Key Questions to Ask When Establishing a Clinical Practice: What I Wish I Knew When I Started

Whether you are a recent graduate or transitioning into a new position, it can be a daunting challenge to develop a practice site. Previous reports in the literature have discussed establishing a clinical practice and overcoming practice site challenges.1–3 We provide pearls of wisdom for establishing successful clinical practices and key questions to discuss with stakeholders during the interview process.

SEARCH OUT UNMET NEEDS

Determining the need for a service or practice cannot be emphasized enough. Workplaces are dynamic settings; adapting your practice to meet unmet or changing needs will be an enormous asset for an employer. Intrapreneurship, or acting as an entrepreneur within a larger organization, serves as the foundation of many new and innovative clinic services. Specific factors to explore when determining need include patient population, cost savings, quality improvement, medication safety, and generating revenue through billing.

In addition, certain medication classes can serve as the basis of successful pharmacotherapy clinical practices, such as medications with complex prescribing regimens, dose individualization requirements, narrow therapeutic index, high cost, and strict adherence requirements.1 A clinical practice based on these factors will have a much greater chance of success.

SELL YOUR IDEAS

Whether the interview is structured or open ended, the time allotted to ask questions is perfect for pitching your clinical practice ideas. Preparing beforehand with an elevator speech, a clear message about you, and a written practice philosophy statement will help you present your ideas. Proposed key elements of a practice philosophy include the optimal patient care role, role of technicians and technology, value of the pharmacy profession, role of a pharmacist as part of the interdisciplinary care team, leadership and stewardship, and the value of scholarship to practice.4 Promote no more than 3 ideas to keep your presentation within the time constraints and to demonstrate a practical outlook.

BUILD YOUR PRACTICE

After accepting the position, you should spend considerable time developing short- and long-term goals. One strategy is to set SMART goals – specific, measurable, attainable, realistic, and timely.5 For example, if your desired practice is ambulatory care, a SMART goal could be the initiation of a once-weekly anticoagulation clinic within 3 months that will use point-of-care testing and a collaborative practice agreement. Setting short-term steps or subgoals to achieve this clinical practice will greatly increase your chance of success. In addition, seek out a champion in your organization and reach out to established clinicians outside your organization to review your plans, offer feedback, and mentor you as you develop your services.

NOTE FOR FACULTY

For practice-based faculty positions, open lines of communication between all parties are essential. The American College of Clinical Pharmacy's Clinical Faculty Survival Guide is a great resource, and it is applicable for all types of new practitioners.6 This text provides guidance about the 3 pillars of academia – teaching, service, and scholarship, and it includes discussion about leadership and lifelong learning. A think tank established by the University of Tennessee College of Pharmacy on building good relationships between faculty members and clinical training sites revealed that friction often occurs from a lack of understanding between parties. Issues such as holiday coverage, faculty responsibilities outside of clinical care (eg, committees, scholarship), and perceived lack of accountability to the pharmacy director or supervisor at the practice site were noted as common complaints.7 Clear communication up front would prevent many of these issues and foster a sense of collegiality.

Buying into the system's culture, building your network, and promoting your clinical practice are 3 key areas that are especially critical for the new practitioner. We offer our experiences in these areas.

PERSONAL PERSPECTIVES

Buying Into the Culture (J.W.)

My first position after residency training was a clinical faculty position affiliated with a regional private medical center. In meeting with the department director and clinical coordinator, we found that a practice interest of mine met a mutual need of theirs – pulmonary medicine. We agreed that I would provide clinical coverage 3 days per week for the progressive pulmonary unit. A few months into the position, our hospital transitioned to an electronic medical record (EMR), which decreased order processing time and allowed staff to pursue clinical initiatives. With support of hospital leadership, we began interdisciplinary rounds 3 days per week, which helped advance my clinical practice.

Several elements early in the process were crucial in my success: (1) I partnered with successful individuals in my organization and developed a team-based clinical practice; (2) I found physician champions and administrators who supported me when obstacles occurred; and (3) I took time to evaluate and change my clinical practice.

For new practitioners, buying into the practice site's culture is especially critical. The new practice site may be vastly different from where you trained. A classic example would be recent residency graduates from academic medical centers establishing clinical practices at community-based institutions, where formalized teaching patient rounds, noon conferences, and grand rounds lectures may not be the norm. Understanding the culture of the institution will help you build services that will be successful in the long term. Making an effort to support department functions (staff huddles, fundraisers, social events) goes a long way. My first year, I offered to provide a continuing education series accredited through our university, which aligned with the medical center's department of pharmacy goals and extended the university's mission of teaching.

Building Your Network (N. B-H.)

