Faculty: Brian L. Erstad, Pharm.D., FCCP, BCPS Professor, College of Pharmacy-Pulido Center, The University of Arizona, Tucson, Arizona

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1 Clinical Career Advancement, Part I Activity No L04-P (Application-Based Activity) Monday, October 17 3:45 p.m. 5:45 p.m. Convention Center: Rooms 310 & 311 Part of the ACCP Academy Career Advancement Certificate Program. For more information, visit the ACCP Web site at Participants in the Certificate Program must attend Part I and Part II to receive Academy credit. Part II of this session will be presented on Tuesday, October 18, 1:15 p.m. 3:15 p.m. Faculty: Brian L. Erstad, Pharm.D., FCCP, BCPS Professor, College of Pharmacy-Pulido Center, The University of Arizona, Tucson, Arizona and Stuart T. Haines, Pharm.D., FCCP, BCPS Professor, University of Maryland School of Pharmacy, Baltimore, Maryland Agenda 3:45 p.m. Introduction 3:55 p.m. Taking a Scholarly Approach to Your Practice 4:25 p.m. Small Group Case Study 5:00 p.m. Debrief/Facilitated Large Group Discussion 5:35 p.m. Next Steps Faculty Conflict of Interest Disclosures Brian L. Erstad: no conflicts to disclose. Stuart T. Haines: no conflicts to disclose. Learning Objectives 1. Define scholarship in its broadest sense; describe the scholarship of discovery, integration, application and engagement. 2. Implement strategies to capitalize on scholarly opportunities within your practice. 3. Network and collaborate with other clinicians in your specialty or subspecialty on scholarly projects. 4. Identify appropriate ways to disseminate your scholarly work. Annual Meeting Clinical Career Advancement, Part I 1

2 Self-Assessment Questions Self-assessment questions are available online at Annual Meeting Clinical Career Advancement, Part I 2

Conflicts of Interest Taking a Scholarly Approach to Practice Brian Erstad has no conflicts to disclose. Stuart Haines has no conflicts to disclose. Brian L. Erstad, Pharm.D., FCCP Stuart T.

3 Conflicts of Interest Taking a Scholarly Approach to Practice Brian Erstad has no conflicts to disclose. Stuart Haines has no conflicts to disclose. Brian L. Erstad, Pharm.D., FCCP Stuart T. Haines, Pharm.D., FCCP Outline A little bit about us, a little bit about you Definitions- research, scholarship Scholarship and practice A scholarly approach to practice Concluding remarks What We Do Responsibilities: the usual triad for a clinical faculty member Teaching Service Scholarly activities Teaching, service, and scholarship are not mutually exclusive if integrated and prioritized (admittedly, not always easy!) I ve been doing this for a long time... Audience Response What is your experience? A. Currently in training (student, resident, fellow) B. Less than 3 years post-training C. 3 to 6 years post-training D. 7 or more years post-training Clinical Career Advancement, Part I 3

Audience Response For those of you that are not trainees, would you describe your position as primarily: A. Faculty B. Clinical C. Staffing (work in centralized pharmacy) D.

4 Audience Response For those of you that are not trainees, would you describe your position as primarily: A. Faculty B. Clinical C. Staffing (work in centralized pharmacy) D. Mixed clinical/staffing Research/Scholarship Audience Response Which of the following is the best example of research? A. Randomized controlled trial B. Pharmacoeconomic evaluation C. Review of literature for use of drug D. Development of new teaching technique E. Anything with HPLC in methods F. Anything involving pharmacogenomics What is Scholarship? Boyer Discovery e.g. Bench, clinical, or translational Integration e.g. ethnography and direct observation studies, comprehensive or systematic review, economic analysis Application e.g. changing hospital practice as a result of research, leadership in professional organization Teaching (and learning) Engagement (with public/community) Audience Response Based on the broader definition of scholarship, does your current position require some degree of scholarship? Yes No Think Scholarship Clinical Career Advancement, Part I 4

Scholarly Approach to Practice and Life Scholarship and Practice Healthy skepticism Scientific method With scholarly approach to practice, goal isn t (necessarily) publication Good science makes for

review Hypothesize therapy most likely to be best choice in terms of maximizing benefits and minimizing adverse effects and cost Control other confounders (as much as feasible) Implement therapy and

5 Scholarly Approach to Practice and Life Scholarship and Practice Healthy skepticism Scientific method With scholarly approach to practice, goal isn t (necessarily) publication Good science makes for good practice and vice versa Scholarship in Practice Every patient is arguably an n of 1 study Disease requiring intervention Consider a variety of options based on clinical experience and literature review Hypothesize therapy most likely to be best choice in terms of maximizing benefits and minimizing adverse effects and cost Control other confounders (as much as feasible) Implement therapy and evaluate response Hypothesis appears to be confirmed, no Δ Hypothesis not confirmed; new hypothesis Unusual Clinical Problems Problems infrequently / rarely encountered in practice requires scholarly approach Literature search find and evaluate evidence from disparate sources (often data is of low quality) Case Report report the outcome of an unusual case Review summarize the evidence in a systematic manner and synthesize recommendations Example: Haines ST, Casto DT. Treatment of infantile spasms. Ann Pharmacother 1994; 28: 779 Case Report Acute Care Case: Community Hospital You are the first pharmacist assigned to a general surgery service (ICU and non-icu) You have one PGY1 resident each month Hospital has CPOE, automated dispensing devices, and smart pumps Order verification takes 30% of your time Your pharmacy director wants you to use the remainder of your time as you see fit However, director wants biggest bang for buck Clinical Career Advancement, Part I 5

