Many pharmacists are interested in expanding their clinical role to include carrying out of medication reviews. In order to do this, there is a requirement to become formally accredited to conduct these reviews.
The accreditation process can be daunting for some pharmacists, as it involves an assessment of their clinical knowledge and their ability to appropriately apply that knowledge to particular patient situations (clinical skill, rather than clinical knowledge).
The AACP has identified that some pharmacists progress through the accreditation process more easily than others, and that each pharmacist’s background, clinical and communication skills can influence their progression through the accreditation process.
This module is intended to provide feedback on your background and clinical and communication skills, as a guide to how demanding the accreditation process may be for you.
All pharmacists have the necessary basic foundation to undertake the accreditation process. However, it is clear that those with experience in clinical settings and a desire and commitment to further their clinical skills, progress through the accreditation process more smoothly.
The following questions are intended to determine the appropriateness of your background and experience.
1. Some pharmacists may consider conducting medication reviews as a relatively easy way of augmenting their income without any major additional work or upgrading of skills. Becoming an accredited pharmacist will require you to demonstrate a high level of clinical and communication skills and a commitment to maintaining these skills for the duration of your accreditation. While being an accredited pharmacist can be rewarding (particularly in terms of satisfaction), it can also be a demanding and sometimes daunting practice. A genuine passion and focus on the satisfaction associated with conducting professional pharmacy activities and services is often associated with a smoother progression through the accreditation process.
Which of the following best describes your main reason for considering becoming an accredited pharmacist?
2. Becoming accredited by the AACP will require you to undertake a baseline online assessment as well as completing four written case studies that will be assessed. The preparation for the online assessments and the written case studies can be considerable, and it is recommended that sufficient time be allocated to do this. If pharmacists do not allocate an appropriate amount of time to complete the assessment tasks, then their progression through the accreditation process slows. Depending on the prior level of clinical skills, an allocation of up to one week per case study (ie one month of full time work) over the assessment period may be required.
Will you be able to commit an adequate amount of time to the accreditation process?
3. Pharmacists with a strong clinical or educational background often progress through the process of becoming accredited relatively easily. Experience in a clinical setting, such as hospital pharmacy often expands the pharmacist’s clinical knowledge of common diseases and their management. In addition, the experience of working with other health professionals in such clinical settings enhances the pharmacist’s ability to communicate with patients, medical practitioners and others.
Do you feel that you have spent some time in a clinical setting that would enhance your ability to progress through the accreditation process?
4. Pharmacists who have completed relevant clinical study (diplomas, degrees or research) may find that the clinical knowledge assessment process requires less preparation. The breadth of topics covered in clinical or hospital masters courses or other similar clinical or disease management programs forms a foundation for the clinical skills required to progress through the accreditation process.
Do you believe that you have completed some relevant study/research that would enhance your ability to progress through the accreditation process?
5. In order to practice as an accredited pharmacist, you will be assessing the medications taken by patients and determining whether there are any medication related problems that need to be addressed. You will need to make recommendations to General Practitioners and these will (obviously) need to be appropriate and current. As an indication of the advanced practice of being an accredited pharmacist, you will be required to maintain a high level of relevant continuing professional development (60 credits per year) in order to maintain accreditation.
Do you believe that you can easily meet the CPD requirements for accreditation?
6. Pharmacists who have an easily available colleague who is already accredited or is a competent clinical practitioner may find that the advice and mentorship from that colleague facilitates their progress through the accreditation process.
Do you have easy access to an accredited or other clinical pharmacist who may be able to mentor you through the accreditation process?
A score of 4 or more in this domain (background and experience) is likely to be associated with a pharmacist who has an appropriate degree of motivation, time and additional experience and/or resources to complete the accreditation process. Pharmacists with lower scores may still complete the process, but are likely to have to undertake some additional studies or obtain some assistance to do so.
All pharmacists have a great deal of knowledge regarding medications and the disease conditions they are used to treat. This knowledge is gained through a combination of formal training, continuing professional development and experience in practice. Being an accredited pharmacist will require that you apply that knowledge to particular situations that you identify as part of medication reviews.
The clinical skills required fall broadly into three areas
• Obtaining appropriate information (by undertaking medication histories, patient interviews, interpretation of pathology test results etc.)
