In this article a specialty pharmacist discusses the reality versus her expectation of working in the area of specialty pharmacy.
Authored By: Sheila Montalvo, Pharm.D., BCPS
Article Posted 10 May 2022
Prior to and during pharmacy school I was fortunate to have various experiences in pharmacy practice including volunteering at an adolescent HIV clinic where I assisted in providing medication education and drug interaction reviews alongside fourth year of pharmacy students (P4s) for patients living with HIV (PLWH). I saw firsthand how vital the pharmacist’s role was in ensuring the maintenance of a patient’s overall health. After this experience I knew I wanted to continue work with this population.
During my P3 year I applied to and was accepted for a longitudinal residency-focused rotation block for my P4 year. This led me to complete a post-graduate year 1 (PGY-1) Pharmacy Practice Residency at a large academic, acute care hospital with a significant population of PLWH. At the time, I experienced various inpatient rotations such as infectious diseases, critical care, solid organ transplantation, and administration. Unique to my experience as compared to most other pharmacy students and residents, I gained exposure to the practice of specialty pharmacy. During my administration rotation I was partnered with one of the pharmacy leaders who was working on building a specialty pharmacy service for our hospital and I was able to see the ins-and-outs of creating as well as accrediting a robust specialty pharmacy program. In the moment, I had not considered specialty pharmacy as a career option, because I focused on staying in the inpatient pharmacy practice setting.
When it came time to graduate from residency, I was at a cross-roads where I was deciding if I should pursue a PGY-2 Specialty Pharmacy Residency or apply for jobs. Ultimately, I chose to start working as a clinical pharmacist at a local community hospital. It was during my first two years as an inpatient clinical pharmacist that I took every opportunity to enhance our hospital’s management for PLWH. The hospital leadership team was very supportive of my efforts and allowed me to pilot an inpatient antiretroviral stewardship program with one of their pharmacy residents. We were able to reduce antiretroviral therapy (ART) errors by more than 50% and champion our services with our medical providers . This project led me to accepting a position as the HIV/ID pharmacist for our hospital’s specialty pharmacy and infectious disease clinic where I help to service over 1500 PLWH and provide comprehensive pharmaceutical support and education. With this transition came several expectations that were either true or debunked.
In this article I reflect on the reality versus expectation of being a specialty pharmacist, in the hopes that sharing my journey and perspectives will serve helpful for other pharmacy professionals considering this as a career path.
1. I expected I might only manage a patient’s HIV/Hepatitis and lose knowledge in other clinical areas
Specialty pharmacies are often structured where one pharmacist handles a particular specialized disease state, such as oncology, transplant, neurology. In my case it is HIV/hepatitis. As such, most of my patients are living with and being treated for HIV or hepatitis B or C. While a large part of my day consists of educating a patient on their ARTs and doing medication reviews for drug interactions and optimization, where I make a big impact is in my patient’s chronic diseases, such as their: diabetes, hyperlipidemia, heart failure, etc.
The providers I work with know that a basic question (e.g., Does this patient’s P2Y12-inhibitor interact with their protease inhibitor-based therapy?) will result in an answer where I will note the interaction and provide a reasonable solution. I will also note the patient is out of the window of needing dual antiplatelet therapy and should be on aspirin therapy only per guidelines, as well as, the patient’s statin therapy ordered should be modified due to drug interactions. This is where my previous clinical experiences shine through and I am able to provide our prescribers with evidence-based medicine to help our patients reach their goals and I am able to keep up with my knowledge in non-infectious disease areas.
2. I thought it would take me a while to feel comfortable working in a Specialty Pharmacy
I was surprised how quickly I acclimated to my position working in specialty pharmacy. While I was not a Certified Specialty Pharmacist (CSP), I had my Board Certification Pharmacotherapy Specialist (BCPS) and my inpatient experiences helped in navigating the care of my patients. Additionally, I have an amazing leadership and pharmacy team to help guide me in the areas I did not have experience in such as neurologic agents, Medicare B billing and other clinical and regulatory matters. Our team consists of CSP and Board of Pharmacy Specialty certified pharmacists whom specialize and manage specific disease states. The CSP exam helps to provide pharmacists with a strong foundation on all clinical specialty disease states and regulatory aspects of the area of Specialty Pharmacy .
