Establishing a New Practice Site in the Ambulatory Setting

Katherine Saunders, PharmD BCOP
Ambulatory Oncology Clinical Pharmacy Specialist
Georgia Cancer Center/Augusta University Health
Augusta, GA

The role of the oncology pharmacist on the care team continues to expand, and this growth is especially apparent in the ambulatory setting. Our training, skills, and pharmacotherapy knowledge place us in a unique position to care for this patient population, and other healthcare providers and administrators are seeing the potential for pharmacists to improve the quality of care for patients with cancer. Given this expanding role in the ambulatory setting, many current postgraduate year-2 (PGY-2) oncology residents find themselves applying and interviewing for positions that involve establishing a new practice site. But how does a brand-new graduate go about carrying out this task?

After completing my PGY-2 oncology residency at University of Wisconsin Health in Madison, WI, I took a position at Augusta University (AU) Health in Augusta, GA, in the ambulatory oncology setting. My mission: (1) to establish a new practice site in the solid tumor clinics that would enhance patient care and be successful enough to justify more positions in other oncology clinics and (2) to create a new learning experience for PGY-2 oncology residents, PGY-1 pharmacy residents, and advanced pharmacy practice experience students. Sounds simple enough, right? Having just completed my PGY-2 at an institution that launched new pharmacist positions in the oncology clinic at the beginning of my residency year, I had seen some of the challenges my preceptors faced as well as the projects that had been successful and well received. I had also once been a student and resident, so I felt confident that I could develop learning experiences while also establishing myself as an independent practitioner. I thought that I had set realistic expectations for myself and that I could reasonably achieve my goals during my first year at AU Health. Reflecting on my first year out of residency and the subsequent experiences I have had in my position has shown me that my expectations were not as realistic as I had hoped. I want to share what worked well for me, what was not successful, and what I recommend to anyone creating a new practice site.

First, the Dos

Do learn about the pharmacy department and oncology pharmacy service line.

Your initial onboarding is a key step in being successful in your clinic. This is your chance to see the priorities of the institution and pharmacy department in action. It is also an opportunity to see what initiatives other pharmacists are working on and what they struggle with in carrying out their daily duties. How do your goals for your position help the department? What can you do for your pharmacy team members? After completing a PGY-2 residency in oncology, you will be very familiar with the challenges involved in transitions of care. What initiatives are the inpatient oncology pharmacists working on? Can your role in the clinic help them be more successful in their jobs, and vice versa? The answer is yes, and when you are observing the inpatient practice site during your orientation, you will start to see how you can enhance their practice from the clinic.

Make sure your initial orientation to your position includes the opportunity to shadow pharmacists in other service lines. Even if the clinic position is new for oncology, the institution may have pharmacists in other clinics, such as those for internal medicine or infectious diseases. If this is the case, ask that your orientation schedule includes time in those clinics. How are those pharmacists integrated into the healthcare team? What clinical services do they provide? What challenges do they face in their clinics? Although the disease states are different, I have found that many of my ambulatory pharmacist colleagues face the same issues I do, and they can be great sounding boards for new ideas.

Finally, spend time in your infusion pharmacy to understand the operational opportunities in the cancer center. How can you improve the safety and efficiency of the production process? What challenges do the infusion pharmacy staff members face? Having a pharmacist in the ambulatory clinics will improve the communication between the infusion pharmacy and the providers, and improvements in this area will enhance patient care.

Do learn about your clinic.

When you are establishing a new pharmacy practice site, it is important to remember that the clinical practice site was likely already in existence. It has been successful enough to still be in operation and to expand services to include its own clinical pharmacist! One of the best pieces of advice I can give is to begin by listening and observing. You will be eager to provide several services: among them, patient education, supportive care management, cancer therapy optimization, and therapeutic drug monitoring. Make a list of services you think a pharmacist should be providing in clinic. Are these services being offered? Most likely, the answer is yes. Who is currently performing these duties? For example, in my practice site, the nurse navigators were responsible for patient education on new regimens. I wanted to learn the following from them:

• How do you fit patient education into your workflow?
• What resources do you use and provide to patients?
• How do you document that education has been conducted?

Asking about their process taught me that, although they loved speaking with patients about their treatment plans, they had to balance that task with many other duties, such as receiving referrals for new patients and triaging calls from existing patients. Having this information, I realized that offering to help educate patients on medications meant I was doing something I was passionate about and that patients would benefit from, while also helping with the overall workflow of the clinic. Make it a collaborative decision and seek out their ideas on how a pharmacist can improve patient care.

Do find a mentor.

As a new graduate from residency, you are going to have a wealth of knowledge and experiences to call upon during difficult times in your position, but you (or anyone, for that matter) cannot know everything. Having someone who either practices in the same area you do or understands the challenges you are facing will be invaluable during your transition to becoming an independent practitioner. Seek out advice from other pharmacists and stay in touch with your preceptors from residency! This is something I wish I had recognized earlier in my career.

Do delegate, and say no if you need to.

This is a lesson I learned the hard way—you cannot do everything on your own. In addition, you do not have to take on every project offered to you. In my experience, many people were excited to have a pharmacist in their clinics and wanted to involve me as much as possible, but it is okay to tell someone you are not able to participate in a project if you truly feel you will not be able to dedicate the effort needed for it to be successful. Maybe you are not the right person for the project. Colleagues would much prefer that you be honest than overcommit and underdeliver. The transition from residency is tough, and it takes practice learning to say “no” when you want to help. Lean on your mentors and supervisor in these instances—they can help you navigate the process of establishing boundaries and prioritizing.

Now, the Don’ts

Don’t set unrealistic timelines.

You will have just completed residency, where everything needs to be achieved in 1–2 years. This is not the case in your first job as an independent practitioner, especially if it is a new practice site. It takes time to develop your job, and changes will be small at first. Pharmacists feel a significant amount of pressure to make interventions and justify their position, but it is okay to take time to create and learn the system, modify workflows, and establish boundaries. A strong foundation in these will help you be a more effective and efficient pharmacist.

Don’t take on learners too early.

I am a strong advocate for having protected time in your practice before taking on learners. You are still doing a considerable amount of learning yourself—about your institution, clinic, and the disease state(s) in which you are practicing. One thing we all love about oncology is the fast pace at which it changes, but this is also a challenge. It is difficult to teach and figure out how to integrate learners of all levels into your workflow when that workflow is not yet established. Ask when you will be expected to precept students and residents and be honest about your ability to effectively precept when that time comes.

Don’t get burned out.

This advice may seem like a given, but new pharmacy residency graduates are at particularly high risk of burnout, regardless of the position they take. Your institution likely has resources, such as employee assistance programs, to help with this transition. Be up-front and honest with your supervisor and your teammates if you are struggling or sense that you are getting burned out.

Establishing a new practice site can be daunting and will inevitably involve challenges you cannot expect. Making the time to learn the current practice and workflow will allow you to integrate yourself more successfully into a clinic. It is important to establish boundaries and be honest with your supervisor, your colleagues, and, most important, yourself about what you need to be successful.