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Fifty Shades of Pharmacy Grey: things future intern pharmacists must know – by a 2013 intern

Pharmacy

“There was a very interesting Catch 22 situation that unfolded in fourth year pharmacy. They taught us a subject called Integrated Dispensing, where we were severely punished for overlooking the pettiest of details. As the funny saying taught to me by my first ever pharmacist manager went: “crooked sticker –crooked pharmacist”.

So here’s a scenario. Let’s pretend it’s Saturday morning and a young lady walks into the chemist, and asks you, the pharmacist, for the morning-after pill. How would you respond? What would you ask? Knowing the full consequences of a poorly made decision, what will be your final decision? And with the most up to date knowledge of the risks and benefits, what sort of drug and lifestyle counselling should you provide?

If you do a great job, then you get E for excellent.

But what if you forget to screen for other medical conditions? What if you overlook another piece of crucial information? What if this leads to patient harm or even death? My friend, now you could be easily facing an automatic U for unsatisfactory. So joke aside, it’s not petty. It’s important to ask the right questions to come to the most informed decision.

Maybe that’s why the marking was so harsh.

What happens when you finish pharmacy school?

When you finish your four years of undergraduate pharmacy school, you are required to work alongside experienced pharmacists for a year before you are eligible for full national registration. Apart from experience, the only other major difference between you and a real pharmacist is that you are not allowed to do the final check of a dispensed prescription medicine.

The above rule is based on the traditional pharmacist supply role of checking that a medicine the doctor ordered is safe before a patient is allowed to take it home. There is a serious side to the dispensing process because it has been shown to keep patients safe and to save lives.

Funnily enough, this significant piece of history gives you the freedom to work under the guidance of registered pharmacists while engaging quite independently (but very collaboratively of course) in every single other clinical activity under the sun! This includes extended drug and therapeutic counselling sessions e.g. family planning.

Negotiating for your future

So you would think that all that disciplining in pharmacy school taught us a thing or two when it came to contract negotiations!
Today the pharmacist’s role continues to evolve from a basic safety check to one that is very much focused on working as part of a combined team effort with doctors and many others, helping to ensure the effective use of treatments in healthcare.

Yet I can still recall how the chairman of a boutique pharmacy chain contemplated on the significance of the internship year, and how it set the tone for the rest of a pharmacist’s career.

Maybe that’s why all the big chains like to fight for the best interns.

Oh, and what else did he say? That you would be lucky just to get a job these days with the current oversupply of pharmacists. One thing I wish some of my friends and I realised at the time is that it is so competitive to get a good job in any field today, not just in pharmacy…

I watched on with horror as some of the brightest and most intelligent people I knew signed up for internship contracts as round-the-clock dispensing robots. They knew the work was going to be mind-numbing and soul-splitting. So why on earth did they agree to it?

Oh yes, please forgive me for forgetting that they wanted the security of a job. They wanted to sign a contract with no negotiation for allegedly the most important year of their career.

Questions prospective pharmacy interns must ask when job-hunting:
•    Does this role embrace all aspects of my personality? Know your sweet-spots, both clinical and non-clinical.
•    Is this retail pharmacy or hospital department a strong learning organisation?
•    Is the manager willing and able to allocate time for me to work on an independent project? Prepare a pitch.
•    Will I be taken seriously here as an intern or am I just cheap labour?
•    Will this place offer me variety and the flexibility to try new things?
•    Will there be meaningful interactions with both patients and other professionals?

It’s important to remember that just because something is compulsory, it doesn’t mean you completely disregard your career goals and personal preferences.  While no workplace is perfect, I was lucky enough to land myself in one loaded clinical internship program that did indeed satisfactorily answer the above questions.

Pharmacy after all, just like every other healthcare profession, is a work in progress. It’s a trial and error business when it comes to helping others and reaching out to them. That’s why healthcare professionals care about research and development. And this needs lots of skill and will from everyone, interns included.

To summarise in a nutshell, your internship will set the precedent for the rest of your career. So in order to make an informed decision, please be prepared to ask questions. And be prepared to negotiate. A good job is something definitely worth fighting for!!

Acknowledgements: A special thank you to Sara White and Neil Johnston for generously giving from their time to review this article and provide valuable guidance.