3. I expected the physicians would not readily value pharmacists assistance
I was struck to find our talented team of providers would seek out guidance for their patients. Many of our patients have complicated and highly resistant infectious diseases as well as socioeconomic concerns that require an in-depth review of their medical histories. Knowing these barriers can be challenging, our clinic holds weekly interprofessional meetings with physicians, nurses, pharmacists, and case managers to brain storm solutions to best assist our patients. As a Specialty Pharmacist, I help the team with finding the best pharmacological options, keeping in mind the patient’s ability to afford and adhere to the medication. It has been humbling to know that our providers trust me to make these recommendations.
It is readily apparent now that interprofessional teams are the secret ingredient to great patient care.
4. I expected my days to be bogged down with prior authorizations or appeals paperwork
The treatment of complex and specialized disease states can be expensive, sometimes amounting to more than $100,000 annually. These medications are exclusive, restricted or limited to certain specialty pharmacies. They often require prior authorizations, appeals or patient assistance programs to allow for patients to afford the medication(s). While a large portion of a specialty pharmacy’s services involve drug reimbursement, this is handled by reimbursement specialists who work diligently with insurances and programs to assist patients in obtaining these medications. This allows time for the clinical pharmacist to review profiles for drug interactions, drug optimization, educating patients, and providing clinics with personalized patient support.
5. I thought I would be physically located within a community pharmacy
Truth be told, when I was informed of the position, I was reluctant to apply. I feared my years of inpatient experience would be a distant memory and my position would be reduced to a dispensing role with scripted responses. However, I was graciously afforded the opportunity to shadow one of the oncology specialty pharmacists prior to accepting the position and quickly learned that most of his time was afforded to doing comprehensive clinical reviews and patient education.
My position entails most of my time at our hospital’s Ryan White/340B-funded infectious disease clinic. I spend my days working alongside our medical team triaging drug information questions, reviewing medication profiles for optimization, and providing patient education on medication and disease-state management. My role still allows me the opportunity to be involved with inpatient and district-wide opportunities such as HIV formulary reviews, guideline updates, and drug study trials.
My days at the pharmacy are spent doing clinical management of the patient’s medications and providing initial educations and periodic reassessments of their specialty medications. Having this position allows me to have direct one-on-one care with my patients on a continuous basis while still allowing me to use my inpatient knowledge.
1. Bernard GB, Montalvo S, Ivancic S, Eckardt P, Kehn-Yao Poon K, Parmar J, Sherman EM, Andrade DC. Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors. J Am Pharm Assoc (2003). 2022 Jan-Feb;62(1):264-269. doi: 10.1016/j.japh.2021.08.007. Epub 2021 Aug 11. PMID: 34474965.
2. National Association of Specialty Pharmacy. https://naspnet.org/certification
ABOUT THE AUTHOR
Dr. Sheila Montalvo received her Doctorate of Pharmacy from Nova Southeastern University (Fort Lauderdale, FL) and subsequently completed post-graduate pharmacy residency training at Jackson Memorial Hospital (Miami, Florida). She is a Board Certified Pharmacotherapy Specialist. She currently practices within the Memorial Healthcare System at both Memorial Physician Group’s Division of Infectious Disease (Hollywood, FL) and Memorial Specialty Pharmacy (Miramar, FL) providing comprehensive pharmaceutical support to patients within their Ryan White Clinic and pharmacy. In her role as an HIV/Infectious Diseases Pharmacist she has worked on expanding HIV education in the inpatient setting, as well as, enhancing the pharmacy’s clinical services in HIV management through their antiretroviral stewardship program.
Over the course of her career, Dr. Montalvo has conducted research within the adult and pediatric population, focusing on improving HIV/AIDS medication adherence in the inpatient and primary care settings.
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