Hospitals and physicians increasingly are relying on the expertise of clinical pharmacists like Wendy St. Peter to help manage patients' care

[Reprinted with permission from Minnesota Medicine, August 1995. Copyright 1995, Minnesota Medical Association.]

by William Hoffman

Life sometimes takes funny twists. As an undergraduate student at the University of Montana in Missoula in the late 1970s, Wendy St. Peter was majoring in microbiology when some pharmacy students talked her into switching to pharmacy. Years later, the person who had done most of the convincing became her husband and, ironically, one of her students in a Pharm.D. program. Today they work across the hall from each other at Hennepin County Medical Center (HCMC).

Wendy St. Peter, Pharm.D., is a clinical pharmacist at HCMC and an assistant professor of pharmacy at the University of Minnesota [College of Pharmacy]. Through her activities with the Drug Evaluation Unit and Caremark/RKDP (Regional Kidney Disease Program), she deals with patients directly every day. That is, she practices what people in the field call "pharmaceutical care."

As a member of the renal health care team, St. Peter meets daily with an attending physician, a nephrology fellow, medical residents, and nurse practitioners to discuss each patient's case. Pharmacy is represented on patient rounds by either a clinical pharmacist (St. Peter) or a Pharm.D. resident-in-training and a Pharm.D. student doing a month-long rotation to gain clinical experience.

Clinical pharmacists are now performing tasks that previously were the exclusive domain of physicians, such as evaluation of the appropriateness of prescribed medications. "It's very difficult, with the number of new, complex medicines being released, to keep track of everything-even for a pharmacist who has been specially trained, let alone for a physician who is expected also to know all the information on diagnosis and physical assessment of their patients," St. Peter says.

Is the blurring of boundaries between physicians' and pharmacists' duties a problem? Not in St. Peter's view, particularly not in an era of rapid change and managed care. "No one professional, whether a physician or pharmacist or nurse, can know it all. As we talk more about primary care and the need to emphasize evaluating the whole patient, the pharmacist really does become valuable because of our background and knowledge in the use of medicines," she says.

Caremark/RKDP dialysis units in Minnesota, South Dakota, and Wisconsin serve more than 800 hemodialysis and peritoneal dialysis patients. Acutely ill renal patients require the most sophisticated care. On average, those patients receive 12 prescribed medications.

"With additional years of education, you have the background and skills to clinically assess patients," says St. Peter, who has the traditional five-year bachelor of science degree, a two-year doctor of pharmacy degree, and a two-year post-Pharm.D. fellowship in adult medicine. "With the extra education and training gained through a Pharm.D. program, most people feel they can handle the added responsibility of taking care of patients. [Pharm.D.s] have been quite successful at doing that-within the health care team approach."

The pharmacist's expanding role in patient care is leading to a major shift in pharmacy education (see related story, page 10). Colleges of pharmacy across the country are going to six-year all-Pharm.D. programs and eliminating the traditional five-year bachelor of science in pharmacy. The University of Minnesota will offer only the Pharm.D. degree beginning this fall. St. Peter says the Pharm.D. degree is necessary "to further educate pharmacists in patient care and in new and evolving technologies. It takes the extra education to turn the pharmacist from somebody who is dispensing a product into somebody who can work directly with the patient. I have always advised my students to get their Pharm.D. degree because I believe the extra knowledge and skills enhance patient care skills and ultimately benefit the patient."

St. Peter's personal experience in the field parallels the changes in pharmacy education initiated when she was a college student, changes that correspond with the larger role pharmacists are assuming in many health care settings.

After she completed her bachelor's degree at Montana, St. Peter worked for a year in a hospital pharmacy in Texas, where her husband, John St. Peter, was serving in the Army. She then entered a two-year Pharm.D. program at the University of Texas in San Antonio and graduated in 1986. She completed a two-year fellowship in adult medicine to gain additional research and clinical experience.

While a fellow, she taught pharmacy undergraduates and Pharm.D. students. One student was her husband, the individual mainly responsible for her decision to switch to pharmacy. John is also a clinical pharmacist at HCMC and an assistant professor of pharmacy at the University of Minnesota.

"It's funny how things work out sometimes," she says. "John needed to complete four years of Army service. He became a practicing pharmacist at Ft. Hood, Texas, and I entered the Pharm.D. program at San Antonio. For two years we saw each other every other weekend. Then he got his Pharm.D. degree at San Antonio while I was doing my fellowship."

When a fellowship in pharmacokinetics and a clinical pharmacist position in nephrology both opened at HCMC in 1988, the St. Peters seized the opportunity. "I was looking for a job at the time, and John wanted to get some research experience-a fellowship," she says. "It just happened that the best positions were here, which was also close to our family. It was very convenient and lucky.

"When I got here, my role was evaluating the pharmacokinetics of drugs and monitoring drug therapy in hospitalized renal patients," says St. Peter. "Currently, I'm evaluating ways to expand our pharmacy services to our outpatient dialysis units."

The Veterans Affairs Medical Center has been especially progressive in allowing clinical pharmacists to act as primary caregivers in clinics serving patients with diabetes, lipid disorders, hypertension, and other conditions, says St. Peter. Now other hospitals, including HCMC, are joining in. St. Peter's husband, for example, assesses chronic stable patients on routine follow-up and recommends medications at the HCMC Endocrinology Clinic under clinic director Mehmood Kahn, M.D., who confirms his evaluations.

"Physicians now being educated-for example, the medical residents on our renal service-know what trained clinical pharmacists can do, what their knowledge base is, and how they can help them out," says Wendy St. Peter. "I think many of the physicians now being trained are very comfortable with our role. Some physicians probably feel uncomfortable. It's a matter of getting to know those physicians, working with them, and gaining their trust."

The expanding role of the pharmacist in patient care is also being felt in outpatient settings, even in the neighborhood drug stores. The University of Minnesota Pharmaceutical Care Project has developed a model for implementing comprehensive pharmaceutical care in the community practice setting (see related stories, pages 10 and 14). "Instead of just dispensing medications and preparing notes about how to use them, community pharmacists are learning to evaluate the patient in the outpatient setting," says St. Peter. "They are being trained to evaluate patients and know what to look for in terms of compliance, drug interactions and duplications, and dosage, particularly in patients with chronic diseases like diabetes and hypertension."

Pharmaceutical care, both as a concept and a growing reality, is in many ways a natural evolution, given the high level of public trust and confidence pharmacists have always enjoyed. With the additional training provided through Pharm.D. education and post-Pharm.D. training, clinical pharmacists are well positioned for the transformation to managed care.

"This is an exciting time for pharmacy," says St. Peter. "The opportunity is there. We need to reach out and grab it. I think the physician acceptance is there. Not everywhere, but a lot of medical residents are being trained with pharmacists now and they understand what skills pharmacists actually have. They can appreciate what we bring to the health care system."

William Hoffman is assistant to the director of the Biomedical Engineering Center at the University of Minnesota and a free-lance writer.