its typical use pattern. AI captures information on standard dosages and indications, aiding drug selection, dose recommendations, drug-drug interaction detection, and order entry.⁴⁹ This tool supports pharmacists and other healthcare providers in clinical decision-making to minimize medication-related errors and improve patient outcomes.⁴⁹

Generative AI models may streamline providers’ documentation processes. Clinicians spend approximately 35% of their time documenting patient data and notes.⁵⁰ AI technologies may reduce this workload, allowing providers to focus more on patient care. However, before integrating AI into documentation, leaders must set clear guidelines. For effective use, these guidelines must address concerns such as data security, accuracy, reliability, ethical considerations, and the need for ongoing evaluation of AI programs to ensure regular maintenance and optimization.⁵¹

The possibilities for AI integration in EHR are endless. With proper use, these resources help streamline workflow and increase time providers spend on direct patient care.

PAUSE AND PONDER: What are the opportunities and challenges for AI integration into healthcare?

AI CHALLENGES

A major challenge is AI’s inability to explain how it arrives at its conclusions, referred to as model transparency. Predictive modeling and deep learning procedures are difficult to adopt in clinical environments. The algorithms behind these models often lack transparency and experimental context.^8,22

For clinicians to accept AI, they must understand how models generate recommendations. By detailing internal decisions, behaviors, and actions, AI’s developers can build trust among healthcare providers. Developers must equip clinicians with sufficient information to understand each event’s causes. Subsequently, providers can determine how to incorporate AI recommendations into their clinical decision-making processes.^8,22

Another barrier arises from EHRs’ limitations. Since EHR data is not publicly available, AI technologies may struggle to generate comprehensive recommendations. Also, healthcare organizations often restrict data access to internal use, leaving predictive modeling without sufficient information.²²To address this challenge, some experts propose federated learning. This allows institutions to contribute to a global model while keeping sensitive data within their respective systems.¹⁰ However, as AI processes large volumes of data, the risk of data breaches and unauthorized access increases. Protecting databases from security threats remains a challenge.⁸

Bias presents another obstacle. If data used in AI models is homogenous, the results may be skewed. Developers must ensure that training datasets include a wide range of patient demographics and conditions to prevent biased outcomes.⁸

Cost inhibits widespread adoption of AI. Institutions allocate resources for AI differently. Smaller, rural hospitals may struggle to implement these technologies due to financial constraints.⁸ Also, demonstrating a clear return on investment for AI integration is difficult. The limited cost avoidance data per intervention and impact on patient outcomes makes it challenging for hospital executives to justify AI investments.⁸

Legal and ethical considerations further complicate AI acceptance. Mistakes are inevitable with AI technologies. Who will be held accountable for errors, especially when they impact patient outcomes? Healthcare providers may be reluctant to adopt AI technologies if responsibility for potential AI errors is unclear.^8,10 This also calls into question regulatory compliance. If AI becomes the standard of care, providers who choose not to use these tools may face legal and regulatory consequences.^8,10

Before implementing AI in clinical practice, healthcare institutions must thoroughly test and validate each model. A designated committee containing diverse healthcare professionals should lead the approval process to ensure safe and effective implementation of AI models. This approval process and integration into daily practice may take years.¹⁰

After looking at how AI is used currently, the research underway, and AI’s challenges, Dolly feels confident that she can discuss changes in the workplace and pharmacy processes with Miley.

TAILORING AI TO PHARMACY PRACTICE

Many healthcare providers already recognize the implications of AI integration in healthcare. A recent survey asked pharmacists, “How likely is it the following will occur by the year 2029 in the geographic region where you work?”⁸ Table 3 displays the findings on AI integration in pharmacists’ documentation and medication histories.⁸

Table 3. Forecast Panelists’ Survey Responses to AI Integration in 2029⁸
Response	Percent of Responders
Statement 1: 50% of health systems will adopt technology in the EHR for pharmacist documentation to be completed by generative AI.
Very Unlikely	4%
Somewhat Unlikely	33%
Somewhat Likely	44%
Very Likely	19%
Statement 2: 25% of health systems will use a Chatbot to obtain medication histories.
Very Unlikely	10%
Somewhat Unlikely	33%
Somewhat Likely	43%
Very Likely	14%
AI, artificial intelligence; EHR, electronic health record.

As healthcare professionals acknowledge AI’s expanding function, they must develop a strong understanding of these technologies. Pharmacists and pharmacy technicians, in particular, need a basic knowledge of AI.⁴⁸With this foundation, pharmacists can assess AI models’ strengths and limitations and determine when and how to use them effectively.

To establish a baseline understanding of AI technologies, institutions must integrate education and didactic experiences into training for pharmacy technicians, pharmacy students, and pharmacists.^52,53This will equip healthcare providers with the basic skills needed to evaluate AI models and understand its responsibility in improving patient care.

AI and the Pharmacy Workforce

Like Miley, may pharmacy personnel worry that AI may replace pharmacists and pharmacy technicians. In the United Kingdom, researchers estimate 35% of all jobs—including some pharmacy-related positions—could be automated in the next 10 to 20 years.¹⁰ However, they also predict job losses will amount to less than 5%. This is because of factors like cost of automation technologies, labor market dynamics, and regulatory and social acceptance. These circumstances create major barriers in the widespread adoption of AI across industries and may mitigate actual job loss.¹⁰

In healthcare, similar trends are expected. To date, AI has not eliminated jobs.¹⁰ Pharmacy student enrollment is unlikely to rise, and researchers predict that 20% of first year post-graduate residency spots will remain unfilled after the match. As a result, they anticipate the pharmacy workforce will decline.⁸ This projected reduction has led to expectations that AI will assist with repetitive pharmacy tasks, allowing pharmacists and technicians to focus on responsibilities that require human expertise.

With the integration of AI into healthcare, pharmacists are expected to expand their scope of practice into areas where they can use their skills more and influence outcomes.^8,10 These include managing high-cost medications, bridging gaps in primary care, applying empathy and persuasion, and taking a big-picture approach to patient care. While AI is designed to mimic certain human actions, it is not human. It lacks interpersonal skills and the ability to build relationships. Ultimately, AI will complement pharmacists by streamlining repetitive tasks, addressing workforce shortages, and enabling them to use their unique human intelligence abilities.^8,10

Adverse Drug Reactions

A primary responsibility for pharmacists in medication management is to mitigate patients’ risk of adverse drug reactions (ADRs). EHR systems use AI for ADR prediction and detection. For example, if a prescriber orders amiodarone for a patient who is already taking warfarin, the system is designed to alert healthcare providers that the combination leads to high bleeding risk. Current systems already deliver this alert, and an AI-assisted system may recommend providers decrease the patient’s warfarin dose empirically by 30% to 50%.⁵⁴ However, like any test or algorithm, false positives and negatives can occur, meaning these systems are not foolproof. It is crucial that clinicians and pharmacists do not rely solely on these alerts for detecting ADRs or sending notifications. Instead, they should apply clinical decision-making and rely on their expertise.

A recent study involving 412 patients used a machine learning algorithm to predict the likelihood of ADRs in neonates.⁵⁵ Researchers designed the algorithm to associate a risk score to predict and prevent ADRs, rather than simply display a warning as is done currently for certain medications. The model displayed high predictive accuracies, successfully detecting ADRs in patients with allergic, renal, central nervous system, and hepatic ADRs 78.9% to 90.2% of the time.^49,55These models illustrateAI’s broad application in ADR detection which supports clinical decision-making.

AI also offers opportunities to improve patient adherence. It can trigger patient-specific message alerts, such as medication renewal reminders for both the pharmacist and the patient. This ensures timely prescription refills, helps maintain a consistent medication supply, and supports better medication adherence for improved health outcomes. Wearable devices like smartwatches and smartphones also integrate AI technology that may encourage behavioral changes and enhance adherence.¹⁰ For example, some smartwatches offer a time-to-stand reminder. If individuals have not moved within the first 50 minutes of an hour, the watch will remind them to stand. Simple alerts like these increase movement and encourage behavior changes.

Beyond clinical applications, AI has the potential to transform pharmacy operations. AI technology may request and process prior authorizations (something of great interest to Dolly and Miley), manage the supply chain, optimize pharmacy revenue cycles, and track financial performance.⁸

CONCLUSION

AI technologies are likely to revolutionize healthcare by enhancing clinical decision-making, improving patient outcomes, and streamlining workflows. Through automation of routine tasks and data analysis, AI can help healthcare providers deliver more efficient care. However, significant barriers including algorithm transparency, bias, cost, and accountability concerns must be addressed before AI is widely adopted. Overcoming these challenges requires collaboration among healthcare providers, policy makers, and AI developers. Establishing clear guidelines and validation procedures will help ensure AI technologies are safe and used properly. With proper implementation and education, AI is a powerful tool that enhances healthcare professionals’ abilities. Dolly and Miley now appreciate that it cannot replace human skills like empathy, critical thinking, and personalized communication.

PAUSE AND PONDER: Take a moment and look at this list. Which of the following are AI powered? These are the answers that we promised to provide!

Air conditioner
Automatic washing machine
Basic calculators
Customer service chat box
Email services
Facial recognition
Media/playlist recommendations
Purchase recommendations
Refrigerators
Social media
Television remote control
Voice assistants
Wearable fitness trackers

Answers	Examples
Customer service chat box	· Chatbots answering basic customer service questions
Email services	· Emails automatically categorized as spam
Facial recognition	· Unlocking devices · Password security · Tagging individuals in social media posts
Media/playlist recommendations	· Spotify or Apple Music playlists · Audiobook platforms · Streaming services
Purchase recommendations	· Social media advertisements · Web browser advertisements
Social media	· Facial recognition · “For you” page geared to user interests
Voice assistants	· Siri · Alexa · Google Home
Wearable fitness trackers	· ECG monitoring · Fall detection

PHARMACIST AND PHARMACY TECHNICIAN LEARNING OBJECTIVES
After completing this continuing education activity, learners will be able to
• Recognize artificial intelligence (AI) and the models underlying these technologies
• Describe the implications of AI within the healthcare and pharmacy fields
• List the opportunities and challenges that AI introduces to healthcare and pharmacy services
• Recognize AI’s impact on the pharmacy workforce and its implications in shaping the future of pharmacy practice

1. An artificial intelligence developer uses an algorithm that mimics the human brain and consists of nodes that mimic human neurons to process and learn from data. What model is the developer using?
A. Deep learning
B. Neural network
C. Rule-based expert system

2. Which of the following is the BEST descriptor of a possibility associated with AI?
A. Performs tasks in predictable and unpredictable conditions with minimal human oversight
B. Performs tasks in predictable conditions only with minimal human oversight
C. Performs tasks in unpredictable conditions only with direct human oversight

3. An AI algorithm is designed with the following input and output: “if the patient has diarrhea and vomiting, then consider the possibility of norovirus infection.” What model does this rule represent?
A. Deep learning
B. Neural network
C. Rule-based expert system

4. When generative AI uses machine models to analyze data patterns and create content in healthcare, how might it enhance patient care?
A. It can assist with medical image interpretation, inform disease diagnosis, and identify care gaps.
B. It can replace the clinician’s need to be present at clinic appointments.
C. It can make decisions for clinicians, write treatment plans, and prescribe medications.

5. Effective diabetes management requires a collaborative, specialized approach. Since primary care alone is insufficient to handle this complex condition, which of the following current barriers to diabetes management could AI BEST help overcome?
A. It can help urban areas that have unlimited access to care for diabetes management.
B. It can help rural areas struggling with limited access to care for diabetes management.
C. It can help primary care providers eliminate challenges in diagnosing patients with diabetes.

