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Outpatient Diabetes Case: You are a clinician educator working in an interprofessional primary care training clinic. In this setting there are primary care providers (MD, NP—faculty and trainees) supported by a team of pharmacy, health psychology, social work and physical therapy trainees and faculty. This team is embedded within the clinic in a patient centered medical home model. You are precepting one of your MD residents who is presenting a patient who she has taken care of for two years and is a very poorly controlled diabetic. You both agree that referring the patient to your team pharmacist and health psychologist might be useful to contribute to this patients diabetes management. The MD resident suggests to the patient that she thinks referral to her team members might be helpful and the patient agrees. The resident is about to go off immersion block and will return to immersion block in 6 weeks. When the resident returns she sees that her patient was seen by both the pharmacist and the health psychologist in her absence. The pharmacist changed the medication regimen that the patient had been taking, started the patient on telehealth and review of blood sugars look dramatically improved, although the patient has had a few hypoglycemic episodes. The resident comes to you and is upset that the pharmacist did not contact her first prior to changing her patients medication regimen. She states that she is the primary care provider and thought that the pharmacist was just a consultant. This certainly can be a common situation for trainees and healthcare professionals who are not used to working with clinical pharmacists, as the role/responsibilities of the clinical pharmacist in primary care can be much different than a traditional pharmacist’s role that many are accustomed to (for example, retail/community pharmacist). It’s important for clinical pharmacists on the primary care team to advocate for themselves (as well as other team members to advocate for their pharmacist colleagues) and explain what pharmacists are capable of doing in patient care in order for the team to understand their role. It would be important to assure that every member of the team realizes that the pharmacist works under a scope of practice/collaborative practice agreement with the institution/clinic that allows them to prescribe/make adjustments to medications under that scope (for primary care this usually includes diabetes, hypertension, cholesterol medications, but may include others depending on the scope of practice—for instance, thyroid medications or anticoagulants). This could be an explicit communication to all team members that could have happened before this direct patient care encounter OR a discussion with resident during precepting session. Clinical pharmacists are certainly available for questions, advice, and consults, but when a patient is referred to Pharmacy Clinic pharmacists are expected to work at the top of their license in order to provide increased access to care (for instance, when PCP is not available or PCP’s schedule is booked full but patient needs close follow up) and aim for improved patient outcomes in terms of managing medications to treat chronic disease states. 1. How would you respond to this resident? 2. Who is the “leader” in this case? Does there need to be a leader? a. When working in an interprofessonal team setting, the leadership role may change from professional to professional depending on the needs of the patient and availability of staff. It would be beneficial for different healthcare professionals who are caring for the same patient to communicate which professional will act as a leader in particular aspects of care. 3. How could the team best work together as team members to achieve the best care possible for the patient? a. Teamwork goes beyond simply referring to another healthcare professional. Team members should work to collaborate with their colleagues of different professions and communicate to make plans together. The outcome of this situation may have been different if the team members discussed together each of their expectations for management of this patient’s diabetes to identify potential problems ahead of time. For example, if the resident did not want to change a particular medication for a clinically significant reason, it would be important for the resident and the pharmacist to have this discussion together to reach an agreed upon goal for this patient’s care. It is common for different healthcare professionals to have different goals of care, so it’s important to communicate between professions to come up with a common goal/plan. 4. What could you have done differently during the precepting encounter prior to referral to the pharmacist? a. When suggesting a referral to clinical pharmacist during precepting, it may be helpful to ask the resident/trainee what their expectations of how pharmacist referral would be helpful—to gain insight on resident’s perspective of clinical pharmacist’s role. 5. What explicit communication about all health care team members could have happened prior to this direct patient care encounter? a. It is important when working collaboratively in interprofessional teams to ensure all team members are familiar with roles/scope of practice and expectations prior to working in the team. This communication must be explicit and agreed upon by all team members. Direct observation of team members in a patient encounter is helpful to fully understand these roles.