Rita is a pharmacist who undertook her graduate clinical year in 2013 at Prince of Wales Hospital in Sydney. Some were surprised at why someone with an entrepreneurial streak like hers would even consider working in a major teaching hospital. But as soon as she saw their clinical program, there was no turning back! 

More articles on My Health Career:

Image: Mike Mozart – flickr

 

12 replies to “Fifty Shades of Pharmacy Grey: things future intern pharmacists must know – by a 2013 intern”

  1. Or you could sign onto a great teaching hospital and watch it implode and watch your career go down with it.
    If your internship sets the tone for your future what about those who get shafted with terrible situations 4 months into their prereg year and have to suck it up the remaining 8?

    1. Hi Josh,

      Thank you for your note. No workplace is perfect, so it’s worth considering what is most important to you including the setting, geographical location, compensation, etc.

      I have friends who were stuck in the very situation you described. One of them documented everything inappropriate that happened to her, walked off the job and pursued industrial relations proceedings against her former workplace. She was lucky to find another pharmacy to work in soon after.

      Another friend, who was younger and with less work experience, decided to stay at her pharmacy for the full year. It was not a pleasant time. These situations can occur in sectors outside pharmacy as well -at any stage of your career.

      I guess the take home message is to know your rights and to be ready for surprises.

    2. Great Article Rita

      One thing i would say to Josh and other graduates/interns/early career pharmacists is that you have to remember that as a pharmacist you are a professional, and you are autonomous

      The reason I say this is because I see a lot of early career pharmacists and interns who take jobs in poor situations (either conditions, pay, or both) and just seem to think that they have to take it… which is just not the case. You can’t be forced to practice in any manner other than you feel is correct, and if the only work you can find is not sitting comfortably, then look further afield (geographically, or vocationally).

      If the situation Josh describes is happening, then contact the board and your intern training course coordinator, and ask their assistance in rectifying the situation (including moving).

      If you are in a situation that you feel is out of control, ethically grey, you’re unsure, you feel overwhelmed, or similar, there is support. Contact the PPA (union), contact the Guild (they provide good advice to employee pharmacists), contact the board, contact the PSA (or SHPA), Contact PDL (insurance). One resource I think it is very important to know about is the Pharmacy Support Service – 1300 244 910. They are invaluable.

      Pharmacy is a great career, and it is definitely what you make of it. Working in a community pharmacy, working in hospital, becoming accredited with clinical services, or moving into other areas of practice are all great opportunities. Just don’t expect it to be ho-hum or humdrum – you can make your career as boring as you let it be (just like any other job) or you can really enjoy it every day.

  2. “Apart from experience, the only other major difference between you and a real pharmacist is that you are not allowed to do the final check of a dispensed prescription medicine”

    From the Pharmacy Board of Australia’s ‘Supervised practice arrangements registration standard’ available at http://www.pharmacyboard.gov.au/Registration-Standards.aspx : “Supervised practice, which includes internship, is undertaking pharmacy practice under the direct supervision of a pharmacist who holds general registration (a preceptor), while the pharmacist is providing pharmacy services in pharmacy premises or other circumstances as determined by the Board.” Anything you do that involves you “providing pharmacy services” needs to be supervised by a registered pharmacist.

    1. Hi ‘A Concerned Pharmacist’,

      Thanks for sharing your note. I will draw your attention to the full paragraph from where you obtained your quote:

      “When you finish your four years of undergraduate pharmacy school, you are required to work alongside experienced pharmacists for a year before you are eligible for full national registration. Apart from experience, the only other major difference between you and a real pharmacist is that you are not allowed to do the final check of a dispensed prescription medicine.”

      Re the document you shared, I am familiar with it :-). It is a very vague document that doesn’t go beyond the details you quoted. Compare this with the registration standards for other professions such as medical interns, which specifies different levels of supervision depending on ability and demonstrated performance.

      Additionally, this article was reviewed by experienced pharmacists before it was submitted. Does this address your concerns? If not, then please let me know.