I can't stress enough the importance of identifying your team. My first practice site was a family medicine clinic, and I sought out the best phlebotomist to help me when international normalized ratio values from my point-of-care machine exceeded the available range. She understood the urgency and did not mind the interruptions. In this same setting, I worked with a standout medical resident yearly to identify their learning needs.

When I worked for a clinical trial organization, I identified ideal physicians to partner with for research collaborations. Because it was a private endocrinology practice, the physicians did not have any research requirements, but many of them wanted to pursue this avenue and just did not know how. Also, one of my study coordinators was trained as a paramedic. He was patient and willing to teach me how to perform an EKG and phlebotomy.

In the community pharmacy setting, I relied on rockstar pharmacy technicians. I made a point to regularly say thank you and offer small treats when I could.

The saying is true, there is no “I” in team. You may not have a role in the hiring of staff, but finding the right partners can help make a better you.

Promoting Your Clinical Practice (T.H.)

My first practice was in an inpatient setting in a teaching hospital. I was the third pharmacist at my medical center with a clinical practice. My team wasn't sure what to do with me at first. Some of the team members, such as the physician assistants and nurse practitioners, were unsure of what my role as the pharmacist would be and were wary of my involvement. They had their own way of doing things and were not willing to change just because a pharmacist was part of the team now. Instead of trying to jump in with both feet and “prove” my expertise, I took some time to get to know the patient and team dynamics. I made specific patient interventions where needed and assessed where medication procedures could be improved. Once I had built up trust with my fellow team members and staff nurses, I prioritized what could and should be done with the input of the director of pharmacy and the team. Education was needed on pharmacokinetics and parenteral nutrition ordering, and that is where I started. As time went on, I became an integral part of the team, and we all worked together very well. I think that if I had come in and started changing the way things were done immediately, there would have been some significant pushback from some team members.

When starting a practice in a new setting, regardless of whether clinical pharmacy services were there prior to your arrival, it is always a good idea to take time to assess the processes currently in place. Start with small adjustments, while always keeping patient care first. Build up to the big modifications. Get to know how the team works. Don't try to take on too much all at once. Over the first few months, let your team members get to know you and appreciate your input and expertise.

CONCLUSION

We have developed a list of questions (Appendix) that the candidate should ask when negotiating a practice site. While every practice site is unique, we hope that these questions stimulate open discussion necessary to establish a long and successful relationship between all parties involved. While one cannot predict every possible obstacle to success, proper planning and asking the right questions can make all the difference.

APPENDIX: New Practice Site Questions and Items to Address.

1. Appreciate the practice environment's culture:

   • ○ Review the organization's mission statement and patient population.
   • ○ Inquire about current clinical pharmacy services. Is this the first?
   • ○ Ask to meet with as many future colleagues as you can in your area of interest – technicians, nurses, administrations, and physicians.
2. Determine the expectations of the employer:

   • ○ How will you be evaluated?
   • ○ Do opportunities for advancement exist?
   • ○ What are the patient care responsibilities and day to day expectations?
   • ○ Discuss the funding for the position.
   • ○ Ask about professional opportunities (committee membership, precepting students, presentation and publication opportunities, travel to professional meetings).
3. Review operations and regulatory requirements:

   • ○ Discuss available workspace, technological resources, and access to medical record systems.
   • ○ What are the licensure and training requirements?
   • ○ Examine the collaborative practice agreements.
   • ○ Review the Institutional Review Board (IRB) processes.
4. ○ Discuss the clinical environment and interprofessional collaboration:

   • ○ Ask the pharmacy director (or hiring manager) about potential physician champions and opportunities to collaborate with clinicians in the organizations with similar interests.
   • ○ Discuss the credentialing process.
5. Questions for clinical faculty (if applicable):

   • ○ Ask about the potential for collaboration in teaching, scholarship, and clinical services.
   • ○ What are the expected hours, degree of flexibility, coverage for campus duties, professional meetings, and campus holidays?
   • ○ What is the orientation process?
   • ○ What is the anticipated date to begin patient care duties?
   • ○ What is the date to begin precepting duties and what is the expected number of students?
   • ○ How will you be evaluated? Will you have separate evaluations from the practice site and college?
   • ○ What is the working space for students?
   • ○ What are the steps to obtain access to patient care (ID badges, login credentials for EMR, computer training, other requirements)?
   • ○ Precepting loads can vary widely. Can the site accommodate multiple students?
   • ○ Will the practice site accept university IRB approval?
6. Introduce continuing professional development:

   • ○ Set aside time for active reflection.
   • ○ Establish a written practice philosophy.
   • ○ Consider requesting a practice site evaluation from a supervisor or senior leader (for clinical faculty, this is usually part of the annual evaluation).
   • ○ Collect data on achieving your objectives and use them to promote or publish your clinical services.