6. Which of the following represents the MOST significant implication for AI models in cancer imaging?
A. AI models can improve the efficiency, reproducibility, and quality of tumor measurements.
B. AI models can improve the accuracy of tumor detection and consider patient’s medical history.
C. AI models have the potential to enhance the accuracy in detection, monitoring, and make decisions for providers.

7. Which of the following is a CHALLENGE associated with AI use in healthcare?
A. Identifying patients by their unique identifiers may be impossible.
B. Identifying solutions with good specificity and sensitivity is difficult.
C. Identifying who holds responsibility when an error occurs may be unclear.

8. Dr. Smith is interested in integrating AI technologies. He mentions difficulty reading patients’ notes and getting a complete understanding due to residents copying notes from previous days without updating important details. How can AI technologies BEST address this issue?
A. NLP-based systems can transcribe interactions, such as medication reconciliations.
B. NLP-based systems can prepare reports, such as patient notes within the EHR.
C. NLP-based systems can analyze text, such as patient notes within the EHR.

9. The Dolly Hospital is a 100- bed facility located 100 miles from the nearest large city. Which of the following is MOST likely a CHALLENGE for AI integration at this institution?
A. They may struggle to secure the necessary funds.
B. They may struggle to demonstrate a clear return on investment.
C. They may struggle to obtain accurate cost avoidance data.

10. Why is it UNLIKELY that AI will replace pharmacists and cause widespread job loss?
A. Experts anticipate AI has reached its heyday and will be difficult to develop in new ways.
B. Experts anticipate the federal government will implement laws preventing AI use in healthcare.
C. Experts anticipate the pharmacy workforce will decline, making more jobs to be filled.

11. With the integration of AI into healthcare, how is AI expected to complement pharmacists?
A. By assisting with repetitive tasks, allowing pharmacists to focus on responsibilities that require human expertise
B. By assisting with relationship-building, allowing pharmacists to focus on responsibilities that require human expertise
C. By assisting with personalized communication, allowing pharmacists to focus on responsibilities that require human expertise

12. Molly needs to provide discharge medication counseling to a patient but is pressed for time. She sends an AI robot to provide the counseling instead. However, the patient refuses this service. Why is it LIKELY that the patient declined the AI robot’s counseling service?
A. The patient did not want to pay for AI’s automated labor.
B. The patient did not want to accept AI technologies.
C. The patient did not want AI-related errors in counseling.

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15. Rule-Based System. OpenTrainAI. Accessed February 18, 2025. https://www.opentrain.ai/glossary/rule-based-system#:~:text=Examples/Use%20Cases:,a%20structured%20set%20of%20guidelines.
16. Greenway N. Apple Watch Fall Detection—Which Apple Series Detects Best? Medical Alert Advice. 2024. Accessed February 20, 2025. https://www.medicalalertadvice.com/articles/apple-watch-fall-detection/#:~:text=Fall%20detection%20technology%20is%20not,%2C%20watch%2C%20or%20other%20device
17. Manne R, Kantheti SC. Application of Artificial Intelligence in Healthcare: Chances and Challenges. Current Journal of Applied Science and Technology. 2021;40(6): 78-89. doi:0.9734/CJAST/2021/v40i631320
18. Sheng B, Pushpanathan K, Guan Z, et al. Artificial intelligence for diabetes care: current and future prospects. The Lancet. 2024;12(8):569-595. doi:10.1016/S2213-8587(24)00154-2
19. Guan Z, Li H, Liu R, et al. Artificial intelligence in diabetes management: Advancements, opportunities, and challenges. Cell Rep Med. 2023;4(10):101213. doi:10.1016/j.xcrm.2023.101213
20. Dugani SB, Mielke MM, Vella A. Burden and management of type 2 diabetes in rural United States. Diabetes Metab Res Rev. 2021;37(5):e3410. doi:10.1002/dmrr.3410
21. Five key barriers to healthcare access in the United States. UpToDate, Wolters Kluwer. 2022. Accessed February 20, 2025. https://www.wolterskluwer.com/en/expert-insights/five-key-barriers-to-healthcare-access-in-the-united-states
22. Yang CC. Explainable Artificial Intelligence for Predictive Modeling in Healthcare. J Healthc Inform Res. 2022;6(2):228-239. doi:10.1007/s41666-022-00114-1
23. Labib A, Rosen J, Yosipovitch G. Skin Manifestations of Diabetes Mellitus. Endotext [Internet]. 2022. Accessed February 19, 2025. https://www.ncbi.nlm.nih.gov/books/NBK481900/
24. Shi T, Zhang B, Tang YY. An extensive analysis of various texture feature extractors to detect Diabetes Mellitus using facial specific regions. Computers in Biology and Medicine. 2017;83:69-83. doi:10.1016/j.compbiomed.2017.02.005
25. Li J, Yuan P, Hu X, et al. A tongue features fusion approach to predicting prediabetes and diabetes with machine learning. J Biomed Inform. 2021;115:103693. doi:10.1016/j.jbi.2021.103693
26. Tomooka K, Saito I, Furukawa S, et al. Yellow Tongue Coating is Associated With Diabetes Mellitus Among Japanese Non-smoking Men and Women: The Toon Health Study. J Epidemiol. 2018;28(6):287-291. doi:10.2188/jea.JE20160169
27. National Diabetes Statistics Report. CDC. Accessed February 18, 2025. https://www.cdc.gov/diabetes/php/data-research/index.html#:~:text=Total:%2038.4%20million%20people%20have,older%20(48.8%25)%20have%20prediabetes
28. Contreras I, Vehi J. Artificial Intelligence for Diabetes Management and Decision Support: Literature Review. J Med Internet Res. 2018;20(5):e10775. Published 2018 May 30. doi:10.2196/10775
29. Virdi N, Poon Y, Abaniel R, Bergenstal RM. Prevalence, Cost, and Burden of Diabetic Ketoacidosis. Diabetes Technol Ther. 2023;25(S3):S75-S84. doi:10.1089/dia.2023.0149
30. What is Heart Failure? AHA. 2023. Accessed February 18, 2025. https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure
31. Khan MS, Arshad MS, Greene SJ, et al. Artificial intelligence and heart failure: A state-of-the-art review. Eur J Heart Fail. 2023;25(9):1507-1525. doi:10.1002/ejhf.2994
32. Yoon M, Park JJ, Hur T, et al. Application and Potential of Artificial Intelligence in Heart Failure: Past, Present, and Future. Int J Heart Fail. 2023;6(1):11-19. doi:10.36628/ijhf.2023.0050
33. Choi DJ, Park JJ, Ali T, et al. Artificial intelligence for the diagnosis of heart failure. npj Digit Med. 2020;3(54). doi:10.1038/s41746-020-0261-3
34. Hospital Readmissions Reduction Program (HRRP). CMS. 2024. Accessed February 18, 2025. https://www.cms.gov/medicare/quality/value-based-programs/hospital-readmissions
35. Reduce heart failure hospitalizations in adults. Healthy People 2030. Accessed February 18, 2025. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/heart-disease-and-stroke/reduce-heart-failure-hospitalizations-adults-hds-09/data?group=None&from=2016&to=2020&state=United%20States&populations=#edit-submit
36. Haas R, McGill SC. Artificial Intelligence for the Prediction of Sepsis in Adults. CADTH Horizon Scan [Internet]. 2022;2(3). https://www.ncbi.nlm.nih.gov/books/NBK596676/
37. Schinkel M, van der Poll T, Wiersinga WJ. Artificial Intelligence for Early Sepsis Detection: A Word of Caution. Am J Respir Crit Care Med. 2023;207(7):853-854. doi:10.1164/rccm.202212-2284VP
38. Adams R, Henry KE, Sridharan A, et al. Prospective, multi-site study of patient outcomes after implementation of the TREWS machine learning-based early warning system for sepsis. Nat Med. 2022;28:1455-1460. doi:10.1038/s41591-022-01894-0
39. Kennedy JN, Rudd KE. A sepsis early warning system is associated with improved patient outcomes. Cell Rep Med. 2022;3(9):100746. doi:10.1016/j.xcrm.2022.100746
40. Alert Fatigue. PSNet. 2019. Accessed February 19, 2025. https://psnet.ahrq.gov/primer/alert-fatigue#:~:text=The%20term%20%22alert%20fatigue%22%20describes,respond%20appropriately%20to%20such%20warnings.
41. Li T, Wu B, Li L, et al. Automated Electronic Alert for the Care and Outcomes of Adults With Acute Kidney Injury: A Randomized Clinical Trial. JAMA Netw Open.2024;7(1):e2351710. doi:10.1001/jamanetworkopen.2023.51710
42. Wilson FP, Martin M, Yamamoto Y, et al. Electronic health record alerts for acute kidney injury: multicenter, randomized clinical trial. BMJ. 2021;372:m4786. doi:10.1136/bmj.m4786
43. Nelson SD. Artificial intelligence and the future of pharmacy. Am J Health Syst Pharm. 2024;81(4):83-84. doi:10.1093/ajhp/zxad316
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46. Lim JI, Regillo CD, Sadda SR, et al. Artificial Intelligence Detection of Diabetic Retinopathy: Subgroup Comparison of the EyeArt System with Ophthalmologists' Dilated Examinations. Ophthalmol Sci. 2022;3(1):100228. doi:10.1016/j.xops.2022.100228
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50. Joukes E, Abu-Hanna A, Cornet R, de Keizer NF. Time Spent on Dedicated Patient Care and Documentation Tasks Before and After the Introduction of a Structured and Standardized Electronic Health Record. Appl Clin Inform. 2018;9(1):46-53. doi:10.1055/s-0037-1615747
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The Scoop on Pharmacy Burnout: Description and Management Strategies

Burnout is a response to prolonged work-related stress that has not been managed adequately. Although burnout is present in other professions, researchers have found it to be more prevalent in health services professions. In the pharmacy profession, increasing workload, staffing shortages, and hard-to meet company performance metrics are among the factors that contribute to burnout. The consequences of burnout in the pharmacy are substantial and range from low morale and employee turnover to serious dispensing errors. The onus for addressing burnout lies with employers and companies, although employees have a role to play as well. Several states are enacting new laws to address working conditions in pharmacies. Recently passed laws include mandating breaks for pharmacists, capping shift lengths, and disallowing excessive metrics.

INTRODUCTION

Burnout is a response to prolonged work-related stress that can impair physical health and psychological wellbeing.^1,2 Interest in burnout is growing. Employers and employees alike would like to understand burnout and determine a solution that will keep employees engaged and enthusiastic about work. For healthcare professionals and the pharmacy team to carry out their roles in improving the health of the population optimally, they must pay attention to their physical and psychological wellbeing. Consequences of burnout adversely affect both providers and patients in their care.