  3. As a very experienced ( ie getting older by the minute), I think your article is very good. However to my ears / eyes it does seem a little naive. When you state “Apart from experience, the only other major difference between you and a real pharmacist is that you are not allowed to do the final check of a dispensed prescription medicine.”, I think you over-estimate the abilities of a newly qualified unregistered pharmacist.
    That little thing called experience, is probably the difference between a safe and accepted colleague in the multidisciplinary team of modern hospital practice and someone who has a degree/ masters but no real value as a practitioner when they start.. The intern year is generally a metamorphosis from idealistic graduate to competent, calm and knowledgable practitioner. I remember that happeing to me so many years ago and I see it every year with our 2 interns per year. It takes about 3 months just to feel competent and confident to (maybe) be able to talk to one of the doctors, Interns, JMOs or registrars, let alone the consultants. You need to be able to communicate without causing offense and understand that the text books hide a continuum of acceptable practice. The next 3 months see you understanding how to communicate with patients of all varieties and understand body language so you can restate information in a way they may understand. Later in the year the registered supervising pharmacist who you think you are no different from, may and I repeat may allow you some responsibility based on perceived competence.
    The last 3 months may see you becoming more and more competent and looking back on how ignorant you were at the beginning. You are ready to move to that goal of becoming a registered pharmacist after you prove you know your stuff at exams. THEN… 1st day you work after registering, you realise that the ‘buck stops with you’, that a patients life rests in YOUR hands and you realise that your initial statement a year ago was so silly and naive. You then start advising a new brash Intern and guess what? You believe as I do, that they learn as much in that year as they have over their whole university course! Congratulations to all interns when they register. If their Intern year was in a hospital, you have been clinically challenged, trained to communicate well in a broad team, had a very broad exposure to all clinical situations and done justice to the difficult course you have completed at Uni.
    The Tweed Hospital
    Tweed Byron Health Service Group, Northern NSW Local Health District.

  4. Hi Michael,

    Thanks again for having me for a week-long placement at Tweed during the summer of 2010. It was a nice place!

    You are a very passionate and experienced pharmacist, so I am going to make this reply even MORE thought-provoking than the original article because I’d like to run my perspective by you. I’d like to know just how naïve I am as a “millennial”.

    I’m glad to see that this article has generated two key discussion questions:

    a) What is the difference between a real pharmacist compared with a (P-plate) provisional pharmacist?
    b) In what way does your internship set the tone for other stages of a pharmacist’s career?

    Your description of the hospital intern year sounds very familiar! It is this linear model you shared that most likely formed the foundation of my clinical program at POW Hospital. Looking back, I agree with aspects of it. I appreciate that it’s something that would have worked quite effectively in the past…

    Our healthcare system today, however, is far more complex than it was in the past. Furthermore, the things that shape the experiences of a graduate pharmacist in his/her four years as a student are also very different. Our baseline knowledge is greater, we learn faster, and our degree is one year longer than it used to be in the late 1990s.

    A long time ago, for example, pharmacists never provided recognised services other than safe medication supply. I can tell. You talk about the ability to skilfully communicate with doctors. In my 5.5 years in pharmacy, I have watched many “real” pharmacists operate as nothing more than passive people pleasers in this area…

    In reality, most of the doctors I interacted with in the hospital were interns and residents of similar age and work experience time as myself. In addition to on-the-job experience, all I needed was good social skills and to know what I was talking about in order to work independently -this is a lifelong process in my eyes not restricted to the intern year!

    So, in my opinion, it is an easy thing to confuse an intern’s adjustment to full time work (e.g. 3 months to learn the ropes, 6 months to feel settled in) -quite typical of any high-skill job in the economy -with the ability of an individual to be held accountable for their own actions. How else would you objectively measure perceived competence?

    At the start of 2013, when the 2012 interns had their “handover week” with us, 2 of the 4 interns (the ones that had secured work/study elsewhere) were kind enough to tell us what they really thought. They told us that they loved all the educational opportunities and the department, but that they would have preferred to be given a lot more independence as opposed to the last three months of the year.

    Is an oral exam, which is currently out-of-date in relevance -given the gap between what you would say in order to pass verses the true extent to which you would make a case-by-case judgement in “real” life -really a good excuse for an intern to wait the whole year for the buck to stop with them? These days, there is more to being a pharmacist than dispensing -but the oral exam only focuses on what you need to know in order to do a basic dispensing motion. How will a pharmacist make a buck in the future? It won’t be dispensing alone.