6 Acute Care Case: Academic Medical Center You are clinical faculty pharmacists assigned to a mixed med/surg ICU service You have 2 students (4 th years) each month Hospital does not have CPOE, but has automated dispensing devices, smart pumps You have no order entry responsibilities, but You are asked for input on all formulary drugs primarily used in the ICU You are pharmacist member of ICU team responsible for developing order sets/bundles Examples of Scholarly Approach to Practice Scholarship in Practice Scholarship is applicable to practice and vice versa Formulary reviews or restrictions Order sets, bundles, protocols and guidelines Clinical service evaluations Medication use evaluations (MUEs) Quality improvement (QI) projects Unusual clinical problems Reporting and evaluating medication errors and adverse drug events Experiential education Formulary Reviews / Restrictions Albumin Erstad et al. Arch Int Med 1991;151:901; Erstad BL. Technology Report: Serum Albumin (author of monograph). UHC Technology Advancement Center, September 1992; Formulary Reviews / Restrictions Immediate surgery Diagnostic endoscopy- oral PPI Diagnostic endoscopy only (low risk) Diagnostic endoscopy + oral PPI [+] Immediate surgery Endoscopy + Hi dose IV PPI Diagnostic endoscopy only (low risk) Diagnostic/therapeutic endoscopy + Hi dose IV Patient twith PUDbl bleeding [+] [] Immediate surgery Endoscopy + Oral PPI Diagnostic endoscopy only (low risk) Diagnostic/therapeutic endoscopy + Oral PPI [+] Immediate surgery Protocols/Guidelines ICU adult analgesia ICU adult sedation ICU adult delirium ICU adult neuromuscular blockade ICU stress ulcer prophylaxis Endoscopy- No PPI Diagnostic endoscopy only (low risk) Diagnostic/therapeutic endoscopy [+] Erstad et al. Crit Care Med 2004;32:1277 Maloney et al. Am J Health-Syst Pharm 1997;54:1841 Clinical Career Advancement, Part I 6

Clinical Service: Economic Evaluation Student looking for research project New floor-based pharmacists trying to demonstrate value of clinical efforts Studied interventions most likely to have

results Clinical Service: Adherence Monitoring Adherence with medication and life-style recommendations is often problematic Some disease states / medication require meticulous adherence to achieve

7 Clinical Service: Economic Evaluation Student looking for research project New floor-based pharmacists trying to demonstrate value of clinical efforts Studied interventions most likely to have largest impact on patient care based on medicationrelated problem severity and associated cost Cost-benefit analysis performed Resulted in national presentation and publication multiple win-win results Clinical Service: Adherence Monitoring Adherence with medication and life-style recommendations is often problematic Some disease states / medication require meticulous adherence to achieve desired outcomes Scholarly approach to improving adherence Example: Cushenberry L, et al. Impact of a Medication Reminder System on HIV Patients Medication Use Behavior in a Community Pharmacy. J Am Pharm Assoc 2001; 41: 300. Medication Use Evaluations Erstad et al. Crit Care Med 1997;25:1678 Cefazolin Serum Free Co oncentration (mcg/ml) Quality Improvement Time from Dose Administration to Sample Collection (hours) Koopman et al. AJHP 2007;64:1927 Quality Improvement Problem how to qualitatively evaluate the performance of clinical practitioners with advanced scopes of practice Peer evaluation of direct-patient care activities is common practice in medicine Constructing a non-punitive (formative) evaluation system Quality Improvement Protected Practice Evaluation Haines ST et al. Protected Practice Evaluation: A Continuous Quality Improvement Process. AJHP 2010 ; 67: Clinical Career Advancement, Part I 7

Adverse Drug Events Medication Errors and Adverse Drug Events Adult and pediatric ICU medication error and adverse drug event studies Interdisciplinary group of

of pharmacy practice site learning experience Attempt to increase experiential component of curriculum (now known as IPPE) Assumption that more is always better Evaluation of

8 Adverse Drug Events Medication Errors and Adverse Drug Events Adult and pediatric ICU medication error and adverse drug event studies Interdisciplinary group of investigators: Brian J. Kopp, Pharm.D., Andreas A. Theodorou, M.D., Gail Priestley, RN, MS, Michelle E. Allen, Pharm.D., Mitch S. Buckley, Pharm.D. Resulted in national presentations and publications multiple win-win results Number of studies with similar methodology in planning stages Experiential Education Evaluation of pharmacy practice site learning experience Attempt to increase experiential component of curriculum (now known as IPPE) Assumption that more is always better Evaluation of rotation with pre- and postwritten testing of students Erstad BL et al. Am J Pharm Educ 1997;61:87 Erstad & Favre. Am J Pharm Educ 2000;63:426 Small Group Activity Case Studies Developing a Scholary Approach Take Advantage of Development Opportunities Example: Deans Teaching Scholars Program at University of Arizona Coordinated by educational specialists with involvement of health professionals in their areas of expertise Interdisciplinary monthly meetings aimed at improving teaching and research skills Real-life examples (e.g.,osces) Required research project Example: Arizona Clinical Research Training Program Presentation/Publication Dissemination of scholarship If at first you don t succeed Clinical Career Advancement, Part I 8

9 Questions Clinical Career Advancement, Part I 9

The Promotions Process at Johns Hopkins

The Promotions Process at Johns Hopkins Nauder Faraday, MD MPH Professor of Anesthesiology/Critical Care Medicine, Surgery, and Medicine Sr. Associate Dean for Faculty Development nfarada1@jhmi.edu Johns