Abstract
Pharmaceutical Care Practice: The Clinician’s Guide is a textbook, a handbook, and a guide to clinical pharmacy practice to those who may be interested in a potential career or in starting a practice. The three authors of this text are best qualified to explain the subject matter based on their conceptualization of many of this field’s ideas more than 25 years ago in addition to their most recent hands-on research. The pharmaceutical care practice is an exciting field that is developing to meet the need for a clinical professional who can bridge the gap among the clinical services currently being provided to patients. This specialty does not aim to replace the dispensing pharmacist, the physician, or the nurse. In addition, this book is a great overview for all clinical specialists (e.g., physicians, pharmacists, and nurses) to enhance their understanding of this specialty niche and help them collaborate to improve their services to patients.
This is a step-by-step guide to understanding the concepts and skills needed by practitioners to deliver the best care through a comprehensive therapeutic relationship with their patients. The practitioner considers patient-related therapy aspects that are not addressed well enough by any colleague who cares for the patient. For instance, two main questions that are part of the pharmaceutical clinical practitioner’s arsenal: “Is the patient’s problem caused by drug therapy? Can a patient’s problem be treated with drug therapy?”
This second edition appears about 6 years after the first edition (1998); however, this delay is for good reasons. For instance, Chapter 2, one of the pivotal chapters, explains the “size of the problem” that this specialty aims to solve based upon information collected from a comprehensive database from 1997 through 2002. In addition, a number of new concepts are presented, including the patient’s medication experience, the pharmacotherapy workup, standards of care, ethical considerations, and the importance of documentation. There is also discussion of some considerations in establishing a new practice with an overview of reimbursement. All of these aspects are essential to this new specialty.
Among the book’s assets are its format, clarity, and simple language. Each chapter begins with a minitable of contents, followed by a list of key concepts, and ends with a summary and practice questions. The book length is “just right” for its targeted audience. The general format, illustrations, and language provide a clear picture of the discipline. The text is well-edited and the book is easy to read with straightforward explanations of all basic concepts.
The text is divided into 14 chapters, with two appendices (standard of practice and a glossary).
The first chapter provides an introduction, history, and definitions and concludes with a good preview of the whole book. The authors define the discipline from the theoretical, linguistic (new terms and vocabulary), philosophical, and ethical points of view.
In Chapter 2, the authors support the need for this new discipline with the experience of 20,000+ patients, with >60,000 encounters collected through a specific software program from 1997 to 2002. Table 2.8 is particularly useful, though additional information on dietary supplements would have been helpful. This is a well-placed chapter, and is well-supported by illustrations and tables, and an explanation of the economic burden of the problem, purported to be $177 billion/year. It describes the “most common” (a concept that will be reiterated many times as the most pivotal for all clinicians) regarding therapy. A panel of clinical experts agreed that decisions made by pharmaceutical care practitioners collected in this database were accurate more than 90% of the time. The impact of adverse drug reactions (ADRs) shows that 71% were not dose related, out of this percentage 14% were discovered during the first encounter with the pharmaceutical clinical practitioner. Another statistic in Chapter 6 ($3.3 billion worth of prescriptions dispensed in the United States in 2002, with a rate of 44,000-hospitalizations/year due to medication error) drives the point home.
Chapters 3 and 4 stress the fundamental value of developing the practitioner-patient relationship, and grasping in-depth the needs of the patient based on his/her overall experience, rather than the practitioner’s preference as the driver for the practice of the pharmaceutical clinical practitioner. These two chapters provide a road map for the focused practitioner-patient relationship, which was termed a “therapeutic relationship.” It provides an explanation of the new practitioner/student, and his/her responsibilities toward the patient, the patient’s expectations, professional standards, and how to measure success in serving the patients needs. It also stresses patient rights.
