Career Paths in Inpatient Care 11

career destination, psychiatric residencies are an especially direct pathway into psychiatric pharmacy practice. Pharmacy residency training involves either one or two years of postgraduate training. Postgraduate year one (PGY1) residencies are broader, more generalized residencies, while postgraduate year two (PGY2) residencies are specialized in a particular area, such as , , infectious diseases, or solid organ transplant. The experiences in PGY1 residencies vary considerably, and students interested in psychiatric pharmacy might consider selecting a PGY1 that offers a psychiatry experience. Furthermore, some students may elect to complete a PGY1 at an institution that offers a PGY2 in psychiatry in the hopes of completing both years at the same institution, but this is certainly not a requirement. The PGY2 psychiatric residencies also vary con- siderably among institutions. Some PGY2s in psychiatry are offered at university hospitals or mental health clinics, while others are housed in state psychiatric hospitals or veterans’ affairs facilities. Other factors that students should consider with PGY2 psychiatric residencies include the setting (e.g., inpatient, outpatient, or both) and the experiences offered (e.g., adult, adolescent, geriatric, addiction, or forensic psychiatry). Students interested in residency training should begin learning about and preparing for residencies sooner rather than later during their tenure in pharmacy school. Psychiatric pharmacy continues to be a vibrant field in which to practice pharmacy. The constant stream of new medications, expanding literature, and evolving diagnostic criteria create a dynamic environment for pharmacists to thrive professionally. There is immense satisfaction in working with the mentally ill and molding the next generation of pharmacists. All these years later, I continue to think psychiatric pharmacy is pretty cool—just for completely different reasons.

PERSPECTIVES FROM TWO NEW PRACTITIONERS IN INPATIENT CARE POSITIONS Perspective I Riane J. Ghamrawi, PharmD, BCPS

Working as a pharmacy specialist means you are trained to be the expert in a field as well as an accessible resource and educator to your medical colleagues, students, residents, and department members. As a result, a huge responsibility comes with your job and many personal and career-fulfilling rewards.

A Typical Day A typical day of an infectious diseases (ID) pharmacy specialist will differ depending on the site, exact title, and job description set by the department and the institution’s needs. An ID-trained pharmacist can be involved in many different roles, but is predominantly involved in either direct patient-care, an antimicro- bial stewardship program (ASP), or a combination of both—with the latter being the more common job description for ID pharmacy specialists. Additionally, an ID pharmacy specialist’s job may involve inpatient, outpatient, or combination of both aspects of an institution’s patient-centered care. Therefore, managing time between the different aspects of the job is one of the many keys to success in this field of practice. Inpatient Direct-Patient Care. The ID specialty service is usually referred to as a consult service in the inpatient world. As a consultative service, the care of managed patients can overlap with many other disci- plines and departments (i.e., , pulmonary-critical care, internal , solid-organ transplant, bone-marrow transplant). Therefore, a strong baseline of clinical knowledge is essential to understand the 12 Career Paths in Inpatient Care pathophysiology and management of patients with very distinct and varying medical backgrounds. A typical day for an inpatient specialist starts with preparing for patient care rounds by reviewing charts and orders within the medical record. Notation of patient progress (improvement or worsening of infections), recom- mendations (change of doses based on drug levels or fluctuating renal function), and monitoring for adverse events is completed and discussed with attending , fellows, and residents on rounds. In most hospitals, ID rounds are in the afternoon, allowing for other disciplines to care for patients in the morning and calling for ID’s expertise, if needed, afterward. A pharmacist is key in managing antimicrobials requiring therapeutic drug monitoring (e.g., , aminoglycosides, voriconazole). Additionally, specialists are key in optimizing the care of patients with ID processes by performing daily reviews of microbiology data, which may necessitate escalation (broadening antimicrobial spectrum of coverage) or de-escalation (narrowing antimicrobial spectrum of coverage), as deemed necessary and appropriate. Fur- thermore, a thorough review of patients’ laboratory test results provides information on toxicities caused by an antimicrobial, reveals opportunities for antibiotic dose optimization or adjustments based on renal or hepatic function, and identifies interacting medications. Additional morning activities include answering ID-related drug information questions from other pharmacists, physicians, and nurses, attending pharmacy and medical conferences, attending pharmacy and ID department meetings, and reviewing and updating protocols, as necessary. Protocols may be departmental, program, or drug-related. Examples of ID-related protocols include intravenous to oral antibiotic switch criteria, restricted antibiotic approval processes, and automatic renal dosing adjustment guidelines for antimicrobials. During months of precepting pharmacy students and residents, the mornings are spent reviewing patients and recommendations before rounds as well as preparing and participating in topic discussions. As an ID specialist, one may also be directly involved in the training of medical residents and fellows. As a result, time may be spent in instruction and in preparation of didactic lectures for all or a select group of trainees focusing on providing them with the knowledge necessary to act as the medication expert to the medical staff and providing the necessary pharmacy-related resources that will assist with optimizing and monitoring of their ID patients. Feedback on recommendations provided on rounds and topic discussions completed on specific patient cases or diseases states are essential. Furthermore, depending on the special- ist’s affiliation with a pharmacy or , time may be spent preparing for didactic lectures to be given at the different institutions. While the day of an inpatient ID pharmacy specialist is definitely busy, the rewards of being involved directly and indirectly in patient care activities and training future practitioners are aspects of the job that make long working hours worthwhile. Antimicrobial Stewardship Program. Antimicrobial stewardship program (ASP) goals include the optimi- zation of antimicrobial use to improve overall patient care and healthcare outcomes through the selection of appropriate antimicrobials, while minimizing the risk of adverse events and long-term individual and epidemiological sequelae due to inappropriate antimicrobial therapy. This is particularly important in an era where infections caused by multidrug-resistant continue to threaten the treatment of once manageable infections. The ID specialist, as an integral part of the medical team participating in patient rounds, is heavily involved in antimicrobial stewardship, which is inherently a necessary aspect of their job description. However, some hospitals and health systems have more formalized ASPs that involve active surveillance of the entire hospital’s antimicrobial use and microbiologic data. A typical day of a pharmacist involved in ASP will differ vastly based on the size of the institution, availability of certain technology, and overall institution’s goals for the program. Typically, on a day-by-day basis, ASP activities include reviewing, updating, and developing set protocols and policies (i.e., intravenous to oral antibiotic conversion policies,