In this episode I’ll discuss how pharmacists can improve their working relationships with physicians.
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I’ve done a lot of listening, watching, and reflecting on interactions between physicians and non-physicians. It seems, whether consciously or unconsciously, physicians place non-physicians they interact with into one of two categories:
1. Those that help the physician take care of the patient.
2. Those that make it harder for the physician to take care of the patient.
Other physicians make it into the first category automatically. They are constantly helping each other take care of patients in the form of consults.
Nurses are the physician’s eyes and ears, and the patient’s guardian angels. Nurses automatically get placed into the first category.
A Pharmacist’s job is clearly to help take care of the patient, but it is easy for us to be misconstrued. We need to work hard to avoid being placed in the second category. Take for example the simple case of discussing a drug interaction with a physician:
One pharmacist may say “I’m calling you because the computer says there is a serious interaction between valproic acid and meropenem.”
Another pharmacist may say “I’m concerned that the meropenem will decrease serum levels of valproic acid, increasing the chance the patient may have a breakthrough seizure. Based on your progress note it looks like you are covering pseudomonas pneumonia. I’d like to switch the meropenem to cefepime to avoid the interaction.”
While how you phrase a recommendation is important, I have 4 additional tips that I use to improve my working relationships with physicians.
Tip #1 – Don’t be the general that points out the mistakes made after the battle is over, instead get in the trench when the battle is being fought
Part of a pharmacist’s job is reactionary. We may only find out about a potential issue with a patient’s pharmacotherapy regimen after it has been implemented. No matter how we sugar-coat our recommendation we have to essentially say to the physician “Don’t do it that way, do it my way instead.” If this is all a physician ever hears from us it is easy for them to place us in the category of people that make it harder for them to take care of the patient. That’s why whenever possible, I like to be side-by-side with the physician as they try to solve the patient’s problems rather than tell them afterwards that I don’t agree with what they did. In order to maximize the chance that I am working side-by-side with the physician I do these three things:
1. Spend as much time as possible on the nursing unit as opposed to in the office/main pharmacy.
2. Whenever I get a phone call from a physician with a question, I usually go to the unit the physician is on and answer the question face-to-face.
3. Whenever I hear a new patient is coming to the ICU whether from the emergency department or from another unit, I go to where the new patient is and start my patient workup. Inevitably I will encounter the physician there and will be able to work side-by-side with them.
Physicians that I work with remember and appreciate when I am side-by-side with them, helping make sure the first order they write for the patient is the best one.
Tip #2 – Do something to make the physician look good
Whenever possible, I like to structure my recommendations and interventions to make the physician look good.
Some of our recommendations are basic like: “add VTE prophylaxis” or “discontinue metformin since the creatinine is elevated” or “change levothyroxine from 25 mg to 25 mcg”.
I try to convey these recommendations privately and ‘off the grid’ with a sticky note or an informal conversation rather than in a written progress note or on patient care rounds. Don’t get me wrong – I’m not suggesting that you don’t document necessary pieces of information in the medical record, or that you don’t document your interventions. But for basic interventions like I just described, it makes the physician look good when they “fix up” orders based on your informal recommendations.
Tip #3 – Do your “due diligence” before approaching the physician
If you don’t have a solid understanding of who the patient is and why they are in the hospital, you run the risk of your recommendations being “tone deaf”. Here is an example:
A few years ago I watched as an infection control officer was trying to reduce the use of urinary catheters. They would come to ICU rounds where the patient case would be presented as “A 55 year old female with septic shock, multiple vasopressors being titrated, oliguria, elevated lactate and a low CVP.” Then the infection control officer would ask “Can the foley come out?” Clearly, the patient’s urine output needed hourly measurement to assess the degree of shock and whether current therapy was being successful. But the “tone deaf” robotic request for the foley to come out – regardless of what was going on with the patient – hindered the infection control officer’s ability to reduce inappropriate foley catheter use in other patients. When the infection control officer changed their approach to more carefully examining exactly what was going on with each patient and what the foley was being used for, they were able to become much more effective in reducing unnecessary foley use.
For pharmacists I think doing your “due diligence” means at a minimum to have reviewed a patient’s H&P, problem list, most recent progress notes, and current labs & medications prior to approaching a physician with a recommendation. When I review these items first I find my recommendations are better, and I am better able to explain them if asked to.
Tip #4 – Have follow-up conversations with physicians about patients you cared for together to build relationships
A quick, easy way to build positive working relationships with physicians is to have follow-up conversations with them about patients that you cared for together. This is something that I do the first few times I interact with a physician. It only takes a few seconds. Here are a few examples:
“Mr. Smith’s pain seems under control today after we added extended release morphine.”
“Mrs. Jones’ kidney function improved – it looks like I didn’t need to adjust the levofloxacin dose after all. Let’s change it back to the original order.”
“I’m glad you sent Mrs. Smith to the ICU; when they laid her flat to place the central line she developed respiratory distress and needed to be intubated.”
When you have brief follow-up conversations like these with physicians, it demonstrates that you are genuinely concerned about the patients you cared for together.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
Great advice, I think this is an excellent episode, although on a picky perspective, I don’t advise “sticky notes”.
Thank you John! When records become 100% electronic, the “sticky note” will go the way of the dinosaur! 🙂
This is well said. I would only add, when you come with a problem, have a solution ready.