People who experience burnout feel emotional exhaustion, depersonalization, and reduced personal accomplishment.¹ The Maslach Burnout Inventory (MBI) is the most widely used research measure on burnout.¹ The Maslach Burnout Inventory Human Services Survey (MBI-HSS) is an assessment tool for burnout syndrome in human services occupations such as healthcare.¹ Christina Maslach, a psychology professor at the University of California, Berkeley, is one of the pioneering researchers on burnout and its definition, predictors, and measurement.³ She is the architect of the Maslach Burnout Inventory and based on her work, the World Health Organization (WHO) included burnout as an occupational phenomenon in the International Classification of Diseases (ICD).³ Maslach and her colleagues’ initial research into burnout included surveys, interviews, and field observations of workers in human services professions such as health care, social services, mental health, criminal justice, and education. Their findings indicated that burnout could reduce the quality of care or service provided by the worker.¹ Their findings also found a link between burnout and negative health outcomes for the worker such as headaches, muscle tension, hypertension, sleep disturbances, and cold and flu episodes.² Burnout also seemed to be associated with personal dysfunction such as physical exhaustion, insomnia, increased use of substances, and poor interpersonal relationships.¹

The Agency for Healthcare Research and Quality estimates that 30% to 50% of physicians, nurse practitioners, and physician assistants may be affected by burnout.⁴ Various professional organizations and studies have extensively reported on burnout in physicians. While more research is needed, researchers have conducted some studies to identify occupational burnout’s prevalence and risk factors in pharmacists and pharmacy technicians. These studies detail the existence of burnout among pharmacy staff.

Health care providers’ well-being impacts patient safety and patient care quality. It is essential that pharmacy team members understand burnout syndrome, and stakeholders in the profession must take steps to improve employee well-being.

Pause and Ponder: How would you describe the working conditions at your workplace?

Burnout Definition and Description

In the early 1970s, psychologist Herbert Freudenberger was one of the first to describe professional exhaustion and is credited with introducing the concept of burnout.^4,5Freudenberger did his burnout research observing staff working in a free medical clinic.^4,5 After he completed his normal workday, he worked at a free clinic that he had helped organize during the Free Clinic Movement—a movement that involved healthcare providers in work that required almost endless effort and empathy. During these work shifts, he recognized the syndrome. He described burnout as putting a great deal of yourself into your work, with the staff and population you serve demanding this of you, while you also demand it of yourself. He further described it as eventually finding yourself in a state of exhaustion.⁵

Similar to Freudenberger’s description, the WHO defines burnout as a syndrome conceptualized as resulting from chronic workplace stress that has been poorly managed.⁶ Burnout can develop in employees such as healthcare professionals who work with other people in some capacity.¹Note that burnout is limited to work environments, an occupational hazard, if you will, and the ICD does not classify it as medical condition.⁶

Indicators of Burnout

Burnout has three subscales (scales used to obtain a rating or measurement that contributes to a rating or measurement on a larger scale). The terms that describe burnout’s three components may be familiar to pharmacists and technicians, but they have specific meaning when used to describe burnout. If pharmacists and technicians recognize how burnout presents, they will be better prepared to intervene early if they or their colleagues exhibit any of the feelings or attitudes described in the subscales.

The following are burnout’s subscales¹:

Emotional exhaustion: Presents as feelings of energy depletion or exhaustion attributed to one’s work. As emotional resources are depleted, workers feel they are no longer able to give more of themselves on a psychological level.¹ Other descriptions of emotional exhaustion are being worn out, having a loss of energy and enthusiasm for work, or feeling drained and fatigued.⁷
Depersonalization: Increased mental distance from one’s job, or feelings of negativity or cynicism related to one’s job. Other descriptions of this state are negative and cynical attitudes and feelings about one’s clients or negative, inappropriate, and irritable attitude toward clients.¹ This perception of others may lead staff to view clients or patients as somehow deserving of their troubles.¹
Decreased sense of personal accomplishment: Reduced professional efficacy, or feelings of reduced personal accomplishment. Workers may evaluate themselves negatively regarding their work and may also feel dissatisfied with their accomplishments on the job.¹ Some words used to describe this condition include reduced productivity or capability, and low morale.

Table 1 describes studies and research on burnout in different pharmacy practice settings and their findings.

Table 1. Burnout Studies in Different Pharmacy Practice Settings^8-12

Target Population	Study Design and Description	Result
Community pharmacists	· Anonymous electronic surveys including the MBI-HSS and a work-factors-based questionnaire · To identify the prevalence and risk factors for occupational burnout in community pharmacists	74.9% of respondents reported burnout in at least one MBI-HSS subscale, most owing to emotional exhaustion (68.9%).
Health system pharmacists	· Multi-center cross-sectional cohort survey study · Used MBI-HSS · To determine levels of, and risk factors for professional burnout among health system pharmacists	53.2% of study participants reported a high level in at least one MBI-HSS subscale. 8.5% of study participants had scores that indicated burnout on all 3 MBI-HSS subscales.
Clinical pharmacists in a hospital inpatient setting	· Prospective, cross-sectional pilot study · Online survey · To characterize the level of and identify factors independently associated with burnout among clinical pharmacists practicing in an inpatient hospital setting within the United States	Low response rate. However, 61.2% of respondents reported burnout, largely driven by high emotional exhaustion.
Pharmacy residents	· Electronic anonymous survey · To quantify burnout status of pharmacy residents and to correlate burnout to professional conduct and career outlook	74.4% burnout rate was reported among respondents.
Pharmacy technicians	· Used MBI-HSS · To assess burnout among pharmacy technicians working in a hospital or health system setting	69.1% of respondents were experiencing burnout.
ABBREVIATIONS: MBI-HSS = Maslach Burnout Inventory-Human Services Survey

Risk Factors and Causes of Burnout

Across many occupations, common risk factors contribute to burnout. Table 2 describes those risk factors.

Table 2. Risk Factors for Burnout²

Risk Factor	Description
Workload	· Job demands exceeds human limits · Workload is unsustainable · No opportunity to recover from, or have a restful period after a particularly demanding event such as meeting a deadline or addressing a crisis resulting in acute fatigue · Prolonged overload becomes a chronic job condition leading to exhaustion
Control	· Employees have no personal control in the workplace · Role conflict · Lack of opportunity to contribute to or participate in organizational decision-making
Reward	· Insufficient reward be it financial, institutional, or social · Lack of recognition from managers, workers, and stakeholders devalues the work and leaves the worker with a sense of inefficacy
Community	· The overall quality of social interaction at work and the ability to work as a team is inadequate. · Lack of a supportive and positive work environment
Fairness	· Decisions at work are perceived as unfair or inequitable · Employees perceive an imbalance between their inputs (time, effort, expertise) and outputs (reward, recognition)
Values	· A conflict exists between individual and organizational values o Values are the ideals or principles that originally draw people to a particular job. · Individual values unaligned with organizational goals could lead to burnout

Although employees in other professions experience burnout, workers in the human services professions such as healthcare, social services, mental health, criminal justice, and education are more prone to burnout.⁴ Workers in human services professions spend considerable amounts of time with other people. Their relationships often involve addressing a patient’s or a client’s health needs (medical, psychological, physical).¹ Patients and clients have continuous health needs and challenges and frequently require ongoing, lengthy, or chronic support and care. In an effort to make a positive impact on the lives of others, healthcare workers can become overwhelmed.¹ The nature of healthcare work coupled with stressful working conditions can be emotionally draining and lead to burnout.

Pharmacy professionals like other healthcare professionals are prone to burnout due to common risk factors and profession specific factors.

The following risk factors contribute to burnout among the pharmacy team^4,10,13

Long professional work hours
Workload and inability to meet company specified performance metrics
Staffing shortages
Incompatibility between skills and actual daily tasks

Because the pharmacy profession is highly regulated, the pharmacy team must remain up to date with regulatory requirements.⁴ Everyone on the team must document extensively with no room for error. Attention to detail is a required skill for the pharmacy team because errors could lead to injury or potentially death.

An increasing workload, long working hours, and day-to-day tasks that may sometimes be incongruent with employees’ actual skills may lead to burnout at some point.⁴ A fear of retribution from speaking up about working conditions further exacerbates the risk of burnout.¹⁴

In a March 2021 NBC news story “Overworked, understaffed: Pharmacists say industry in crisis puts patient safety at risk” that aired, NBC news interviewed 31 retail pharmacists and technicians from 15 states.¹⁴ These pharmacists and technicians described extremely busy 12-hour shifts during which they were unable to take lunch or bathroom breaks. The interviewees further described crying in their cars after work and enduring sleepless nights from worrying about mistakes they may have made while working under such busy and rushed conditions.¹⁴ For a common daily scenario in a busy community pharmacy, see the SIDEBAR.

SIDEBAR: Does this busy community pharmacy sounds familiar?¹⁴

Long lines while short-staffed
Ringing phones
Busy drive-through
Weekly order that still needs to be put away on shelves
Patients waiting for vaccines

The story described working conditions in community pharmacies where pharmacists were being “pushed to do more with less.”¹⁴ Pharmacists described working faster to fill more orders, while juggling a wider range of tasks with fewer staff members at a rate that compromised patient safety.

A 2019 national pharmacist workforce study found two-thirds of pharmacists experienced increased workload in the past year. A high percentage of retail chain pharmacists in this survey rated their workloads as high or excessively high.¹⁵

Burnout rates among pharmacy employees may differ depending on practice setting.⁴ Community pharmacists report higher rates of burnout than employees in other practice settings like hospitals and independent pharmacies.⁹

Pause and Ponder: Do you dread your upcoming shift and live for your day off? Why or why not?

BURNOUT ASSESSMENT

Assessing burnout in the pharmacy profession is necessary for research and most importantly for interventions. With the MBI-HSS specifically, employers can design interventions to address the specific burnout subscale that their employees may report.¹ Interventions addressing emotional exhaustion will differ from those addressing a reduced sense of personal accomplishment. Organizations or employers can focus strategies to address employee burnout.¹ Finally, the assessment of burnout and the subsequent awareness that a problem exists can be the initial step in preventing or alleviating full blown job burnout.

The Maslach Burnout Inventory

The MBI is an assessment tool for the three components of burnout syndrome: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.¹ Although other measurements for burnout exist, the MBI is largely considered the gold standard for assessing burnout in a group of workers in a profession. The MBI is not an individual diagnostic instrument.¹ This assessment tool was designed originally to measure burnout in human services professions such as healthcare, social work, and criminal justice.¹ Maslach has since developed alternate forms of the MBI: the MBI-Educators Survey (MBI-ES) for the teaching profession, and the MBI-General Survey (MBI-GS) for other occupational groups.¹ The MBI-HSS distinguishes burnout in health services occupations from burnout in other professions.¹ This questionnaire is a self-administered tool and takes approximately 15 minutes to complete.¹

The MBI is copyrighted.¹ Researchers and individuals can purchase and administer it either as an online survey or as a paper and pencil survey.¹⁶ For the online surveys, score reports are generated online.¹⁶

The MBI is divided into three components, each of which includes personal statements that the respondent must rank.¹ Examples of such personal statements are “I feel burned out from my work” and “I don’t really care what happens to some recipients.” MBI-HSS administrators score the items on the questionnaire on a seven-point scale. The scale ranges from a 0 response for “never,” to a 6 response for “every day.” Below are the three components¹:

Emotional exhaustion – nine statements on this subscale assess “feelings of being emotionally overextended and exhausted by one’s work.”
Depersonalization – five statements on this subscale assesses an unfeeling and impersonal response the employee has towards their patients or clients.
Personal accomplishments – eight statements on this subscale assess “feelings of competence and achievements in one’s work with people.”

