This September, the American Academy of Emergency Medicine and several other physician groups released a statement saying that the terms “resident,” “residency,” “fellow,” and “fellowship,” should only apply to medical school physician graduates, as opposed to nurse practitioners or physician assistants. Though clinical pharmacists weren’t mentioned in the letter, some took to social media to call foul on the statement; soon thereafter, the American College of Clinical Pharmacy released a response of its own.
Ultimately, the various sides met and “reiterated their commitment to high-quality, team-based care,” with the American College of Emergency Physicians clarifying that the initial statement didn’t apply to clinical pharmacists. This is good news – for no matter where you stand on the terminology debate, it’s crucial to appreciate a multi-disciplinary, team-based approach to both medicine and medical training. We see it in practice in emergency departments (EDs) and intensive care units (ICUs) every day: a clinical pharmacist working side-by-side with physicians, nurses, practice clinicians and others in everything from medication reconciliation to code blue scenarios – all to deliver the most robust and evidence-based medicine in the ED and beyond.
Jami Johnson, who serves as a Medical Science Liaison at BTG Specialty Pharmaceuticals, knows all of this firsthand. She earned her Doctor of Pharmacy degree from the University of Oklahoma College of Pharmacy and completed a postgraduate Clinical Toxicology and Emergency Medicine Fellowship at the Florida/USVI Poison Information Center-Jacksonville and UFHealth-Jacksonville. Before joining BTG, she served as Assistant Director of the Oklahoma Center for Poison and Drug Information and is an adjunct faculty member at the University of Oklahoma College of Pharmacy. We talked with her about the rigors of her education, why she chose toxicology, the power of a team-based approach to care, and more.
What drove you to pursue a PharmD degree? And toxicology more specifically?
I’m a science nerd, but I also really like direct patient care. A clinical pharmacy role was the best combination of those two things.
As for how I landed on toxicology, I worked at the poison center in Oklahoma during pharmacy school, and I really liked it. Then when I was researching Emergency Medicine pharmacy residency programs, I found out there was a clinical toxicology fellowship. It was a perfect combination of my two passions.
I’ve always thought of myself as a lifelong learner; I’m interested in a lot of different things. Toxicology was the best way to specialize in something while at the same time getting to touch a broad range of clinical areas. My boss at the poison center – he knew the answer to whatever question you asked him. I wanted to be like that. I wanted to know a little bit about everything.
What is it about toxicology that allows you to do that?
There’s a classic toxicology maxim from Paracelsus: “All things are poison, and nothing is without poison: the dosage alone makes it so a thing is not a poison.” Which is to say, everything is a toxin, it’s just dependent upon the dose. To be a good toxicologist, you can’t just know the side effects of a medication. You must know why and how medication works to anticipate the potential toxic effect seen in patients. And it’s not just pharmaceuticals, it’s also envenomations, toxic plants and mushrooms, household products, occupational exposures – all these things require you to have a very broad baseline knowledge.
What was your residency like?
It was a two-year program with month-long rotations. I spent five months in the ED (both pediatric and adult) and five months in the ICU (both adult and pediatric units). I also staffed the inpatient toxicology consult service for twelve months. Then there was a therapeutic policy management rotation, poison center administration and multiple longitudinal projects like staffing the poison center emergency phone lines, presenting grand rounds and journal clubs. It was a busy 24 months to say the least.
What role did you play as part of a multi-disciplinary team while you were there?
As part of the inpatient toxicology consult service, we worked closely with the ED and pharmacy department as well as the admitting services. So if a patient presents to the ED with a snake bite or an overdose, the emergency physicians might order a toxicology consult, just as they would any other consult service, like surgery, cardiology or neurology.
The only difference is that, because we were a pharmacist-driven service, when we made a recommendation – for instance, an acetaminophen-toxic patient needs hepatic lab work ordered or n-acetylcysteine therapy continued – we didn’t order the medication ourselves. We recommended that the admitting service do that. But otherwise, we were integrated into the team like any other consult service.
It seems like there’s an increasing integration of clinical pharmacists onto these teams. Can you talk about that a bit? Why is it so important to have pharmacists on the team?
To illustrate the shift: when I finished my fellowship training and moved back to join the team at the poison center in Oklahoma, there were no emergency medicine pharmacists on the entire University of Oklahoma Health Sciences Center campus. Now they have a whole team of emergency medicine pharmacists, for both adults and kids.
Having a multi-disciplinary team is great because it gives you multiple viewpoints on things. Physicians, for instance, aren’t always experts in medications – but pharmacists are. This is especially true now, as medicine gets bigger and bigger and we learn more and more. It’s impossible for physicians to know everything about, say, valproic acid. We can fill that gap, and make sure the team knows what levels are right, what side effects to worry about, etcetera. I think it’s important, too, from a reimbursement angle. One way of avoiding readmissions is to make sure patients are discharged on the right medications. Pharmacists are a key player in transitions of care.
No matter the case, pharmacy is diversifying as a field, and our clinical experience is growing. In our day-to-day work, we’re finding ourselves smoothly integrating into a hospital’s clinical care team. And the team is better off for it.
Jami Johnson, PharmD, is a Medical Science Liaison at BTG Specialty Pharmaceuticals