• Identifying and prioritising medication related problems (by applying an understanding of medications and their use and focusing on issues that are relevant to the patient)
• Selecting an appropriate recommendation to address the problems identified (by assessing the options and choosing the most appropriate for the specific patient situation at hand)
The questions below are intended to provide you with some indication of the level of clinical sills required to complete the accreditation process.
1. A 78 year old man had a heart attack 10 years ago and has hyperlipidaemia, hypertension and heart failure. He was a smoker until his heart attack (30 pack year history) and also has some mild airways disease. In addition he has some osteoarthritis of his knees and lower back.
Aspirin 100mg each morning
Atorvastatin 40mg each night
Frusemide 40mg each morning
Metoprolol 25mg twice daily
Paracetamol 665mg 2 three times daily when required
Ramipril 5mg each morning
Salbutamol inhaler 100mcg when required
Tiotropium powder for inhalation 18mcg daily
Over the past few months he has become increasingly short of breath, especially when he lays down at night. On two occasions he has woken during the night with a sudden onset of shortness of breath. On these occasions, getting up and using his salbutamol has relieved the symptoms. He has taken to sleeping in a recliner chair which is beginning to exacerbate his lower back pain.
Which of the following statements concerning the most likely cause of his breathing difficulties is most appropriate?
While the role of pharmacists is to focus on medication related matters, there is a requirement to understand common disease processes and their consequences. This is because some symptoms may appear to be related to medications, but could be due to underlying disease processes.
In this question, the symptoms of positional shortness of breath (orthopnoea) and the sudden onset of nightime shortness of breath (paroxysmal nocturnal dyspnoea) are classical symptoms of worsening heart failure. Thus option a) is incorrect (in fact the metoprolol is probably helping his shortness of breath by improving his heart failure). Option b) does not address the cause of the problem and the fact that salbutamol was effective for his nightime shortness of breath was more likely to do with his getting out of bed (changing his position to upright), rather than any effect of the salbutamol. Option c) may actually worsen the situation as prednisolone may contribute to fluid and sodium retention. Option d) is the only option that addresses the most likely cause of the problem and is the correct answer.
2. An 88 year old woman has chronic atrial fibrillation, hypertension, osteoarthritis and has had a stroke in the past. She is still mobile (using a 4 wheel walker) and lives at home with support from her daughter to help with shopping and cleaning.
Her current list of medications is as follows:
Amiodarone 100mg daily
Atorvastatin 40mg each night
Digoxin 125mcg daily
Diltiazem 180mg each morning
Metoprolol 25mg twice daily
Paracetamol 665mg 2 three times daily when required
Warfarin 3mg daily
She visited the GP 2 weeks ago as she was feeling a bit more lethargic. At that time her blood pressure was 100/60mmHg, her heart rate was 52bpm at rest and her INR was 2.6.
There are a number of drug interactions in this patient’s drug list. Which of the drug interactions seems to be impacting on her signs and symptoms the LEAST?
Many drug regimens contain multiple drug interactions. One of the clinical skills required as an accredited pharmacist is to be able to determine which of the drug interactions are more important. Those interactions that are more important are those that are having an impact on the patient in terms of signs (measurable things) or symptoms (what the patient tells you) or have a significant potential to do so.
In this question, the INR is normal but there is a degree of bradycardia (52 bpm) and some associated lethargy. Thus, although drug interactions with warfarin are always of concern, in this case, the drug interactions that may be present relating to warfarin (amiodarone and possibly diltiazem) are of less concern as the INR is normal. On the other hand, any interactions that impact on heart rate are more important as they may be contributing to the bradycardia and lethargy. Options b), c) and d) are examples of drug interactions that all may produce bradycardia. The correct answer is option a) as although there is an established drug interaction between amiodarone and warfarin, the situation is stable as evidenced by the appropriate INR.