Each subscale is scored separately as low, average, or high using directions from the scoring key. There is not a total combined score. Respondents receive three separate scores—one score for each subscale. Receiving a score for each subscale benefits the assessment-taker because interventions to reduce burnout can be designed based on the specific component of burnout that needs to be addressed.¹

For the emotional exhaustion and depersonalization subscales, a higher score corresponds to a higher degree of burnout. For the personal accomplishment subscale, however, a lower scale corresponds to a higher degree of burnout.¹

The MBI has several drawbacks. Everyone has a different view of burnout and because the questionnaire is self-administered, respondents’ answers may be influenced by talking to other people such as friends and coworkers. For this reason, respondents should complete the MBI privately without knowing how other respondents are answering. The survey has also been labeled “MBI Human Services Survey” rather than “Maslach Burnout Inventory.” This reduces the chances of respondents linking the survey specifically to burnout; rather, the questionnaire’s title suggests it measures job-related attitudes and issues.¹ Once all respondents have completed the survey, an open discussion of burnout is then appropriate. MBI administrators require no special qualifications. However, as a best practice, managers or supervisors should not administer the survey since this would affect how employees respond, i.e., employees may not be candid about their feelings.¹

Although the MBI cannot be used as an individual diagnostic tool, it can be used as a self-assessment tool.¹ Employees can compare their scores to those of others in their occupational group so they can recognize potential problems.¹

ICD-11 Codes for Burnout

The ICD is the international standard for reporting diseases and health conditions and is the diagnostic classification standard for all clinical and research purposes.¹⁷ ICD-11 is the global standard for health data, clinical documentation, and statistical aggregation. It is scientifically up to date with multiple uses including use in primary care. The ICD defines diseases, disorders, injuries, and other related health conditions.¹⁷ The WHO maintains the ICD.¹⁷

The WHO’s 11^th revision of the International Classification of Diseases (ICD-11) includes burnout, defining it as “a syndrome conceptualized as resulting from workplace stress that has not been successfully managed.”⁶ The previous revision, ICD-10, also included burnout. The definition in the 11^th revision is now more detailed. According to this classification, burnout is work-related and does not apply to experiences in other areas of life.⁶

Alternative Measures to Assess Burnout

While experts consider the MBI to be the gold standard for burnout assessment, other measures exist that are not copyrighted, require no payment to use, and are publicly available.¹⁸

The Oldenburg Burnout Inventory – developed in Germany, this 16-item survey measures burnout in any occupational group. It covers two areas: exhaustion (physical, cognitive, and affective aspects) and disengagement from work (negative attitudes toward work objects, work content or work in general). It treats each burnout dimension separately.¹⁸
Single Item Burnout Measure – developed in the U.S., it measures burnout in any occupational group. The single question on the measure asks users to rate their burnout level based on their own definition of burnout. Users pick from five response options and receive scores that suggest no burnout symptoms, or one or more burnout symptoms.¹⁸
Copenhagen Burnout Inventory – developed in Denmark, this 19-item survey measures burnout in any occupational group and covers personal-, work-, and client-related burnout. It treats each burnout dimension separately.¹⁸

Recognizing Burnout’s Effects

Burnout influences quality of life and the team’s ability to perform optimally in their personal and professional capacities. In addition to negative health outcomes for employees such as muscle tension, headaches, sleep disturbances, hypertension, and cold and flu episodes,² burnout’s consequences in the workplace include^1,13,14,19

A decline in the quality of patient care
Dispensing errors
Low morale
Employee turnover
Missed days

Pause and Ponder: Do you feel rushed daily at work? How might that contribute to dispensing errors?

Dispensing Errors

We have described how an unsustainable workload is a risk factor for burnout (see Table 2). The costly effects of burnout include dispensing errors. Staff shortages, increasing workload, and long professional work hours contribute to dispensing errors in pharmacies.^14,19Community pharmacists and technicians, for example, work to fill prescriptions, give vaccinations, counsel patients, answer phones, tend to the drive-through and the register, and call insurance companies. They do all this while trying to meet their company’s specified performance metrics. The likelihood of a dispensing error is increased when working conditions in the pharmacy are rushed and chaotic.^14,19

In 2006, in a comprehensive study of medication errors, the Institute of Medicine estimated that medication errors harmed at least 1.5 million Americans annually.²⁰ Indirect costs of such errors include loss of productivity, emotional stress and suffering, and additional healthcare costs.²⁰ A recent New York Times article tells the story of working conditions in pharmacies and metrics set by companies that pharmacists find hard to meet.¹⁹ The article reports several examples of dispensing errors. In one instance, an 85-year-old woman died after receiving the chemotherapy drug methotrexate instead of an antidepressant refill. Another patient went to the emergency room after receiving ear drops instead of eye drops, which caused eye swelling and burning. In another medication mix up, a patient received a blood pressure medication instead of her asthma medication, resulting in a pounding headache, nausea, and dizziness.¹⁹

Some states including Illinois and California are trying to change pharmacy practice. In Illinois, a new law requires pharmacists to have scheduled breaks. The state could also impose penalties on companies that do not provide a safe working environment.¹⁴ California’s new law requires that pharmacists not work alone.¹⁴ Changes from state boards of pharmacy could play an important role in improving the working conditions in pharmacies.

Employee Turnover

Employee turnover is the voluntary or involuntary loss of employees and the act of replacing them. Employees may leave their jobs voluntarily for many reasons including retirement or moving on to other opportunities. Others may leave due to lack of growth opportunities in their current roles, a hostile work environment, or a feeling of not fitting the company culture. Job-seekers and applicants view an unusually high turnover negatively, making turnover costly for employers. Companies must then put great efforts into recruiting, training, and onboarding. It also takes time for employers to train new employees adequately. Others may also view the company as having problems with their working conditions. Most importantly, high turnover diminishes productivity and the chance to build a cohesive team is lost.²¹

In 2004 in the U.S., researchers conducted a study to examine the relationship between organizational and individual factors, and pharmacists’ future work plans.¹³ The study sought to determine factors that contributed to pharmacists either leaving or staying with their current employer.¹³ Researchers in this cross-sectional study mailed surveys to licensed U.S. pharmacists. Respondents were asked to state whether they would leave or stay with their current employers during the next year. The researchers also asked respondents to rate their top five reasons for leaving or staying from a predetermined list. “Leavers” were those planning to leave their employer, and “stayers” were those planning to stay.

For leavers, 35% cited high stress levels as their exit reason, 31.1% cited excessive workload, and 25% cited poor salary or insufficient staffing.¹³

Stayers’ top reasons were good salary (50%), relationships with coworkers (46.6%), and good benefits (42%).¹³

Researchers also asked respondents to identify one main factor that influenced their decision to leave or to stay. A majority of these factors were under the employer’s control. Flexible schedules, ability to use skills, and salary/benefits influenced the stayers, while insufficient or unqualified staffing, poor scheduling and salary, and workload influenced the leavers.¹³

COVID-19 and Burnout in Healthcare Workers

In March 2020, the WHO declared the novel coronavirus disease (COVID-19) a global pandemic. COVID-19 is a highly contagious respiratory illness. As of January 4, 2022, COVID-19 had affected more than 54 million Americans and claimed the lives of more than 820,000.²² Factors such as preparedness for a pandemic, political leadership, availability of personal protective equipment (PPE), and the fear of infection and infecting others have played a role in the nation’s response to the pandemic. At the forefront of these crises were healthcare workers. The pandemic increased the levels of burnout among healthcare workers who have additionally had to witness patient suffering.

Before the pandemic, several studies across various pharmacy practice settings reported burnout among pharmacists. The 2019 national pharmacists’ workforce study reported 71% of practicing pharmacists characterizing their workload as either high or excessively high.¹⁵ During the COVID-19 pandemic however, studies showed that burnout has increased among healthcare workers, pharmacists included.^23,24 Healthcare visits to hospitals and doctors’ offices are sometimes limited during the pandemic, however, community pharmacists are available for face-to face consults. While this is beneficial for patients, pharmacists and technicians face an increased risk of exposure to the virus. Additionally, pharmacists have had to take on new roles and responsibilities during the pandemic.²⁵ The U.S. Department of Health and Human Services (DHS) authorized pharmacists to procure, dispense, and administer COVID-19 vaccines when they became available.²⁵ DHS also authorized pharmacists to order and administer COVID-19 tests to aid in testing expansion in response to the COVID-19 pandemic.²⁶

In the U.S., researchers studied the impact of COVID-19 on pharmacist workload, employment status, feelings of burnout, and overall emotional health.²³ The Wisconsin Pharmacist Workforce Study was a cross-sectional study conducted before the COVID-19 vaccine was available but after the Department of Health and Human Services made the decision to permit pharmacists to administer it.²³ Researchers focused on questions related to burnout domains and emotional health. For the reward domain, questions focused on changes in personal employment, while questions for the workload domain focused on exhaustion. Researchers used questions to measure depersonalization for the social interaction domain and developed questions about pharmacists’ social and emotional health. The study focused on the 2 largest pharmacist populations – community and hospital pharmacists – and had a 33% response rate. Study results are shown in Table 3.

Table 3. The Wisconsin Pharmacist Workforce Study Results²³

Domain Questions	Percentage of Community Pharmacists Reporting	Percentage of Hospital Pharmacists Reporting
Hours Reduced	13	36
Hours Increased	19	8
Reduction in Wages	1	6
Temporary Furloughs	2	6
Concern About Being Furloughed or Losing Job	26	14
Increase in Workload or Work-Related responsibilities	41	42
Reduced interest in talking with patients	26	22
Social/emotional health	Approximately 40% reported increased anxiety. Approximately 25% experienced increased sadness or depression.

The Wisconsin Pharmacist Workforce Study had imitations. Researchers only studied Wisconsin pharmacists, which makes generalization difficult. A non-response bias was also present; pharmacists with the highest workload would have had the least amount of time to respond to the survey. Despite these limitations, the study suggested that although pharmacists rose to the challenge during the pandemic, they experienced increased burnout as a result of COVID-19.²³

Another study conducted across pharmacy practice settings in Australia to measure burnout in pharmacists during the coronavirus pandemic showed that burnout had increased.²⁴ The study, an online survey, consisted of three parts. Researchers collected demographic information such as age, sex, primary practice area, and years of practice. They also used the MBI-HSS to measure burnout, and then asked questions pertaining to psychosocial issues. The questions focused on the pharmacists’ degree of concern for personal and family health, whether duties such as working overtime and workloads changed, and if precautionary measures in the workplace (e.g., PPE and infection control) were appropriate.²⁴

Although only 17.8% of respondents reported caring for COVID-positive patients, an overwhelming 96.3% of pharmacists reported a change in their roles during the pandemic. These changes included increased workload (35.9%) and working overtime (52.2%). The pharmacists reported challenges they faced during the pandemic ranging from medication supply (40.9%) to patient incivility (24%). Regarding precautionary measures however, 71.1% of pharmacists reported that their workplace had sufficient precautionary measures.²⁴

With regards to psychosocial factors, 36% of pharmacists were “very to extremely concerned” about their family’s health and 87.2% reported that their lives had been affected most by isolation from friends and family.²⁴

With the arrival of the COVID-19 pandemic, pharmacy teams have been stretched even further with additional duties such as COVID- 19 testing, deep cleaning, and giving COVID vaccinations. COVID-19 has compounded burnout among the pharmacy team.

The federal government in the U.S. has not yet comprehensively tracked data on healthcare worker deaths, but according to “Lost on the Frontline,” a 12-month investigation by The Guardian, a British newspaper, and Kaiser Health News, more than 3600 healthcare workers in the U.S. died from the coronavirus disease in the pandemic’s first year.²⁷

BURNOUT MANAGEMENT

The responsibility of addressing burnout among the pharmacy team does not only lie with employees but also with employers. In a study to assess burnout among pharmacy technicians working in a hospital or health-system settings in North Carolina, employees’ awareness of burnout resources at their institution was associated with lower odds of burnout, whether employees used those resources or not.¹¹

Employers

The pharmacy profession as a whole must address burnout, and employers’ goals should be to identify and address factors that contribute to burnout.

