Katherine Stringer

Pharmacists and family physicians: improving interprofessional collaboration through joint understanding of our competencies.

Interprofessional collaboration (IPC) is an integral part of the practice of Medicine and Family Medicine. The World Health Organization (WHO) defines IPC as occurring when “multiple health workers from different professional backgrounds work together with patients, families, carers and communities to deliver the highest quality of care” (WHO, 2010). To provide effective, patient-centered care, family physicians must collaborate with other health and social care providers. This is especially true in Canada where there is an increasing level of chronic care and multimorbidity. Between 1998/99 and 2008/09 the prevalence of diagnosed diabetes among Canadians has increased by 70%. Over 36.5% of Canadian adults with diabetes report two or more other serious chronic conditions (hypertension, heart disease, chronic obstructive pulmonary disease, mood disorder, and/or arthritis) in addition to diabetes, and 12.5% report having three or more (Frank, 2005). The Collaborator role has therefore appropriately been included in the CanMEDS framework of competencies by the College of Physicians and Surgeons of Canada (Frank, 2005) and the College of Family Physicians of Canada (CFPC) (Tannenbaum et al., 2009). These frameworks are used in the design and accreditation of undergraduate and family medicine curricula as well as to improve patient care by ensuring that training programs in family medicine are responsive to societal needs (Tannenbaum et al., 2009).

Evaluation of the Characteristics of a Workplace Assessment Form to Assess Entrustable Professional Activities (EPAs) in an Undergraduate Surgery Core Clerkship

OBJECTIVE Entrustable Professional Activities (EPAs) are explicit, directly observable tasks requiring the demonstration of specific knowledge, skills, and behaviors that learners are expected to perform without direct supervision once they have gained sufficient competence. Undergraduate level implementation of EPAs is relatively new. We examined the characteristics of a workplace assessment form (clinic card) as part of a formative programmatic assessment process of EPAs for a core undergraduate surgery rotation. DESIGN A clinic card was introduced to assess progression towards EPA achievement in the clerkship curriculum phase. Students completing their core eight (8) week clerkship surgery rotation submitted at least 1 clinic card per week. We compiled assessment scores for the 2015 to 2016 academic year, in which EPAs were introduced, and analyzed relationships between scores and time, EPA, training site, and assessor role. We surveyed preceptors and students, and conducted a focus group with clinical discipline coordinators of all core rotations. SETTING This study took place at the Faculty of Medicine, Memorial University in St. Johns, Newfoundland, Canada. PARTICIPANTS Third year medical students (n = 79) who completed their core eight (8) week surgery clerkship rotation during the 2015 to 2016 academic year, preceptors, and clinical discipline coordinators participated in this study. RESULTS EPAs reflecting tasks commonly performed by students were more likely to be assessed. EPAs frequently observed during preceptor-student encounters had higher entrustment ratings. Most EPAs showed increased entrustment scores over time and no significant differences in ratings between teaching sites nor preceptors and residents. Survey and focus group feedback suggest clinic cards fostered direct observation by preceptors and promoted constructive feedback on clinical tasks. A binary rating scale (entrustable/pre-entrustable) was not educationally beneficial. CONCLUSIONS The findings support the feasibility, utility, catalytic and educational benefits of clinic cards in assessing EPAs in a core surgery rotation in undergraduate medical education.

Prevalence of medication management by community pharmacists in patients of a Newfoundland family medicine clinic.

Although the degree to which pharmacists may renew or adapt prescriptions varies widely by province, the overarching trend of expanded services is clearly growing.1-3 With the addition of reimbursement programs in some provinces1 and the introduction of prescriptive authority in others,2,4 there is clear growth in pharmacists’ scope of practice. As a result, pharmacists have more responsibility for and input into patient care. Medication management is an umbrella term that encompasses a variety of professional activities undertaken by a registered pharmacist to optimize safe and effective drug therapy outcomes for patients.5,6 Currently in Newfoundland and Labrador (NL), medication management includes providing an interim supply of medications, extending a prescription and adapting a prescription.6 The majority of Canadian pharmacists have the authority to provide these services; however, there are differences between provinces in what is permitted and how this authority is attained.7 In NL, both providing an interim supply and extending a prescription entail dispensing additional medication for a previously prescribed chronic therapy. When an interim supply is provided, the original prescription may have been filled at another pharmacy. An interim supply allows for a small quantity to be given that is usually less than one refill, to bridge the time needed for the patient to see his or her prescriber or to return to his or her usual pharmacy. When a prescription is extended, an additional refill of a 90-day supply or less is given for a medication previously filled at that pharmacy. Adapting a prescription includes changing the dosage form, regimen or quantity, filling in missing information and making a nonformulary generic substitution. These medication management services cannot be applied to a narcotic, controlled drug or targeted substance, including benzodiazepines.6 In 2010, changes to the NL Pharmacy Regulations permitted the use of medication management under the procedure outlined in the NL Pharmacy Board (NLPB) Standards of Pharmacy Practice.6,8 To provide this service, NL pharmacists must provide NLPB with a signed declaration indicating they have thoroughly read and understand the medication management standard of practice. As part of the fundamental requirements for performing medication management, NLPB states that in most instances the original prescriber or the patient’s primary health provider must be notified, preferably via faxing a standard form.6 In June 2012, the NL Prescription Drug Program (NLPDP) agreed to pay pharmacists for medication management services provided to NLPDP beneficiaries.9 The Ross Family Medicine Centre (RFMC) is an academic clinic in St. John’s, NL. Prescribers in this clinic include 5 family physicians, 1 nurse practitioner and family medicine residents. Although the RFMC provides care to patients of all ages, this clinic specializes in geriatric care. Medication management documentation received by the RFMC is scanned into patients’ electronic medical records. On January 28, 2013, the RFMC implemented a policy of referring patients to their community pharmacist for an interim supply or prescription extension if they ran out of medications prior to being able to see their prescriber. The change in policy was driven by the belief that this service would help to more effectively use prescribers’ time by reducing time addressing calls or faxes for medication refills, while maintaining continuity of treatment for patients. Currently, there are limited Canadian data on the use of interim supply and extending and/or adapting a prescription, and there is no information on these practices in NL. In the first year (2009) that this scope was in effect in British Columbia (BC), only 0.17% of prescriptions were renewed or adapted. Of those, 80% were prescription renewals.10 In contrast, when medication management labour costs among 10 BC pharmacists who were known high users of medication management were studied, adaptation or renewal was applied to 8.2% prescriptions over a 40-hour work period. Of those, only 47% involved renewing a prescription.11 Given the potential for optimization of patient care, a better understanding of the local prevalence of medication management use, including the frequency of specific medication management services, may lead to improvements in the process for pharmacists, prescribers and patients. The objectives of this study were to determine the prevalence of medication management use by NL community pharmacists in patients of the RFMC and to determine the frequency of the subcategories of medication management in this same population.