Stephen Ingram, DPh, BCPP
Clinical Pharmacist
Overmountain Recovery
Gray, TN

One of the best things about working in the field of pharmacy is the large number of available opportunities – so many specialties, and every practice site is unique. The common goal throughout is to provide safe and effective medication use to our patients. As we approach our goal, we soon come to realize that we can’t do it alone, and in many cases must work through others. Some of the obvious “others” (depending on the setting) may be nurses, patients’ family members, and other healthcare providers. We are accustomed to working with physicians and advanced practice providers in a collegial manner, but have we considered ourselves as mentors to them? Under the right circumstances, perhaps we should.

While working at Woodridge Psychiatric Hospital, a 180 bed inpatient psychiatric facility located in Johnson City, TN, some of the psychiatric residents and the Residency Director came to recognize that a Board Certified Psychiatric Pharmacist might be able to add value to their own educational program – specifically regarding medication use. At the time, I was precepting senior pharmacy students but had not considered mentoring physicians. After a few discussions and a very easy application process, I became an unpaid faculty member at the Quillen College of Medicine in Johnson City, TN, and was soon offering elective psychopharmacology rotations for their senior psychiatry residents. The rotations were set up as either 5 days per week for 4 or 5 weeks (very much like pharmacy rotations) or 1 day per week for multiple months.

Physician training is different than pharmacy training

It was interesting to interact with the residents because their training was structured quite a bit differently than that for pharmacists. To me it felt like they learned pharmacology primarily by encountering the medications in practice, picking up knowledge as they went along. In medical school, they had had classes in pharmacology, then in the didactic part of their residency, they encountered focused psychopharmacology lectures. Although it felt a little backwards to me, I soon learned that it worked well for them. While they were usually familiar with medications’ side effects, they were often less familiar with mechanisms of action. Based on this insight, I was able to tailor their experience to the specific needs.

Just as pharmacy students choose electives for their own reasons, the physicians did the same.  However, most were acutely aware that they needed to know more about the medications they were prescribing. They had a general idea of the textbook medication regimens, but wanted to know additional details and how to treat patients that were more complicated. To help them along the way, we discussed mechanisms of action, drug/drug interactions, and the reasons why medications worked (or not) as they did. Some examples of the more intriguing psychopharmacology questions are:

  •  “If clozapine is anticholinergic (it is very much so), then why do patients develop sialorrhea?”
  • “If a patient on mirtazapine develops hypertension, why might clonidine potentially be an ineffective treatment?”
  • “Why do some medications (doxepin, mirtazapine) cause more sedation at lower doses than at higher doses?”

To pharmacists, these are delightful questions, but to some of the psychiatry residents they were initially puzzling concepts.

Educational activities

When we had patient medication education groups scheduled on the inpatient units, I encouraged the residents to lead the discussion – or at least actively participate. It came as a surprise at first that they were generally uncomfortable leading a discussion about medications unless there was an outline to follow. From my perspective, it seemed they were often afraid of being asked a question for which they did not have a ready and complete answer.

As part of their rotation, I asked each resident to prepare a 5-page paper on a psychopharmacology topic of their choice. Usually they discussed the topic with me prior to starting their research though that was not always the case. The significant majority of residents chose a topic in which they felt lacking or in which they had a special interest and wanted to know more. One notable example was a resident who, noticing that clozapine was used very little in our area, decided to research that medication, while another chose to look at lithium for the same reason.  As we discussed their research and conclusions, I was able to pick up additional knowledge alongside them.

A positive experience

I benefited significantly by learning from the physicians’ diagnostic and psychotherapeutic skills which made me a better psychiatric pharmacist. Since their view of a patient was very different from mine, I believe that combining the 2 perspectives resulted in better care for our patients. I believe it benefited patients who were admitted during the rotation and it will likely benefit many patients in the future when their physicians apply principles learned in a pharmacist-led rotation. We also strengthened – even if slightly – the working relationships between pharmacists and physicians that is an essential element in optimal patient care.

For any pharmacist who gets (or makes!) an opportunity to work with physician residents in a preceptor role, I encourage them to do it. Doing so can be challenging, rewarding, and a great learning experience for everyone involved.