3. A 67 year old woman has a 10 year history of type 2 diabetes, hypertension and hyperlipidaemia. She is obese and weighs 89kg (BMI = 31kg/m2) and has significant osteoarthritis of the knees. Her GP has advised her to lose weight, or she may have to commence on insulin soon. She would like to do this, but says that her knee pain is stopping her from walking enough to lose weight (she has a dog, so walking may be a good option for her). Her current list of medications is as follows:
Aspirin 100mg each morning
Atenolol 50mg each morning
Irbesartan 150mg each morning
Paracetamol 665mg 2 three times daily when required (takes these approximately once a day)
Simvastatin 40mg at night
Sitagliptin 50mg/Metformin 500mg (Janumet) 1 twice daily
Current blood pressure is 140/85mmHg. Laboratory tests from 3 months ago are as shown below:
Total Cholesterol 3.9 mmol/L
Triglycerides 2.2 mmol/L
HDL Cholesterol 1.1 mmol/L
LDL Cholesterol 1.8 mmol/L
HbA1c 8.8 % (73mmol/mol)
There are a number of potential medication related problems in this case. Which of the following problems would have the highest priority in this lady?
In a medication review process, it is common to identify multiple issues in a particular case. One of the clinical skills that is required as an accredited pharmacist is being able to prioritise medication related issues. Most often, the issue with the greatest importance is the issue that the patient identifies as their main problem. Addressing the issue(s) that the patient identifies, makes the recommendations from the medication review “patient centred” and more likely to have an impact on the patient’s wellbeing.
In this question, the patient has a desire to lose weight (motivated by the “threat” of insulin) but is held back (at least partially) by knee pain. A high priority should therefore be placed on any recommendations that facilitate exercise and/or weight loss. Option a)- stopping the aspirin-would not impact on her quality of life or her weight/exercise capacity. Similarly, option c)- reducing the statin dose- may not result in any symptomatic improvement. Option d)- starting a sulphonylurea- may actually contribute to weight gain and it is highly likely that she has tried a sulphonylurea before. There is also the issue of beta cell failure to consider with sulphonylurea use, and this class may no longer be effective in this lady. Option b)- increasing her paracetamol dose- is the only option that has the potential to reduce her knee pain and would be the highest priority in this case.
4. A 87 year old man is a resident of a nursing home. He had a stroke 10 years ago and was admitted to the home then. He has heart failure, a history of hypertension, ischaemic heart disease and hyperlipidaemia and also has had prostate cancer in the past. Two years ago, his prostate cancer recurred and he now has multiple bone secondaries. He is now bedbound and unable to mobilise without full assistance. His pain is well controlled on his current regimen, his bowels are functioning well. He has some mild shortness of breath when being showered or washed, but is comfortable when he is resting in bed. His mood is good, even though he knows he is going to die. He still does crosswords daily and he sleeps well. There are no recent blood tests available.
Aspirin 100mg each morning
Coloxyl with Senna 1 twice daily
Escitalopram 20mg each morning
Frusemide 80mg each morning and 40mg at lunchtime
Meloxicam 15mg daily
Mirtazapine 30mg at night
Oxycodone 5mg 4-6 hourly when required
Oxycodone/Naloxone 20mg/10mg (Targin) 2 in the morning and 1 at night
Paracetamol 665mg 2 when required once daily
Paracetamol 665mg 2 twice daily
Ramipril 1.25mg each morning
Rosuvastatin 10mg daily
Spironolactone 25mg each morning
There are a number of potential medication related problems in this case. Which of the following problems would have the highest priority in this man?
In order to provide appropriate patient centred medication related recommendations, the overall clinical situation and the goals of care for individual patients should be taken into consideration. One of the clinical skills required as an accredited pharmacist is the ability to “look at the big picture” and ensure that any suggestions made are in keeping with the overall situation. In this case, the “big picture” is an elderly, debilitated man with a limited prognosis, who is relatively comfortable as his symptoms are being managed well, albeit with a large number of medications.
In this question, option a)- increasing the intensity of his near maximal heart failure management- may result in an improvement in his symptoms. However, these do not seem to be of major concern as the shortness of breath is rated as mild. Option b)- ceasing the laxative- is inappropriate given his bowel function is good. Option d)- stopping one of the antidepressants- should be considered in light of the purpose of the combination. Mirtazapine taken at night may be helping with sleep and any anxiety issues, while the escitalopram may be of use more specifically for mood. In the absence of any specific adverse effects and given the fact that he is well and comfortable, stopping one of these agents may result in either disturbed sleep or worsened mood. Option c) –stopping the stroke prophylaxis- seems in keeping with the palliative nature of his goals of care and would be the most appropriate option of the ones given.