    Imagine how frustrated you would feel, when you passed your L-test on graduating from your degree (with flying colours) -only to wait for a year in order to drive your first car alone!! There’s also a fine line between good supervision and micro-management, sometimes by poor role models. This is especially the case with some of my unlucky friends in a retail pharmacy with the same one or two pharmacists on duty all the time.

    What sort of precedent does this set for our future?

  5. Hi Rita,
    Yes I am passionate about the profession and having read your reply still believe that the years at Uni do not prepare you for the real world. I still believe in what you call a linear development. You do need to crawl before walking and if this offends some young graduates then I’m sorry but this is what I’ve observed over the years. I’m referring to in dealing with other professions and the reality of how pharmacy is still unfortunately still perceived in the wider environment, even within the largely converted hospital environment. Like it or not, we are perceived by ‘management’ as having a mainly ‘supply’ function. That’s why in all my plans for the future I absolutely define our services as 2 part – yes supply (mostly supplied by Technicians where possible and ‘Clinical’ work by pharmacists . I’ve taken this to the extreme that because our workload has increased so much with discharges, I have instructed the whole management of the hospital that clinical work will NOT suffer and that if this means patients have to wait for discharges then so be it. Perhaps I’ll get some action on increasing staff numbers to cope with the 400% increase in activity in this area over the last 5 years without staff adjustments.
    So when you seem to fee lthat a young graduate is fully trained on graduation, ready to work anywhere, , it doesn’t wash in my experience. I know it’s hard to accept from where you stand. Your academic life is full of clinical case studies, detailed drug information, all the subjects of pharmacy and pharmacology and possibly some role plays on communication however this doesn’t begin to describe what happens in a real life situation. You state that the recent grads you interviewed / spoke to wanted more independance earlier in the Intern year. Together with all of my experienced pharmacists we all say, you are not ready at that stage! With our years of observation of so many grads / interns we can’t all be wrong.
    My current Intern would agree with that. In fact I would say that every intern we have had for the last 7 years would agree that they were unprepared for more independent action earlier than we gave them. And this is not just an old fella living in the past comments. I would say that my communications with many Directors of Pharmacy across the state would agree with this viewpoint. In fact I believe that the Interns who strain against this ‘restriction’ are the most likely ones who actually need to be careful. They are the gungho ones who believe that they know enough from their limited experience but having completed their degree, who make many dangerous errors. Overconfidence is a dangerous trait.
    Having seen a young pharmacist who was implicated in an error that resulted in death and ruined her professional life, I would argue that it is wise to take my maybe conservative attitude. Even young pharmacists, 1st year out need careful placement into areas that are possibly beyond their ‘scope of practice’ / competency. I have observed this recently, this year.
    So I understand how frustrating it is, having worked hard for so many years for a degree or masters.
    But the analogy with a car is not satisfactory. In pharmacy when you accept the role of being a member of the health care team, where YOUR advice is taken as gospel, it is not OK to get a demerit point. You could harm, potentially kill a patient. And being untrained in the actual world rather than academic success makes a potentially dangerous risk that most experienced practitioners are unable to accept. Sorry but that’s the facts. I think the PSA, the SHPA and others who run an ITP would agree with me.
    I’d love to hear your viewpoint in 5 years time. Try to remember to contact me then.
    Cheers
    Michael

    1. Hi Michael,

      It’s not often you see an honest and informed opinion on the internet -thank you for your valuable insights! Because you care, I’ve got some reflections to share.

      I believe it’s important that the views of pharmacy leaders are circulated to every stakeholder, including future pharmacy students. I’m also a strong believer in participative management. I’m not sure how honest your interns really are -I find that I behave differently in a real job compared with how I behave on committees and on social media. In an advocacy role, I leave no stone unturned :-)

      I’d read somewhere that 50% of Australian pharmacists are aged 35 years and under. Some learning algorithms are linear, some are not. In the same way there are some things that cannot be taught at university. This is what Miss Venezuela 2008 had to say about the differences between the genders (I apologise in advance if you to lose brain cells listening to some of the others):

      Perhaps it’s time you get in touch with your feminine side? :-)

      Pharmacy interns are the best marketing weapon you have, as they graduate with knowledge of cutting edge practices. I am currently liaising with a newly registered hospital psychiatrist, who after six years of specialist training feels out of his depth when it comes to writing a behavioural management plan -when most fourth year pharmacy students from my university can do one in their sleep. The fact is, no one is ever ready, and there are valuable skills that pharmacists can contribute, even before they graduate.