Prevention strategies for burnout include²

Ensuring a sustainable workload at the workplace, while allowing for periods of rest and recovery
Encouraging active participation in organizational decision making
Providing appropriate rewards for employee achievement
Fostering a positive and supportive environment at the workplace
Promoting fairness, impartiality, or equity in decisions at work
Aligning employees’ personal expectations with the organization’s

Federal and State Legislation

Payment Reform

Pharmacists are generally only paid for filling prescriptions and do not bill for clinical services such as counseling and giving vaccinations. A proposed federal bill if passed, would grant pharmacists “provider status.” The Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 2759/S.1362) was introduced in both the U.S. House of Representatives and the U.S. Senate in April 2021. This bill proposes pharmacist recognition as health care providers and allows compensation for their services to Medicare patients in medically underserved areas.^28,29 With this status, pharmacists could bill insurers for clinical services for Medicare patients under Medicare Part B.²⁸

At the state level, several states already assign some form of provider status to pharmacists. The National Alliance of State Pharmacy Associations (NASPA) identifies state provider status-related bills as those that apply to pharmacist scope of practice, payment for pharmacist provided patient care services, and/or the designation of pharmacists as providers. NASPA’s 2021 mid-year update on state provider status reports that in 18 states, 32 such bills have been signed into law. These laws include pharmacist immunization authority, broad prescriptive authority, contraceptive prescribing authority, and payment for services among others.³⁰ In response to the NBC news story “Overworked, understaffed: Pharmacists say industry in crisis puts patient safety at risk,” the American Pharmacists Association (APhA), called for payment reform in pharmacy in a press release.³¹ The APhA went on to say that the broken model of paying for the filling of prescriptions has led to a proliferation of productivity and efficiency metrics that have created a situation that compromises patient safety. The press release further stated that the APhA continues to fight for payment reform at both the federal and state levels.³¹

Burnout can occur when an incompatibility exists between employees’ skills and actual daily tasks. Giving pharmacists the opportunity to consult, provide, and bill for clinical services while spending less time in dispensing activities could be a remedy.^13,31

Legislation

States like California, Illinois, and Virginia have passed new laws that will cap shift lengths for pharmacists. These laws also seek to ensure safe staffing levels and prohibit excessive metrics.¹⁴ According to the National Association of Boards of Pharmacy, about a third of all states now have some regulation that address working conditions in the pharmacy.¹⁴

Assessing Well-Being

Employees in other human services professions experience burnout as well, and it could be beneficial to look to other professions to see what initiatives they have in place to address burnout. The American Medical Association (AMA) for example, has a STEPS Forward program that seeks to prevent provider burnout.³² The program has interactive online educational modules with strategies to confront common challenges in a busy medical practice. The program is physician-developed and physicians can earn continuing medical education credit while learning about practice efficiency and patient care, patient health, physician health, and technology and innovation.³² Programs that improve resilience and well-being among employees might be beneficial to the pharmacy profession.

In an effort to address well-being, the APhA has launched the Well-Being Index, a validated screening tool invented by the Mayo Clinic, to help pharmacists assess their well-being.³³ Respondents to the anonymous online survey that evaluates fatigue, depression, burnout, anxiety/stress, and mental/physical quality of life, receive immediate individualized feedback. This allows pharmacists to compare their well-being with their professional peers’ and directs them to tools and resources that can help promote well-being. Participants can also track their scores over time so they can be proactive in making self-care adjustments.³³

Authors of a commentary on burnout syndrome among healthcare professionals suggest actions that pharmacy organizations can take to recognize and reduce burnout among their employees. These include⁴

Establishing a panel to evaluate burnout in the profession of pharmacy
Conducting further research into the prevalence prevention and effectiveness of treatment strategies of burnout across all practice settings of pharmacy
Incorporating strategies that promote mental health wellness and resiliency into pharmacists’ training.

Employees

“You can’t pour from an empty cup” - Unknown

Employees can adopt strategies to guard against burnout. The following strategies guard against burnout and promote wellbeing in the employee.

Continue to speak up about workplace conditions that affect patient safety and employee well-being.
Adopt self-care habits and foster hobbies outside of work. Ensure adequate sleep, nutrition, and exercise.
Be sure to take your vacation time or paid time off to recharge.
Foster a supportive and positive work environment by communicating and collaborating with teammates.
Keep up with continuing education and join a professional pharmacy organization. This enhances self-esteem and promotes a sense of purpose.

CONCLUSION

The importance of high-quality healthcare cannot be stressed enough. Healthcare professionals including pharmacists and pharmacy technicians play an important role in improving the overall population’s health. Clearly, burnout’s consequences among pharmacy workers could be detrimental for employees, patients, organizations, and society as a whole. It is important to recognize the indicators and risk factors for burnout to be able to address them and improve health care provider well-being. Employers and institutions must implement strategies to combat burnout in their employees. Some state boards of pharmacy are beginning to make changes and institute new laws that will cater to appropriate work environments and employee well-being.

1. Which of the following measures assesses burnout among pharmacy professionals?

A. The Maslach Burnout Inventory
B. DSM-V
C. ICD-11 diagnostic guidelines for anxiety

2. Turnover resulting from burnout in the pharmacy profession can be described as

A. Employees tend to retire immediately after reaching retirement age
B. Employees leave because they don’t fit in with the work culture
C. Employee with good salary/benefits leave due to relocation of spouse’s job

3. Which of the following is a risk factor for burnout among pharmacy professionals?

A. Employees receive hardly any raises or recognition after favorable end-of-year performance reviews
B. Employee is included from decision making in the workplace
C. Employees find the level of social interaction and collaboration at work adequate

4. Which of the following scenarios is a risk factor for burnout among pharmacy professionals?

A. During the COVID-19 pandemic, some pharmacies hired additional staff to help administer covid shots
B. During the COVID-19 pandemic, some pharmacy staff worked overtime, while administering COVID-tests, and consulting face-to-face with patients
C. An extremely busy pharmacy has qualified staffing and flexible scheduling for their employees

5. XY has been a pharmacy technician for 5 years and works at a busy community pharmacy. XY often feels overwhelmed, stressed, and burdened by keeping up with prescription numbers, prior authorizations and patients’ health needs and challenges. What is XY experiencing?

A. Depersonalization
B. Emotional exhaustion
C. A decreased sense of personal accomplishment

6. XY usually lies awake at night dreading the next shift. Pharmacy practice now feels like a chore and XY finds patients at drop-off and pick-up very irritating. What is XY experiencing?

A. Depersonalization
B. Emotional exhaustion
C. A decreased sense of personal accomplishment
7. XY now finds pharmacy practice unmotivating and often questions having accomplished anything worthwhile, or having had a positive impact on patients. What is XY experiencing?

A. Depersonalization
B. Emotional exhaustion
C. A decreased sense of personal accomplishment

8. Which of the following would be considered a good strategy to combat burnout among the pharmacy team?

A. States must mandate more continuing education requirements for pharmacy technicians
B. Employees must seek medications from their healthcare providers

C. States should pass laws that place caps on pharmacy shift lengths and reduce excessive performance metrics

9. Which of the following is best practice for the employee to prevent full blown burnout?

A. Limit hobbies outside of work as they are distracting and hinders job focus
B. Limit communication and collaboration with team mates to help avoid dispensing errors
C. Use vacation times or restful periods to recharge and avoid fatigue

10. Coworker relationships at XY’s workplace are somewhat cordial. XY however feels blind-sided by recent company decisions about technician break times. What is the BEST way for XY’s employer to ensure that XY avoids burnout?

A. Pharmacy technicians understand that management usually makes workplace decisions without employee input.
B. Pharmacy technicians have more continuing education hour requirements within the organization
C. Pharmacy technicians must be actively involved in making certain workplace decisions

References

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Maslach C, Leiter MP. Early predictors of job burnout and engagement. J Appl Psychol. 2008;93:498-512.
Berkeley University of California. Psychology. Christina Maslach. Accessed January 3, 2022. https://psychology.berkeley.edu/people/christina-maslach
Bridgeman PJ, Bridgeman MB, Barone, J. Burnout syndrome among healthcare professionals. Am J Health-Syst Pharm. 2018;75:147-152.
Fontes, F. Herbert J. Freudenberger and the making of burnout as a psychopathological syndrome. Accessed January 3, 2022. https://www.researchgate.net/publication/346586006_
World Health Organization. Burn-out an “occupational phenomenon”: International classification of diseases. May 28, 2019. Accessed January 3, 2022.

https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases

Shrijver I. Pathology in the medical profession? Taking the pulse of physician wellness and burnout. Arch Pathol Lab Med. 2016;140:976-982.
Durham ME, Bush PW, Ball AM. Evidence of burnout in health-system pharmacists. Am J Health-Syst Pharm. 2018;75:S93-S100.
Patel SK, Kelm MJ, Lee HJ, et al. Prevalence and risk factors of burnout in community pharmacists. J Am Pharm Assoc. 2021;61:145-150.
Jones GM, Roe NA, Louden L, Tubbs C. Factors associated with burnout among US hospital clinical practitioners: Results of a nationwide pilot study. Hosp Pharm. 2017;52:742-751.
Kang K, Absher R, Granko RP. Evaluation of burnout among hospital and health-system pharmacy technicians in North Carolina. Am J Health Syst Pharm. 2020;77(24):2041-2042.
Gonzalez J, Brunetti L. Assessment of burnout among postgraduate pharmacy residents: A pilot study. Curr Pharm Teach Learn. 2021;13(1):42-48.
Gaither CA, Nadkarni A, Mott DA, et al. Should I stay or should I go? The influence of individual and organizational factors on pharmacists’ future work plans. J Am Pharm Assoc. 2007;47:165-173.
Kaplan A, Nguyen V, Godie M. Overworked, understaffed: Pharmacists say industry in crisis puts patient safety at risk. NBC News. March 16, 2021. Accessed January 3, 2022.

https://www.nbcnews.com/health/health-care/overworked-understaffed-pharmacists-say-industry-crisis-puts-patient-safety-risk-n1261151

American Association of Colleges of Pharmacy. National pharmacist workforce studies. Accessed January 3, 2022. https://www.aacp.org/article/national-pharmacist-workforce-studies

Mind Garden. MBI: Human Services Survey. Accessed January 3, 2022.

https://www.mindgarden.com/314-mbi-human-services-survey

World Health Organization. International Statistical Classification of Diseases and Related Health Problems (ICD). Accessed at https://www.who.int/standards/classifications/classification-of-diseases, January 3, 2022.
National Academy of Medicine. Valid and reliable survey instruments to measure burnout, well-being, and other work-related dimensions. Accessed January 3, 2022. https://nam.edu/valid-reliable-survey-instruments-measure-burnout-well-work-related-dimensions/
Gabler E. How chaos at chain pharmacies is putting patients at risk. New York Times. January 31, 2020. Accessed January 3, 2022.