A score of 5 or more in this domain (clinical skills) is likely to be associated with a pharmacist who has an appropriate level of clinical skills to complete the accreditation process. Pharmacists with lower scores may still complete the process, but are likely to have to undertake some additional studies to do so.
1. One of the fundamental skills required as an accredited pharmacist is the ability to interview a patient regarding their medication use. This will require dealing with a range of different patients, who may be somewhat unwell and often the discussions may touch on sensitive or personal aspects of their medication use. The accredited pharmacist is required to be courteous and diplomatic and yet is required to “tease out” details of any issues relating to medication that the patient may have. Pharmacists who are good oral communicators are more likely to progress through the accreditation process as these oral communication skills often translate into a good performance in the written case study component of the assessment.
How would you rate your oral communication and interview skills?
2. A RMMR is performed for a 78 year old female nursing home resident with a medical history that includes advanced dementia, depression and frequent falls. Her medications include 150mg dothiepin each night.
As a result of the RMMR, the pharmacist identifies that the dothiepin may be adversely affecting the resident’s cognition and contributing to her falls.
Which ONE of the following statements do you believe most appropriately articulates this issue to the GP in the medication review report?
One of the most important forms of communication in mediation reviews is the clinical assessment report in which drug-related problems are identified and recommendations are made to resolve or prevent these problems. This report, which is sent to the referring general practitioner, is frequently the only communication between the pharmacist and the GP after the review. Consequently, it is very important to use appropriate language in medication review reports, particularly when the problem involves a perceived poor prescribing decision. If accusatory or belittling language is used then there is a much greater potential for professional relationships to be affected than if the report is written respectfully.
In this question, dothiepin appears to be a poor choice of antidepressant for the elderly resident with dementia. In option a), the statement “You have prescribed” is accusatory towards the GP, and may in fact be incorrect information. Many residents of aged care facilities change GPs when they are admitted, so the dothiepin may be been started by another GP prior to the resident entering the facility. The use of the word “contraindicated” in option c) is essentially telling the GP that they have done something that should not be done, which may also be perceived as accusatory. Directly quoting guidelines as per option d) implies that the doctor has prescribed something in contradiction to their colleagues’ recommendations. In this case, option b) most appropriately conveys the nature of the problem.
3. A 58 year old man receives a HMR. His medical history is significant for osteoarthritis in both knees and he has had bilateral hip replacements. He is taking 1000mg of paracetamol three times daily and sustained-release oxycodone 40mg twice daily for pain.
During the HMR interviewed it is identified that his pain is very well controlled. However, he is troubled by constipation despite taking a regular laxative regimen of docusate and senna 50/8mg twice daily, Movicol and lactulose.
Which ONE of the following statements do you believe most appropriately articulates this issue to the GP in the HMR report?
In addition to the style of language used in medication review reports, the length and terminology used should also be appropriate. GPs are generally time-poor, and typically appreciate medication review reports that convey the meaning clearly and succinctly. The use of appropriate medical terminology also assists in the effectiveness of written communication in these reports.
Each of the statements in this question contains the same information, but each is written differently. Option a) uses medical terminology excessively, and is very formal in its construction. In contrast, the use of colloquialism in option b) is unnecessary and may be perceived as unprofessional by some prescribers. Option c) is overly long due to it containing unnecessary information about a straightforward issue- GPs know that opioids cause constipation, and the reasons way are immaterial to the problem.In this case, option d) most appropriately conveys the nature of the problem- it is clear, succinct and uses appropriate medical terminology.
A score of 5 or more in this domain (Communication skills) is likely to be associated with a pharmacist who has an appropriate level of communication skills to complete the accreditation process. Pharmacists with lower scores may still complete the process, but are likely to benefit from some assistance (eg mentoring) to complete the case study assessment process.
This module is intended to provide feedback on appropriateness of background and clinical and communication skills, as a guide to how demanding the accreditation process may be for the candidate.
There are three domains assessed in this module which can be presented on a radar plot to visually illustrate where candidates have scored well. The maximum score for each domain is 8, with a score of 8 in each being represented by an equilateral triangle (Figure 1).
A candidate with strong communication and experience but less clinical acumen may be represented as shown in Figure 2.
A candidate with strong communication skills but less clinical acumen and experience may be represented as shown in Figure 3.