Download Small Group Breakout - Diabetes case - teachers edition

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.