https://www.nytimes.com/2020/01/31/health/pharmacists-medication-errors.html

Eastman, P. IOM Report. Medication errors injure millions. Emergency Medicine News. 2006;28(9):44-46.
Dik, B. Staff attrition vs staff turnover: What’s the difference? March 28, 2018. Accessed at https://jobzology.com/staff-attrition-vs-staff-turnover-whats-the-difference/, June 22, 2021.
Centers for Disease Control and Prevention. Covid data tracker. Accessed January 3, 2022. https:// COVID.cdc.gov/ COVID-data-tracker/#datatracker-home
Bakken BK, Winn AN. Clinician burnout during the COVID-19 pandemic before vaccine administration. J Am Pharm Assoc. 2021;S1544-3191(21)00164-3. doi:10.1016/j.japh.2021.04.009
Johnston K, O'Reilly CL, Scholz B, et al. Burnout and the challenges facing pharmacists during COVID-19: results of a national survey. Int J Clin Pharm. 2021;1-10.
S. Department of Health and Human Services. Trump administration takes action to expand access to COVID-19 vaccines. Accessed June 20,2021. https://www.hhs.gov/about/news/2020/09/09trump-administration-takes-action-to-expand-access-to- COVID-19-vaccines.html
S. Department of Health and Human Services. Guidance for licensed pharmacists, COVID-19 testing, and immunity under the PREP Act. April 8, 2020. Accessed January 3, 2022. https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/authorizing-licensed-pharmacists-to-order-and-administer-covid-19-tests.pdf
Spencer J. KHN. Lost on the frontline. 12 months of trauma: More than 3600 US health workers died in Covid’s first year. April 8, 2021. Accessed January 3, 2022. https://khn.org/news/article/us-health-workers-deaths- COVID-lost-on-the-frontline/
Press Release. Pharmacy associations applaud introduction of bill expanding Medicare patients’ access to pharmacist services. April 21, 2021. Accessed at Accessed January 3, 2022. https://www.ashp.org/News/2021/04/22/ASHP-APHA-Applaud-Introduction-of-Bill-Expanding-Medicare-Patients-Access-to-Pharmacist-Services
APhA Action Center. Provider status for pharmacists. Accessed January 3, 2022. ttps://actioncenter.pharmacist.com/campaign/provider-status-for-pharmacists/, September 10, 2021.
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Mills, RJ. AMA launches Steps Forward to address physician burnout. AMA Press Releases. June 8, 2015. Accessed January 3, 2022. https://www.ama-assn.org/press-center/press-releases/ama-launches-steps-forward-address-physician-burnout
Well-Being Index. Pharmacist Well-Being Index. Accessed January 3, 2022. https://www.mywellbeingindex.org/versions/pharmacist-well-being-index

Are You Curious about Pharmacoeconomics?

After completing this application-based continuing education activity, pharmacists will be able to

Define common pharmacoeconomic terms used for economic evaluations.

Recall the advantages of pharmacoeconomic analysis for formulary management.

Compare and contrast different types of pharmacoeconomic analyses.

List the pharmacoeconomic tools a pharmacy benefit manager uses to lower drug costs.

After completing this application-based continuing education activity, pharmacy technicians will be able to:

Define common pharmacoeconomic terms used for economic evaluations.

Recall the advantages of pharmacoeconomic analysis for formulary management.

Compare and contrast different types of pharmacoeconomic analyses.

List the pharmacoeconomic tools a pharmacy benefit manager uses to lower drug costs.

Many pharmacy practitioners have heard of pharmacoeconomics, but don't have a clear understanding of what that term means. This field of study has a unique vocabulary associated with it and compares different aspects of drugs to determine which drug will produce the best clinical and economic outcomes. Many Pharmacy and Therapeutics Committees are now requiring pharmacoeconomic analysis when they consider formulary changes, but these analysis come in several different forms. Depending on the type and quantity of information available, people preparing reports for Pharmacy and Therapeutics Committee meetings will need to decide which model or studies to use. The foundation for several of the models is quality adjusted life years or QALYs, which have advantages and limitations. Pharmacy benefit managers use cost control tools and pharmacoeconomic analysis to control costs. Some tools that they may use are negotiated price, generic substitution, rebates, and patient copayments. Not all pharmacoeconomic studies are perfect, and this continuing education activity points out some of the ways in which they may be flawed.

INTRODUCTION

Let’s start with an old joke. An economics student once asked her professor how much his shoes cost. The professor responded with “I don’t know, I haven’t finished wearing them yet.” Drugs are just like shoes because their sticker price does not reflect their true cost or value.

PHARMACOECONOMICS BACKGROUND

The term pharmacoeconomics dates back to 1986.¹ Dr. Raymond Townsend used the term in a presentation for pharmacists in Canada.² Dr. Townsend earned his PharmD at the University of California, San Francisco and developed the pharmacoeconomic research department at the Upjohn Company.³ The Upjohn team developed pharmacoeconomics to address payment concerns as the healthcare system transitioned from a cash-based system to a third-party payer system. Its goal was to ensure drug spending was efficient and effective.⁴ Pharmacoeconomics has evolved over the ensuing 30-plus years to become a subbranch of economics.

Pharmacoeconomics compares different aspects of drugs to determine which drug will produce the best clinical and economic outcomes.¹ Pharmacists who work for pharmacy benefits managers (PBMs) or prepare for Pharmacy and Therapeutics (P&T) committee meetings are most likely to use pharmacoeconomic tools. But all healthcare personnel should understand pharmacoeconomics so they can use these tools as part of their efforts to optimize patient care or explain how health systems select medications to include on a formulary.

While these tools are useful, many pharmacists will avoid using pharmacoeconomics. In preparing to write this continuing education activity (CE), we asked faculty from two Schools of Pharmacy to identify pharmacoeconomic studies that have had significant clinical impact. One university pharmacy professor said, “Most pharmacoeconomics studies are ignored in clinical practice because practitioners don’t understand them or use other reasons to select a drug.” This CE activity should address both of those barriers—lack of understanding and the other considerations when selecting drugs.

MEET GEORGE

In this CE, George will join you. George just graduated from pharmacy school. He was hired at Man with the Yellow Hat Hospital and was put in charge of a presentation for the P&T Committee meeting. George is tasked with presenting a proposal to add a new drug, Monkeydex, to the formulary. If the Committee adds Monkeydex, he also needs to make a recommendation about the similar drug that is already on the formulary, Curiosan: should it remain on the formulary or be removed? The U.S. Food and Drug Administration (FDA) has approved both drugs for adventure-induced curiosity overload (AICO). Ted, another pharmacist, suggested George use pharmacoeconomic tools to analyze each drug’s effectiveness and cost.

PAUSE AND PONDER: Before reading further, write down as many pharmacoeconomic terms as you can!

Common Pharmacoeconomic Terms

George figured that common pharmacoeconomic terms are the best spot to begin his learning. George found these terms most helpful^5,6:

Comparators: the interventions being compared (and it’s possible to have two or more comparators)
Costs
- Direct costs: paid by the health system (salary costs, drug acquisition costs)
- Indirect costs: experienced by the patient (including decreased productivity, loss of earnings, hospital travel costs)
- Intangible costs: costs of patient/family’s feelings (worry, distress)
Economic evaluation: comparing two different interventions and assessing their costs and outcomes
Opportunity cost: the loss of benefit from the option not chosen; for example, if you decide to spend two hours on a Friday night paying bills, the opportunity cost is that you cannot spend two hours pursuing leisure activities
Outcomes: the expected results from an intervention
Perspective: the different viewpoint from which an intervention can be assessed (patient, provider, payor, or just a population in general)
Target population: the group of patients who will benefit from the intervention
Willingness to pay: the maximum amount an individual, a system, an organization, or a payor will pay for an intervention

George compared the two interventions (Curiosan vs. Monkeydex) in Table 1. George used the new terms he learned.

PAUSE AND PONDER: Why is it necessary for a health system to consider indirect and intangible costs when entertaining the possibility of adding a medication to the formulary?

Table 1. George’s Use of Pharmacoeconomic Terms to Compare Two Interventions

Term	Intervention Comparison
Economic Evaluation	George will compare Curiosan vs. Monkeydex with the terms provided below
Target Population	Curiosan: Treatment of AICO Monkeydex: Treatment of AICO
Comparators	Curiosan and Monkeydex
Opportunity Cost	The hospital won’t be able to benefit from the drug not chosen
Outcomes	Curiosan Pivotal Trial - Participants: 400 Patients aged 18-40 with AICO - Endpoints: reduction of AICO events per year - Results: patients experienced a 55% reduction in AICO events over a year - Adverse Effects: 15% of patients reported minor adverse effects from the drug such as nausea, infusion site pain, and light headedness Monkeydex Pivotal Trial - Participants: 650 Patients aged 25-45 with AICO - Endpoints: reduction of AICO events per year - Results: patients experienced a 45% reduction in AICO events over a year - Adverse Effects: 20% of patients reported minor adverse effects such as headaches, constipation, and mild weight gain
Willingness to Pay	The hospital is willing to pay up to $4500 for either medication
Perspective	Each intervention will be assessed from the hospital’s viewpoint
Direct Costs	Curiosan (TOTAL - $3900) - Administration - infusion once a month for six months ($400/month) plus each infusion costs $100 in medical service fees - Monitoring - monthly blood tests ($100) - Adverse Effect Treatment - requires OTC products ($50/month) Monkeydex (TOTAL - $4200) - Administration - oral tablet taken once daily for twelve months ($300/month) - Monitoring - monthly blood tests ($25) - Adverse Effect Treatment - requires OTC products ($25/month)
Indirect Costs	Curiosan - Patients may lose productivity time due to travel to the infusion center and medication administration times (~2-3 hour/day) - Transportation costs for gas (~$10 each visit) Monkeydex - Patients may lose productivity time due to adverse effects of drug interrupting the day (~1 hour/day) - Hospital offers free mail deliver for Monkeydex
Intangible Costs	Curiosan - Patients may feel stressed about injections and possible adverse effects - Monthly infusions can take a toll on a patient’s life and having to take off work for monthly injections can be stressful - After six months the patient will be cured Monkeydex - Patients may feel calmer when taking a tablet - Patient receives the medication monthly and does not need to make any appointments - Patient needs to be on the medication for one year and they will be cured
ABBREVIATIONS: AICO = Adventure-Induced Curiosity Overload

ADVANTAGE OF PHARMACOECONOMIC TOOLS FOR FORMULARY DECISIONS

George learned a ton of new pharmacoeconomic terms and understands how they will be useful for his presentation on Curiosan and Monkeydex. George’s curiosity about formularies and the advantages of pharmacoeconomic information prompted him to look for additional material.

What is a formulary?

A drug formulary is a continuously updated list of safe and effective medications approved by a healthcare institution or insurer. The P&T committee is responsible for adding, keeping, or removing medications from the formulary. Although the P&T committee deals heavily with issues related to medications, it has representation from many departments: administrative people, nurses, pharmacists, physicians, and others. The broad membership reflects the fact that medication use is a transdisciplinary function. The P&T committee meets regularly to discuss new FDA drug approvals, revised and updated guidelines, firsthand patient drug experiences, institution policy, and new clinical trials.⁷(See the SIDEBAR.)

