Pursuing a career as a critical care pharmacist offers the opportunity to play a key role in the management of critically ill patient populations. Here, a pharmacist with critical care training reflects on how her expectations have contrasted with the realities of being a critical care pharmacist.
Authored By: Sarah Adriance, Pharm.D., BCPS
Critical care is one of the oldest clinical pharmacy specialties and it is well established that the presence of a pharmacist on rounds in an intensive care unit pays off for the patient, the medical team and the institution [1-3].
Few niche clinical pharmacy areas have documented the powerful impact a pharmacist’s presence can have in the way it has been done in critical care. This influential role critical care pharmacists can have is what drew me in. From there, I was propelled by the challenges I would face and the intensities I would experience.
My first exposure to critical care began when I was a pharmacy technician. I was working in a hospital setting predominately compounding intravenous medications for the intensive care units. Then, as a third-year pharmacy student I enrolled in an Acute Care Elective. This course exposed me to the exciting world of shock syndromes and vasopressor selections. I knew by the close of my third year of pharmacy school (and the close of my didactic training) that I was headed for a career as a critical care pharmacist.
Not everyone is as confident about their professional aspirations early on (and that is ok). I was lucky to find my passion so quickly.
Look closer at the roles a critical care pharmacist may play and you will find the field is subdivided into mini-critical care niches. You may be surprised to know that you can work as a critical care pharmacist, further specializing in burn, cardiovascular, medical, neurosciences, neonatal, pediatric, surgical, or trauma. I started in surgical critical care specifically which eventually led me to neurocritical care when the need for a specialized team was recognized within my health-system.
Over the years, I have learned a great deal about critical care pharmacy and there are realities I have had to face since my apprenticeship years. I would like to share them with you. Perhaps other critical care pharmacists can relate while others may find them intriguing enough to explore this exciting field of medicine.
Reality Check #1: You cannot maintain competency in all things critical care
Just because you receive training in critical care, it does not mean all knowledge and expertise that falls into that realm becomes yours.
It is an unrealistic expectation I had for myself early on as a new practitioner. I had to learn to be comfortable with reaching new depths of knowledge in a small space (neurocritical care) while I moved further away from the broad knowledge base I had acquired following completion of my post-graduate training in critical care.
Few clinicians will have the capacity to be an “expert” in all things critical care. For most people, it is necessary to balance between having knowledge that is an inch deep and a mile wide versus a mile deep and an inch wide.
Reality Check #2: The ICU is not always full of complex patients
Intensity in the ICU can ebb and flow. A picture painted in your mind may be one of non-stop code blues (meaning respiratory arrest) and rapid fire medication questions from your team for a patient with an APACHE II score of 30 (approximately 73% mortality risk) .
In reality, working in the ICU will not be super-charged all the time. Rev up in slower times to accomplish great things for your profession, your unit, and your department. I have learned that my work-life involves so much more than direct patient care. This leads into the third reality check…
Reality Check #3: No, you cannot have it all
Scoring high achievements in leadership, teaching, and research (non-patient care components more than likely also part of your career as a critical care pharmacist) will take time, dedication and networking.
The more seasoned practitioners may find it easier to balance all the non-patient care demands and with ease and be more successful at it. The new practitioner on the other hand may be taking on too much and struggling to be good at everything.
Over a career span of time you could have it all if you so desire but the reality is you will likely not have it all at once. Identify which area or areas you are really good at and focus to develop that talent. Realize that your professional career is a marathon and not a sprint.
Realty Check #4: Patient contact time is up to you
By nature of the ICU environment and the less interactive state the patients tend to be in, there is overall less contact with the patients themselves during their stay.
I have become very close with patients’ families and loved ones however. They see me each and every day on rounds. I interact most with the patient’s visitors, engaging them in medication changes and using them as resources to optimize care.
I have been able to share the profession of clinical pharmacy with them which many do not realize exists. I am proud of that and truly believe the adage; you only get out of it what you put in.
Reality Check #5: The team will rely on you more than you anticipate
In healthcare the importance of a team approach is the standard for critical care practice models. In fact, multidisciplinary critical care should characteristically involve pharmacy collaboration with the medical staff .
I knew I would be expected to be prepared and vocal on rounds as the drug expert. What I was not expecting with each year of experience I have gained is the depth at which the physician and non-physician providers (e.g., bedside nurses, dieticians, respiratory therapists) entrust me with the patient care decisions.
Is patient care really at an absolute standstill right now until the pharmacist weighs in? This is a bit dramatic as surely I am not absolutely necessary to make the decision. However, you may certainly feel that way on some days.
I am naturally there to help optimize patient care decisions, yet I have come to embrace my role as a critical care pharmacist even more, because my medical team openly places value in me and our profession.
1. Erstad BL. A primer on critical care pharmacy services. Ann Pharmacother 2008.42:1871-81.
2. Leape LL, Cullen DJ, Clapp MD et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:167-70.
3. Horn E, Jacobi J. The critical care clinical pharmacist: Evolution of an essential team member. Crit Care Med 2006;34:S46-S51.
4. Knauw WA, Draper EA, Wagner DP. APACHE II: a severity of disease classification system. Crit Care Med 1985;13:818-29.
5. Brilli RJ, Branson RD, Campbell GM et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med. 2001;29:2007-19.
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