Practice spotlight: pharmacist in a family medicine teaching unit.

In 2008, the pharmacy department of the Winnipeg Regional Health Authority (WRHA) embarked on an initiative to incorporate clinical pharmacy services into a University of Manitoba Department of Family Medicine resident teaching unit. The impetus for the project stemmed from knowledge of national and international experience about the potential benefits of clinical pharmacists in primary care and family medicine environments, a local needs assessment that identified a gap in preventive nonhospital care, and the increasing desire to promote and foster interprofessional collaborative practice. The primary funding source for this initiative was the WRHA, with additional support from the Department of Family Medicine. The clinical pharmacist position (1 full-time equivalent [FTE], divided into 0.8 FTE at the primary site and 0.2 at the secondary sites) has been held by Jamie Falk since July 2008. The primary site chosen for this position was Kildonan Medical Centre, a family medicine clinic serving a broad range of patients from its location in the northwest corner of Winnipeg, Manitoba. The centre is a resident-run clinic employing 8 attending physicians, 3 nurses, a nurse practitioner, and a clinical pharmacist. The total number of firstand second-year residents in the clinic at any given time ranges from 7 to 12. A social worker, a dietitian, a psychologist, and a psychiatrist provide services on a part-time basis. The clinical pharmacy practice model at Kildonan Medical Centre encompasses both direct patient care and teaching roles. Patients are referred to the clinical pharmacist primarily by the attending physicians, residents, and nurses. Medication management for chronic diseases makes up the majority of referrals. Although specific foci identified as areas of need at the start of the project constitute a substantial proportion of the referrals (i.e., cardiovascular risk reduction, type 2 diabetes mellitus, and chronic pain), the clinical pharmacist deals with the wide variety of conditions that might be expected in a busy family medicine clinic. Recommendations resulting from patient assessments are discussed with the patient’s attending physician and, when possible and if applicable, the resident and nurse. Evaluation of the first year of this initiative showed that 96% of the pharmacist’s nearly 500 recommendations had been accepted. Discussions with other team members such as the social worker and psychologist have also proven valuable in the management of patients who are being seen concurrently by more than one practitioner, making effective use of the full scope of the multidisciplinary team. Because of the chronic nature of most of the medical conditions seen by the clinical pharmacist, follow-up visits are needed for the majority of patients. This model naturally poses a challenge in this practice environment. Aside from providing patient care, the clinic’s main function is to teach physician residents. As a specialist in pharmacotherapy, the clinical pharmacist has the responsibility not only to provide pharmaceutical care to patients, but also to guide residents. Many of the residents will eventually be working in private practice, without a pharmacist by their side, so this guidance will help them to gain skills in effectively prescribing and monitoring medication therapy. In the current family medicine teaching model, residents rotate through Kildonan Medical Centre in 6-month cycles. As a result, patients are exposed to new faces on a regular basis. Having a fully dedicated clinical pharmacist in the clinic improves the overall continuity of care. As a primary overseer of medication management, the clinical pharmacist gains a deep understanding of each patient, especially those with more complex medical issues. As a result, this individual is viewed as one of the consistent care providers on whom patients come to rely and who can provide supplemental insight to the team. The dedicated pharmacist position is advantageous not only in terms of availability to patients, but also in terms of availability to staff. This consistent presence has reinforced the concept of clinical pharmacy as an integral part of the interprofessional team. Direct patient care regularly progresses to informal teaching opportunities during the frequent “hallway consults” requested by residents and other team members. These consults, often extending beyond basic drug information into