SIDEBAR: P&T Committee Duties⁸

Manage the formulary including any changes and the addition of new drugs
- Evaluate any candidate for the formulary using current evidence and clinical studies to either support or refute a drug’s addition
- Conduct periodic drug use evaluation for all classes of medication
Consider patient safety in all decision processes
Ensure the electronic health record (EHR) integrates strategies to support drug selection
- Specifically, the EHR should help with dosing and monitoring of patients to prevent errors
Develop strategies during drug shortages. The P&T committee finds bioequivalent drugs and decides how to ration the available drugs
Implement medication use policies. Medication use policies guide the use of a medication through prescriber education, pharmacist communication, or team rounds/meetings
Understand the reimbursement process for health systems concerning which insurances will pay for medications

Most formularies are based on a tiered system. A medication’s tier in the formulary reflects the plan’s coverage. Generic medications usually have a preferred tier and lower out of pocket costs, while brand name medications would be placed on a higher tier unless the PBM, healthcare system, or payer has negotiated a better price for a specific product (discussed below). Two types of formularies exist⁷:

Open Formulary – the plan provides coverage for all medications, even if they are not on the formulary. Certain medication classes, such as over-the-counter medications, are not covered.
Closed Formulary – the plan covers only medications that are on the formulary. Non-formulary medications may be covered when a healthcare practitioner deems it necessary, but the prescriber may need to submit a nonformulary drug request or paperwork for prior authorization. Typically, hospitals operate with a closed formulary.

Decision Analysis in Formulary Management

Pharmacoeconomics employs decision analysis to pool data related to medication to determine if one medication is more cost effective than a comparator. It’s easy to determine if a drug costs less than another based sheerly on acquisition price. But it can be a challenge to determine if a more or less expensive drug is a better, more effective choice.⁹ It is important to note that a drug’s effectiveness refers to how it performs in the real world. A drug’s effectiveness differs from its efficacy, which reflects how well a drug performs in clinical trials. Once the trials are over, drugs rarely perform as well in the real world where people who take the drug don’t receive that same support and may have characteristics that study participants did not have.¹⁰ Pharmacoeconomic researchers take into account a multitude of factors including cost, outcomes, and adverse events when analyzing two comparators.⁹

Many people, like the professor quoted at the start of this CE, wonder if pharmacoeconomics is useful. To highlight the effectiveness of decision analysis in the pharmacy profession, the University of Cincinnati James L. Winkle School of Pharmacy added a collaborative decision analysis project to its curriculum.¹¹ Its purpose was for students to evaluate a drug based on multiple factors, not just cost. Students used a decision analysis model in Microsoft Excel to compare two antibiotics, using the model to recommend the better option. Professors released a student survey at the end of the project. The survey found that more than 90% of students felt the project was useful and said it widened their thinking skills about what a drug’s cost involves. Sticker price is not the only consideration.¹¹

While decision analysis incorporates a medication’s cost and clinical outcomes, some organizations take a different approach, eschewing pharmacoeconomics entirely. The United States Preventive Services Task Force (USPSTF) makes education-based medication recommendations.¹² It does not consider a medication’s cost at all when it makes a recommendation for its use. The USPSTF made this decision to focus solely on a medication’s clinical effectiveness because it does not want to limit a patient’s healthcare options based on cost.¹²

Overall, pharmacoeconomic analysis offers tools for formulary management including enhanced decision making, cost savings, and overcoming barriers. Using pharmacoeconomic analyses in formulary decision-making evaluates changes comprehensively and helps select the best intervention.⁹ Additionally, decision makers can select a more informed approach to keep a drug on a formulary by analyzing a drug’s effects in addition to its cost. Last, by using pharmacoeconomic tools more often, it can become more mainstream in formulary decision making.⁹

PAUSE AND PONDER: What drugs or drug classes used in your pharmacy would benefit from pharmacoeconomic analysis?

Common Types of Pharmacoeconomic Analyses

George learned a considerable amount of new information about decision analysis. He sees his error in only considering these medications’ acquisition prices in the past. George was curious about the methods pharmacoeconomic professionals use in their studies to report a medication’s overall effectiveness. He decided to look at the types of analyses.

The four types of analysis in pharmacoeconomic studies are cost benefit analysis (CBA), cost effectiveness analysis (CEA), cost minimization analysis (CMA), and cost utility analysis (CUA). Table 2 provides more information about each type of analysis.⁶

Table 2. Overview of Different Analyses⁶

	CBA	CEA	CMA	CUA
Purpose	-Calculates the cost benefit of an intervention -Both the intervention and its benefits are converted to monetary values	Measures the health benefit in natural units (ex. ulcers healed) and monetary units	-Focuses only on costs to a health service -Used when two interventions have an identical benefit	-Interventions compared based on their impact on a patient’s life -Measured in QALYs
Advantages	Helps to compare the costs of different interventions in completely different therapeutic areas	Compares two or more different drugs with similar outcomes, but different success rates	Great tool to use when comparing a generic drug with its brand name counterpart	Outcomes do not need to be measured on a monetary scale
Disadvantages	May ignore benefits that cannot be measured by money value (ex. anxiety relief)	Cannot compare drugs that treat different conditions	Both interventions need to have identical benefits, besides cost	Measurements in QALYs may differ in different disease states
ABBREVIATIONS: CBA = cost benefit analysis; CEA = cost effectiveness analysis; CMA = cost minimization analysis; CUA = cost utility analysis; QALYs = Quality Adjusted Life Years

George acquired a great basic knowledge of the analyses. He was curious to learn more about some new concepts he found in his research. Specifically, he wanted to know more about calculating outcomes costs for interventions, incremental cost-effectiveness ratio calculations, and how to determine quality-adjusted life years (QALYs). As a basis to understand the different analyses, it’s critical to look at QALY first.

Health economists calculate quantity of and quality of years, which are combined into QALYs.¹³ To calculate a QALY, begin with the utility score, which is scaled from 0 to 1. A chronic condition may have a utility score of 0.6. The Health Utilities Index Mark 3 (HUI3) is used to measure utility scores. The HUI3 asks a serious of questions about eight attributes (e.g., ambulation, cognition, dexterity, emotion, hearing, pain, speech, vision) and combines them into a score that ranges from 0 to 1. The numeral 1 means perfect health and 0 represents death.¹⁴ To calculate QALY, the utility score is multiplied by the time spent in each state, which translates into the number of years of life the typical patient gains on a treatment. For example, consider patients with a chronic condition (utility score of 0.6) receiving a treatment that will add seven years to their life. To calculate the QALY, multiply 0.6 x 7, which equals 4.2 QALYs gained.¹⁵

While QALYs can effectively determine how many life years are gained in many situations, they have some downsides.¹⁶ QALYs are blind to health conditions and personal characteristics such as age, disease severity, residence location, and sex. Additionally, the QALY does not encompass all aspects of an intervention’s benefit. For example, if a single mother takes a medication that rapidly improves her health, it can also improve the health of her kids and allow her to return to work quicker.¹⁶

Cost Benefit Analysis. The main purpose is to compare interventions with different outcomes. Typically, a CBA involves adding all the costs of an intervention and subtracting that figure from the expected benefits of the intervention. A CBA helps an organization to see an intervention’s return on investment. When doing a CBA, it’s important to identify an intervention’s direct, indirect, and intangible costs to compare against the intervention’s benefits.¹⁷ George found this explanation straightforward but had to ask Ted how he would estimate the expected benefits. To calculate the expected benefits, Ted told George to list the indirect and intangible benefits of the interventions and make educated guesses about monetary values for each, looking first to see if any studies have assigned or estimated costs. George can then subtract the intervention’s costs from these expected benefits to equal the net benefits.¹⁸

Cost Effectiveness Analysis compares the cost and outcomes for two or more interventions for the same condition. A CEA is centered around the incremental cost-effectiveness ratio (ICER). This explanation had George scratching his head, and he had to review it several times to really understand it. The ICER is the ratio of cost differences to outcomes differences between interventions.¹⁹ The ICER is useful because it shows the added cost per unit of health outcome gained from a new intervention.¹⁹The ICER is calculated using the equation ICER = costs₁ minus costs₂ divided by effect₁ minus effect₂. For example, intervention 1 costs $200 with an 8 QALY benefit and intervention 2 costs $100 with a 4 QALY benefit. Plug these numbers into the equation and the ICER = 25. This means $25 per QALY for intervention 1 over intervention 2.²⁰

Cost Minimization Analysis considers only half of an economic evaluation because it does not consider the outcomes of interventions. It simply looks at cost. For a CMA to be considered a full evaluation, health economists would need to consider the outcomes of interventions, such as how many life years are saved. If the interventions’ outcomes are equal, then the CMA can be useful.²¹

Cost utility analysis helps compare costs and benefits from different interventions. CUA takes into account benefits in terms of how many years are saved and quality of life.¹³ CUA is helpful to quantify how much an intervention can extend and improve someone’s life. QALYs are used in a CUA to display quality and quantity of years saved for a patient’s life. The best time to use a CUA is when someone wants to determine the cost-effectiveness of a product that is a high cost for the payer. A CUA study plans to show where resources should be allocated for maximum health benefit.¹³

George decided to put together his own CEA after learning more about the pharmacoeconomic analyses. He chose this approach since he was able to acquire the most information about how to properly perform a CEA. Table 3 shows George’s CEA for Curiosan compared with Monkeydex.

Table 3. CEA for Curiosan and Monkeydex

	Curiosan	Monkeydex
Total Cost (Both direct and indirect/intangible)	$3900 (direct costs) + $200 (indirect/intangible costs)	$4200 (direct costs) + $100 (indirect/intangible costs)
Effect (Reduction in Curiosity Overload Events per Year)	3 events prevented	5 events prevented
ICER	($4100 - $4300) / (3 - 5)
Outcome of ICER	$100 from each episode prevented by using Curiosan over Monkeydex
ABBREVIATIONS: ICER = Incremental Cost-Effectiveness Ratio

George analyzed both costs and outcomes from the two interventions. He concluded $100 from each adventure-induced curiosity overload episode was saved by using Curiosan over Monkeydex. The CEA shows Curiosan’s effectiveness over Monkeydex when considering costs and outcomes. Let’s re-examine the pharmacy professor’s quote in which he said, “Most pharmacoeconomic studies are ignored in clinical practice because practitioners don’t understand them or use other reasons to select a drug to use.” What factors is he referring to? One other factor might be patient volume. This hospital generally sees about five AICO patients per day and they are treated in the emergency department. The P&T Committee knows that Man with the Yellow Hat Hospital has an emergency department with 20 available beds that can usually accommodate all these patients. If the emergency room experiences overflow, hospital management has designated the adjacent hallway to hold up to five excess patients. If the hospital only had a total of five beds available, however, or it was having difficulty staffing the ED, the P&T committee’s deliberations might be different.

PHARMACOECONOMIC TOOLS IN PHARMACY BENEFIT MANAGEMENT

George checked the major dailies—the most reliable newspapers across the country that fact-check before they publish—to see if any recent articles talked about the impact of pharmacoeconomics while doing his research. George checked these publications because he wanted to identify any recent major developments in the healthcare industry. He found multiple feature articles and opinion pieces on the function of PBMs. George read that PBMs contribute to formulary decision making for payors or employers and use different pharmacoeconomic tools to support their choices. George wanted to find out more about the PBM’s role and how they contribute to the formulary, so he delved into the topic again.

