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10/11/2017

Small Hospitals Can Offer Big Residency Experiences

Kate Traynor

Kate Traynor

When he was planning his postgraduate future, Christian Calderon never envisioned himself as half of the inaugural residency class at a 99-bed hospital serving the high-poverty community around rural Palatka, Florida.

Calderon was supposed to go to work for Walgreens, where he’d interned for the past 10 years.

“They were set to give me a store 5 minutes from my house on the manager fast track,” he said.

But as he was finishing his experiential rotations, Calderon answered a recruiting call from Gail King, pharmacy director at Putnam Community Medical Center in Palatka. King invited Calderon to become the first participant in the hospital’s new pharmacy residency program.

Calderon had previously completed an experiential rotation at the hospital, which serves one of the poorest areas of the state. He had fond memories of the experience, his colleagues, and the people he served.

“That community out there is just in such need,” Calderon said.

For Calderon, taking the residency position would mean an extra year of training, a lower salary than Walgreens had offered, and a complete rethinking of his future as a pharmacist.

When he talked to his mentors and preceptors about the residency offer, they told him he’d be crazy not to take it.

He then asked King about bringing on a second resident so that the 2 could support each other throughout the year. She got the second position approved, and Calderon’s best friend and Kappa Psi fraternity brother joined him in the program.

“When you get 2 brand-new residents, it takes a little time to where they can start working effectively with each other on projects and be able to hold each other accountable,” he said. “It was lucky it was me and my fraternity brother, because there was already that trust.”

The residency program operated under preaccreditation status the first year before earning full, retroactive accreditation from ASHP. Calderon completed his residency on schedule in 2016 and is now the clinical coordinator and informatics pharmacist at the medical center.

King described the first residency year as “kind of touch-and-go” for the staff.

“We were still learning. The second year was a lot more organized,” she said. She credited Steven Tran, who was hired as the residency program director about 4 months into the first year, with keeping the program on track.

“One of the hardest things was just kind of getting everyone motivated and involved,” Tran said. “If you’re developing the program as you go, you may not have time to think ahead [about] all of the projects that you’re supposed to have.”

He said the preceptors needed to clearly understand their roles, and the staff had to ensure that the residents had the opportunity to complete all of their required topic discussions, grand rounds sessions, and research projects on schedule.

Clint Pentz, pharmacy director and pharmacy residency director at 57-bed Waynesboro Hospital in Pennsylvania, celebrated the graduation of the hospital’s first pharmacy resident this past June.

“It’s been a lot of work, but I feel like it’s been worth it,” he said.

Like King and Tran, Pentz has found that having qualified staff who embrace their role as preceptors was critical for establishing the new residency program.

“If we didn’t have the pharmacists that we have, the caliber that we have, we would not be able to provide a residency,” he said.

He said his biggest personal challenge is juggling his duties as pharmacy director, residency program director, residency preceptor, and staff pharmacist as he pursues full ASHP accreditation for the program.

Pentz saw developing a residency as a way to support the education of the resident, pharmacy students on rotation at the hospital, and the pharmacy staff.

“I felt it would lift our clinical services up and would assist our pharmacist preceptors to become more clinically advanced . . . and also to help train the next generation,” he said.

Although the residency is based at Waynesboro Hospital, part of the program takes place at nearby Chambersburg Hospital, a 248-bed facility. Both hospitals are part of the Summit Health system.

“I think we’re clinically advanced [enough] that we could have run the residency exclusively out of the smaller hospital. But we thought it was valuable for the resident to experience both types of facilities,” he said.

One unusual problem for the program is that collective bargaining rules at the larger, unionized hospital limit the nonmanagerial clinical activities that residents may perform there.

“Basically, all of our learning experiences at the larger hospital are provided by [the] management,” Pentz said, adding that these rotations generally involve administrative work. But one management-level pharmacist at Chambersburg has been able to establish and oversee behavioral health and critical care rotations for residents.

Pentz said he and his staff have needed to “be agile” to overcome such challenges to establishing the residency program.

King and her team at Putnam Community Medical Center also needed agility to overcome an unusual challenge during the initial months of the residency after the hospital was purchased by HCA Healthcare.

She said the hospital’s chief executive officer (CEO) before the change in ownership expressed enthusiasm about the residency program. But the acquisition brought aboard a new CEO who had had a negative experience with a medical residency program. He had to be convinced of the pharmacy residency program’s value before approving the final paperwork—which happened several weeks after the residents had already started.

Now, King said, HCA is actively supporting the development of pharmacy residencies in its Florida hospitals, some of which are using her hospital as a model for their programs.

“Over time we have shown the hospital that we are not expensive; we’re worth it,” she said.

Calderon said it was also important to sell the residency program to physicians at the hospital.

“They’re great people, it’s just that they’re not used to having to work with a pharmacist on the clinical level that we’re being trained at,” Calderon said.

He said the physicians were won over when they learned that the residents would develop a medication management clinic to reduce 30-day readmissions of patients discharged with a diagnosis of diabetes, heart failure, or chronic obstructive pulmonary disease.

Pentz said he was fortunate that the physicians at his hospital strongly support advanced pharmacy practice.

“We have a very pharmacy-friendly physician group all the way up to senior leadership in our health system,” Pentz said. “And our physician leadership wants to utilize pharmacy to the top of our license. So a lot of times they’re asking us to do progressive things that we might not have enough staff to maintain. But it does allow the resident to try things.”

A new resident is onsite after being selected during the second phase of the 2017 ASHP Resident Matching Program. But Pentz said it’s been tough to attract residency candidates.

“When we go to residency fairs in this area . . . there’s 30 people around the Johns Hopkins [All Children’s Hospital] table and 1 person talking to us,” he joked. “But I try to stress to prospective candidates that we take care of the same types of . . . patients; we just don’t have the specialties.”

And he said smaller hospitals offer a personal touch that larger facilities may lack.

“The residents here at the facility get to know the physicians very well; the physicians know them by their first name. And the relationship with nursing is wonderful. So everybody in the facility, all the way up to the CEO, ends up knowing who the resident is,” he said. “And the residents are really charged with decision making. . . . We’re just a phone call away, but there’s not somebody sitting next to them that they can bounce things off of.”

Hurricane Irma Spares Putnam Community Medical Center

Putnam Community Medical Center in Palatka, Florida, activated its emergency response plan as Hurricane Irma approached in September, but the storm didn’t even knock out power to the 99-bed facility.

“Considering how severe it was originally predicted to be, we fared very well,” said Gail King, director of pharmacy. “We are all good.”

The biggest challenge, she said, was that all community pharmacies within 100 miles of the hospital closed on September 9, the day before the storm hit, and they didn’t reopen until September 12. So there was no practical way for local residents to have their outpatient prescriptions filled.

“We only carry about a 4-day supply of medications. So I can’t fill a prescription for 100 of anything, or even 10 or 12 of anything, because then I don’t have anything for my inpatients,” King said.

She said her 14-hospital division, which is part of HCA Healthcare, plans to lobby the state legislature to require at least 1 community pharmacy per county to remain open during hurricanes.

“They should have a generator at their store, they should be hurricane-proof, they should call in their hurricane team just like we do in our facilities,” King said.

She said the group also plans to develop a formulary of common medications to stock for outpatient needs during future storms.

[This news story appears in the November 1, 2017, issue of AJHP.]

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