Different settings, similar goals

Viewpoint By Amy M. Fanous, PharmD, BCACP, and Bethany G. Sibbitt, PharmD

Introduction by Reagan A. Williams, PharmD

I have been spending a lot of my time where my grandparents live—a small, dusty town in nowhere Oklahoma without a stoplight, a place where the speed limit is always 25 mph, and everyone knows each other. While running errands for them, I often went to the only pharmacy in town. It made me wonder how different it is to be a pharmacist in a rural area compared to the fast-paced metropolitan area I work in. What are some services they provide that I could be providing? What might they be able to learn from me? How can we  share our experiences so that we can work toward better outcomes for our patients, no matter where they live?

Luckily, as part of the APhA New Practitioner Network, I have a built-in group of peers that are trying to do that exact same thing: learn from each other and provide the best care we can. In this article, fellow New Practitioners Amy Fanous and Bethany Sibbitt provide a glimpse into their daily practice. Although their settings are different, their goals are the same.  

Rural perspective (Amy Fanous)
Rural areas can have extensive barriers to health care access. In fact, many rural areas are considered to be medically underserved and have a shortage of primary medical professionals. Understanding that rural areas can have limited access to health care services, high rates of chronic conditions, little or no health education, and high poverty rates, can help providers who live in rural areas deliver quality care to all citizens.

Services that improve access to care are needed in many rural communities. A mobile clinic using a multidisciplinary team of health care providers and students is an option for improving access to care. The concept of “bringing health care to the people” is feasible in many settings. Any outreach that consistently provides care for patients outside of a medical facility would serve this purpose. Periodic, rotating mobile care sites in the community that use existing facilities can easily be implemented with proper supplies, personnel, and time. The use of a mobile clinic eliminates the need for transportation as well as the lack of health care access in these rural settings. Mobile clinics can offer a variety of health care services including monitoring and education on diabetes, hypertension, hyperlipidemia, weight management, immunizations, and tobacco use.

When working in a rural setting, it is absolutely essential to take the time and effort needed to establish a relationship with those who live in the community. In order to provide quality health care to patients, you must have a firm grasp on the issues they face. The best way to comprehend this is by spending time out in the community. One way of doing this is by holding consistent clinic events or education sessions at the same places, such as a food pantry or a community diner. This consistency within the community will help to build more trust and rapport with the people. These patients are then more likely to seek out medical care.

Another idea to keep in mind when practicing in a rural setting is to be sure and get concrete feedback from the community being served. Doing so allows the formation of a more robust program that is better prepared to fulfill its mission and that patients can actually use and depend on.

Marketing of clinical services that are available can be another barrier when working in a rural setting. It may be well known that a rural area has many citizens with chronic disease conditions, but if the citizens are not aware of the medical services that are offered in the area, they won’t be able to take advantage of them. This can be a significant challenge. Some marketing ideas that may be helpful in rural areas are being present at local events, utilizing church bulletins, newspaper, and radio.

In my experience, I believe that no matter the clinical setting, having adequate access to quality health care, understanding the needs of the community, and using appropriate marketing strategies for the area will lead to better outcomes for patients.

Urban perspective (Bethany Sibbitt)
Having attended a school of pharmacy located in a proverbial cornfield, transitioning to a more urban environment definitely has its own challenges on top of learning the ropes as a New Practitioner. During my first year as a pharmacist, I have practiced in an area at the heart of the nation’s heroin epidemic. Caring for individuals in the throes of addiction has permeated multiple aspects of the varied rotations I encountered as a PGY1 pharmacy practice resident. My perspective on the impact of this situation plaguing my city has grown as I see the extent of those affected.

Although my practice site saw mostly adult patients, we also service a Level IIIB Neonatal Intensive Care Unit. Starting my residency year off in the NICU exposed me to the youngest victims of the heroin epidemic—those born with neonatal abstinence syndrome due to perinatal exposure. These babies were accompanied by parents who ran the gamut from actively seeking help or in recovery to absent parents and dangerous home situations necessitating social services intervention.

The other, more obvious victims of the epidemic are the patients themselves. I encountered these individuals at various junctures of my rotations this year—the people who overdosed repeatedly in the same week, coming through the ER after being revived with naloxone; those in the ICU recovering from a valve replacement due to developing endocarditis from another bloodstream infection; those names easily recognized during infectious disease rounds due to multiple admissions after failing to complete therapy for their bacteremia or epidural abscess; and those codes we responded to after a patient overdosed in their own hospital bathroom.

As I processed all of these experiences together, I realized that the headlines about my city fall short in capturing the true toll this epidemic has taken. We can easily tally and sensationalize the deaths due to overdose and the lack of space in the morgue, but that fails to account for the mortality from the complications of addiction and disseminated infection, or the generation of orphans created from children who have lost parents to their disease and now are part of the system. This also fails to address the conflict that accompanies caring for those in addiction, the constant battle between frustration and empathy.

As a practitioner in an urban area, I often feel the tension between wanting to provide the best care and advice for my patients and being constrained by the limitation of resources or the lack of motivation to implement lifestyle changes. In many circumstances, treatment algorithms and new drug developments seem laughable for the patients I serve. These are people who have multiple generations living under one roof, who may not speak English as a primary language, or who have opted to purchase pet food for nutrition because it was more affordable.

These challenging situations require some finesse, creativity, and sensitivity as you navigate caring for individuals who have been dealt a difficult hand and are simply trying to survive.