PBM History

PBMs surfaced in the 1950s due to a demand for special management of drug benefits.²² Pharmacists started the first PBMs, founding Prescription Services, Inc in Canada in 1958 and PAID Prescriptions in the United States (U.S.) in 1965. Through the years, health systems and payors began to collaborate with PBMs more often and they grew in size and scope. Now, PBMs handle a wide variety of tasks including formulary maintenance, pharmacy networks, mail order pharmacy operations, and contracts with wholesalers and manufacturers. A PBM’s most important service is maintaining a drug formulary. Most PBMs will handle multiple formularies for different clients. PBMs cover certain drugs on a formulary and some drugs require patients to pay a portion of the costs.²²

George learned from his reading of current events that the Federal Trade Commission (FTC) is looking into PBMs and considering preventing them from combining.²²The FTC often refers to PBMs as the prescription drug middleman industry and has launched inquiries into their operations and practices.²³ It theorizes that if PBMs continue to combine and integrate, they could possibly have unprecedented control over drug prices, blocking competition. Their concern of market concentration is based on the oligopoly theory which states that if five firms in an industry account for more than 60% of the market, competition is stifled. The FTC alleges that the three largest PBMs processed almost 80% of prescriptions dispensed by U.S. pharmacies in 2023, and the top six processed more than 90%. Describing PBM operations as opaque, the FTC reported in July 2024 that despite their efforts to obtain records from six PBMs, several have refused to comply. A significant concern is that the current PBM structure may disadvantage small pharmacies that are not in the PBM network and the patients they serve.^23,24 The FTC’s efforts are focused on promoting fair competition and protecting consumers from high medication prices.²⁵

PAUSE AND PONDER: What are some cost control tools used lower drug costs in your pharmacy?

PBM Cost Control Tools

PBMs use an assortment of cost control tools to control costs^26,27,28:

Negotiated prices. PBMs work on securing a specific price for drugs. PBMs that purchase drugs at a high volume can negotiate discounted prices. The price paid by the PBM is often much lower than other plans’ prices, such as Medicaid. PBMs will apply this discount to the pharmacies in its network, guaranteeing access for pharmacies that contract exclusively with the PBM.
Generic substitution. Here, the goal is to increase the use of generic medication whenever possible. Generally, generic drugs cost 80% to 85% less than their brand name equivalents. Pharmacists may receive an incentive for dispensing a higher number of generics.
Rebates. A rebate is money returned by the seller to the drug purchaser under certain conditions. The seller gives rebates to incentivize higher volume purchases and to stay competitive without directly lowering costs. The PBM often negotiates a rebate and reaches an agreement with the drug manufacturers. A rebate program may stimulate the PBM to increase its use of rebated drugs; on the flip side, rebates may cause the PBM to place high-priced drugs in better tiers than drugs that are more cost-effective, which creates higher out-of-pocket costs for some patients.
Copayments. A copayment is a fixed amount that patients, insureds, or beneficiaries pay for their prescriptions. PBMs use copayments as a cost-sharing mechanism to reduce the insurer’s or employer’s overall medication costs. PBMs adjust copayments depending on the plan they are managing. Generic medications generally have lower copayments, but brand and some generic medications may require a higher copayment.

Do PBMs Create Value in Healthcare?

PBMs have had many significant impacts on the drug distribution system. At their inception, they created systems to replace the manual claims filing process that was dependent on paper with electronic systems that communicated among stakeholders quickly. Today’s systems operate in real-time, which is advantageous to all stakeholders.²⁹

Controversy surrounds PBMs (See the SIDEBAR). PBMs add value to their stakeholders (e.g., insurers, health systems, payors), but it is uncertain whether PBMs contribute significant value to the U.S. healthcare system. PBMs have proprietary contracts that prevent open discussion of the terms they negotiate and tools they use. Some experts allege that PBMs engage in “spread pricing,” meaning they charge health plans and employers more for generic drugs than what they reimburse pharmacies for these drugs, keeping the difference. Again, a lack of transparency allows this to happen: PBMs’ operations are proprietary and confidential. They often lack transparency and it’s possible to conclude they may take value from healthcare. Some evidence exists indicating that agreements with manufacturers agreements require PBMs to exclude generic drugs and biosimilars from their formularies in exchange for higher rebates.^24,27,30

SIDEBAR: Have PBMs Abused the Drug Rebate System?

The 3 major PBMs—Caremark Rx, Express Scripts (ESI), and OptumRX—are currently in the FTC’s crosshairs for allegedly artificially inflating insulin drug prices. The FTC has filed an administrative complaint citing that 3 PBMs have developed and abused a drug rebate system that prioritizes high rebates from drug manufacturers, forcing consumers to spend more on life-saving medication.²⁵

The crux of the issue centers on PBMs ability to establish discounts on the manufacturer’s initial sticker price of brand name drugs. Drug companies will agree to these discounts in exchange for preference and availability on the PBM’s formularies. As the discounts grew larger over time, pharmaceutical companies were forced to raise their initial sticker prices to maintain profits. Therefore, while PBMs have cut prices in half for their clients, patients have suffered because the price at point of service often reflects the initial sticker price.³¹Even if less expensive insulins become available, PBMs are able to design their formularies strategically to exclude those options in favor of equivalent high list price, highly rebated products.³²

The PBMs’ “chase-the-rebate” strategy has shifted the burden of high insulin prices directly to patients.²⁵Take, for example, one insulin product that was listed at $122.59 in 2012. Also in 2012, PBMs introduced exclusionary drug formularies, a tactic weaponized to demand higher rebates in exchange for a desirable spot on the formulary. By 2018, the list price of that specific insulin more than doubled to $289.36. Patients with deductibles or coinsurance do not benefit from rebates at the pharmacy counter. These out-of-pocket expenses for insulin drugs are sometimes even higher than total cost of the drug to the commercial payor.²⁵

All three PBMs have pushed back on the allegations from the FTC, claiming the lawsuit “demonstrates a profound misunderstanding of how drug pricing works.”³² The FTC has also acknowledged that PBMs likely did not act alone, and actions against drug manufacturers may be on the horizon.Over the last year, Eli Lily, Novo Nordisk, and Sanofi all promised significant cuts to the list price of their insulins due to public and political pressure. The recently passed Inflation Reduction Act also has chipped away at insulin prices by establishing a $35 per month cap for Medicare Part D patients.³²

Implications for Pharmacy Teams

Pharmacoeconomics is helpful for pharmacy teams because in a healthcare setting pharmacists need to be able to determine if a drug’s value can be justified by its cost. George learned that a good way to think about cost and value is this: “Value is the results you get divided by the cost. Value is what works, not how cheap it is.”³³ Pharmacy employees, especially those who work in procurement or with the P&T Committee, should understand how to differentiate between the four types of pharmacoeconomic analyses. The different analyses help engage in informed decision making between two or more interventions. Pharmacoeconomics can guide clinical and policy decision making. Today, pharmacists in community and hospital settings provide a wide variety of services including vaccinations and medication use counseling. A health economist might perform a pharmacoeconomic analysis to determine if a pharmacist’s services are adding value to the healthcare system. Additionally, a payment model needs to be established to ensure pharmacists are compensated for their non-dispensing work.³⁴

Red Flags in Pharmacoeconomic Studies

Pharmacy staff must recognize that pharmacoeconomic studies, like all studies, can be flawed. Certain red flags decrease a study’s validity. Below are some common questions to ask after reading a pharmacoeconomic study. These questions help identify the study’s limitations³⁵:

Does the title accurately represent the study’s goals?
Did the researchers clearly state the study’s objective?
Did the researchers use a large enough data sample? Remember that larger sample sizes lead to more reliable results.
If the researchers compared interventions, did they use appropriate comparators?
- If the researchers were reporting on a new treatment, did they compare it to the current standard of care or the most popular marketed options? Or did the authors compare the treatment to a less popular, less effective, or older (and retired) alternative?
Did the researchers provide a description of the competing alternatives’ use in clinical practice?
Did the researchers identify which perspective they employed to measure the costs?
Did the researchers indicate the study structure (retrospective, prospective, etc.)?
Were all the costs of the interventions included?
Did the researchers include all important clinical outcomes from various studies?
Were the study’s conclusions appropriate for the study? Or did the conclusions go beyond the scope of the target population?
Is it possible to extrapolate the findings to your population, or are the populations too different?
Did the researchers present the conclusions in an unbiased manner?

CONCLUSION

George was able to learn so much about pharmacoeconomics. He feels confident about the different pharmacoeconomics terms used for economic evaluations. George also recalls the advantages of pharmacoeconomic analysis and can compare the different types of analyses. Last, he better understands the PBM’s role and the tools a PBM uses to lower drug costs.

Are You Curious about Pharmacoeconomics?

Pharmacist Post-test

After completing this continuing education activity, pharmacists and pharmacy technicians will be able to
• Define common pharmacoeconomic terms used for economic evaluations.
• Recall the advantages of pharmacoeconomic analysis for formulary management.
• Compare and contrast different types of pharmacoeconomic analyses.
• List the pharmacoeconomic tools a pharmacy benefit manager uses to lower drug costs.

1. The P&T Committee at Queens Hospital is considering the addition of Fixitall, a new bi-weekly intravenous infusion drug for the treatment of rheumatoid arthritis, to the hospital formulary. Which of the following describe the direct costs of the proposed intervention?

A. Monthly administration, monitoring, and adverse effect OTC treatment costs.
B. Transportation costs to and from the hospital for each treatment.
C. Loss of wages from missing work during bi-weekly infusion center visits.

2. Which of the following best describes an opportunity cost?
A. The amount of money saved by acquiring drug A instead of drug B.
B. The loss of benefit of drug A if drug B is the preferred choice.
C. The negotiation of a rebate for either drug A or drug B.

3. Which of the following defines the pharmacoeconomic term “willingness to pay”?

A. The amount a drug manufacturer will rebate a PBM to indirectly lower drug costs.
B. The calculated ratio of cost differences to outcomes differences between interventions.
C. The maximum amount an individual, system, organization, or payer will pay for an intervention.

4. Which of the following is an advantage of using pharmacoeconomic analysis to inform formulary decisions?

A. Pharmacoeconomic analysis focuses solely on the medication’s cost in an effort to save payers the most money.
B. Pharmacoeconomic analysis considers drug efficacy rather than drug effectiveness to accurately predict real world implications.
C. Pharmacoeconomic analysis considers cost, outcomes, and adverse events when analyzing two or more comparators.

5. Which of the following describes an advantage associated with a cost benefit analysis?

A. Does not require the intervention and its benefits to be converted to monetary values.
B. Compares the cost of different interventions in completely different therapeutic areas.
C. Analyzes the difference in cost of a generic drug compared to its brand name equivalent.

6. Which of the following pharmacoeconomic analyses is measured in QALYs?

A. Cost benefit analysis
B. Cost minimization analysis
C. Cost utility analysis

7. Which of the following strategies do pharmacy benefit managers implement to lower drug costs?

A. Negotiating rebates with drug manufacturers that incentivize higher volume purchases.
B. Limiting the substitution of generic medications due to the lack of incentive provided.
C. Discouraging the use of copayments due to their tendency to increase overall medication costs.

8. Which of the following is an example of an intangible cost?

A. Transportation costs for gas to and from the infusion center.
B. Copayment costs that occur with every infusion treatment.
C. Cost of patient/family’s anxiety over recurrent injections and adverse effects.

9. You are conducting a cost effectiveness analysis of two new ulcerative colitis drugs. Drug A costs $400 with a 6 QALY benefit and Drug B costs $200 with a 4 QALY benefit. Which of the following is the correctly calculated incremental cost-effectiveness ratio (ICER)?

A. $20 per QALY for Drug A over Drug B.
B. $100 per QALY for Drug A over Drug B.
C. $60 per QALY for Drug A over Drug B.

10. Which of the following describes a disadvantage of a cost minimization analysis?

A. Compared interventions must have identical benefits other than cost.
B. Calculated measurements in QALYs may differ in different disease states.
C. Cannot compare a generic drug with its brand name counterpart.

Are You Curious about Pharmacoeconomics?

Pharmacy Technician Post-test