Chapter 5 is a pivotal chapter that discusses in great detail how to clarify the patient’s encounters with medications. This chapter includes a comprehensive description of all encounters of the patient with medicine, in addition to many of the specific details regarding his/her perceptions, cultural background, preferences, and expectations regarding diet, dietary supplements, drugs of abuse, etc. This results in the coining of the phrase “patient’s medication experience,” which is clearly not being addressed by any other clinical caregiver. The “pharmaceutical clinical practitioner must understand their patient medication experience similar to the physician’s understanding of the disease as a description of illness.” In this chapter, there are many helpful examples that clarify aspects of the patient medication experience, and there is a clear emphasis on the patient’s needs, wants, and concerns regarding his/her medications. The authors argue that the prioritization of addressing a drug therapy problem should depend on the patient’s perceptions, and not on consultation/ advice from the pharmaceutical clinical practitioner. It would have been timely to discuss how evaluation, follow-up, and an explanation of the means for establishing requests for further follow-up laboratory testing for follow-ups and to explain how a practitioner can distinguish between the laboratory failure as a cause of therapeutic failure or as an aggravation of the disease condition. This was a place to emphasize the need for collaborative efforts with other team members and to describe some limitations that a practitioner in this field might face. The topic of limitations, hurdles, and stereotypes was not addressed.
Chapters 6 through 9 uses a step-by-step approach, with many examples to show how the new practitioner would conduct the first encounter with the patient, provide assessment of the medication experience and establish the pharmacotherapy workup. For instance, Table 6-6 is a detailed checklist and a clear tool that can benefit and educate newcomers regarding the value of demographics. The pharmacotherapy workup is a unique concept, and well characterized at this stage, and the pharamcotherapy workup form on pp. 164–168 is a must-have form, which also explains the role of the practitioner. The pharmacotherapy workup is the analytical process that is used by the pharmaceutical care practitioner to make drug therapy decisions. The pharmacist should practice that role. However, a new curriculum should focus on this specialty and should develop new vocabulary (e.g., drug therapy problem), in addition to the common medical terms (assessment, care plan, follow-up evolution). The details of the time requirement for this specialty were not clearly explained, even though some of the expected training, texts, and skills were detailed in Chapters 11 and 12, and there was mention of the pharmacist (with 6 years of course work) as a candidate for such a specialty. On p. 228, a follow-up step is listed as standard care 7, which provides for a unique patient care concept that will result in better outcomes and evaluation, and will benefit the patient in the future and benefit other patients as a result of good documentation practice. More information regarding HIPPA (The Health Insurance Portability and Accountability Act of 1996) would have been appropriate in this section or in Chapter 10.
Chapter 10 touched on ethical principles and provided generic examples, which could be useful for any clinician. More emphasis on the need involving the entire patient’s care providers in reaching decisions with the patient and his/her pharmaceutical care practitioner would have been appropriate.
There was some repetition of facts and tables in some chapters, but this kept the text flowing seamlessly, and connected facts more than once for the reader, which is a useful technique to remind those who are approaching each topic for the first time. It would have been helpful to have more emphasis on adverse events reporting and the specific Food and Drug Administration (FDA) and (ICH)-related regulations that are pivotal to any clinical or pharmaceutical practice.
Chapters 11 through 13 explain important basic concepts regarding acquiring knowledge about the patient, disease and therapy. The authors describe the development of clinical skills including observation, eliciting information, communication, case follow up, clinical case presentation, and proper documentation. Details regarding a pharmaceutical care practitioner physical assessment skills were not clearly explained. It would have been helpful to discuss how a practitioner decides when to defer to the judgment of other colleagues on the clinical team and when to seek consultation/advice.
In Chapter 14, which goes in a different direction from the other 13 chapters, the topic of reimbursement is hastily summarized in relationship to establishing a new business. This chapter is a good introduction to the topic and needed to provide the level of detailed information provided throughout the rest of the book. The summary of the main concepts regarding establishing a business, including some marketing aspects, was insufficient and in part unnecessary.
In summary, this is a well-edited, well-organized guide written by distinguished experts and is supported by solid research. This book explains the role of a new specialty (pharmaceutical care practice) in improving clinical care by providing a comprehensive and focused approach to the therapeutic experience/ outcome for each patient.