      I understand your frustrations -last year we had new Mental Health ward that opened at my hospital, with funding allocated for 0.3 of a full-time pharmacist -clearly a supply role was intended there. My friend told me about a new 60 bed rehabilitation ward at her hospital -funding was allocated for just one pharmacist. All four of us interns last year ended up doing health promotion projects (in pairs) on the Mental Health wards. The one that I led was progressive and involved personalised care. While it was a small pilot, feedback was enthusiastic.

      I agree that you should take a conservative attitude to dispensing at any stage of your career, and stick to the safest path possible. When I was an intern, I was told the reason why we now print out drug interaction stickers for every medication order is because an old, experienced pharmacist accidentally overlooked an interaction between allopurinol and azathioprine and that person, like your young pharmacist, also got into a lot of trouble. Any one can have a car accident at any stage of their life. It’s not an excuse to stop driving.

      There is an art to delegation. And I think experienced pharmacists should learn about it, because I was in an awkward situation last year where my clinical program as an intern was far more satisfying than what I saw the registered pharmacists doing. In the medical world, the interns normally do a lot of the dirty work. At the same time, the team relies on them to understand the limits of their knowledge and when to ask for help. If pharmacists want doctors to collaborate with them, then maybe they should start collaborating with their junior staff first. All it takes is an honest conversation.

      Thanks for wanting to keep in touch :-).

  6. Hi . There are some very interesting comments in this debate. Intern year is a necessary process in my opinion. In recent times I have debated the need for intern year with many senior pharmacists in relation to when can a graduate start to provide medication management services e.g. HMR. There are mixed opinions. I have also debated the need for supervised practice year with people from other professions e.g. optometry. In optometry,you graduate and set up your business and start work. No supervsion but you are allowed to prescribe if you have the prescribing qualifications plus you can make health decisions that can be quite detrimental to a patient.
    In my work for the Pharmacy Board of Qld and now AHPRA I have seen some terrible pharmacists. Their intern year did not teach them morals, quality dispensing standards or how to communicate. Some are belligerent and dishonest and others are just so badly trained by their preceptor that they need months fof mentoring.Until AHPRA sets standards of competency for preceptors who supervise interns than we will always have issues. I know there is a document but who supervises that it is adhered to?
    I have had interns who I would have allowed to practice alone at 9 months and then I have interns that I would not sign off on for 15 months. I have had interns that I would never sign off on.
    I am a fan of the model in where an intern can be ‘shared’ betweeen disciplines to gain an insight to various types of pharmacy. I do agree with Rita that just to teach an intern is not enough. They have to be inspired, stretched and set goals. I wrote my intern training program long before PSA and others moved into this area as I wanted a documented pathway to guide the interns under my care. at the end of their 1824 hours I wanted to be able to asure them that they were competent to practice in an environment with patient safety as their first mantra.
    No pharmacist should ever feel they practice alone-there is a lot of support available so even as a new graduate or a newly registered pharmaist please esatblish your links and ‘dial a fellow professional’
    Great article Rita. You could join the debate at the next PSA intern meeting!

    1. Hi Karalyn,

      Thanks for the note. I’ve been quite active on one of the PSA forums on Facebook recently, but will try to learn more about the meetings.

      You made some interesting points about some things on the minds of pharmacists my age. One of them is accreditation for Home Medicines Reviews (HMRs). Back when HMRs were introduced in the early 2000s, they were new. Pharmacists who had been dispensing all their careers suddenly needed to be trained.

      However, in my degree, medication reviews took up most of our time, and not dispensing class. So at the end of 2011, at the end of third year, a couple of my friends were intelligent enough to realise that they should start the HMR accreditation process. And they passed Stage 1 with flying colours.

      There are huge structural issues with pharmacy, as things which older pharmacists find advanced, many of my peers do not. At the same time, I agree that the internship year is essential but it needs to be used properly. Pharmacists should never dumb down the ability of students and interns to think independently. They have worked hard for their degree, and while there is a long way to go, I think it’s better to be creative under supervision and test the boundaries then. As opposed to spending a lifetime living in fear.

      While medication reviews are a great success, I think pharmacists should move on to new frontiers. Surely, we can do more than “review”? How about “manage”?

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