2021 Australian Clinical Pharmacy Award oration

Sally Marotti

BPharm, MClinPharm, AdvPractPharm, FSHP | Lead Pharmacist, Experiential Learning, Training & Research, SA Pharmacy Adelaide, Australia

[Pharmacy GRIT Article No: 20231384]

Oration presented at Medicines Management 2022, 46th National Conference of the Society of Hospital Pharmacists of Australia, 1–3 December 2022, Brisbane, Australia.

It is a great honour receive this award, being recognised in this way by my peers means a great deal to me, but to be able to share this with my family — who have given me the greatest support and inspiration in my career — is extra special.

I would like to start by taking this opportunity to thank my family. Richard, who has supported me in my many endeavours and is always supportive of my latest wild idea. My kids Lucas, Samuel, and Aria, who have taught me how to be more compassionate and have become a large part of my support network. My mum, who has led by example showing me it is possible to have an extraordinary career in the pursuit of helping others whilst raising a family. I wouldn’t be the pharmacist I am today without my many work and uni colleagues, fellow researchers, and SHPA seminar buddies who I have had the pleasure of working and learning with over the years. I would also like to acknowledge the many pharmacy students, interns, pharmacy assistants, pharmacists, medical students, and medico’s I have had the pleasure to teach over the years. I always learn something new through teaching, and each of you have contributed to the practitioner I have become.

It has been a few years since we were able to meet and celebrate awards such as this in person, which has given me plenty of time to contemplate what it is I would like to share with you as part of my oration. Those few years have also bought significant change to the healthcare environment and the profession, and as a practitioner and leader in the profession, I have also shifted in my own views of the world and the world of clinical pharmacy.

I started my career in community pharmacy as a pharmacy assistant as I supported my way through the undergraduate pharmacy program, having moved from the country to study. This was my first insight into the world of clinical pharmacy, lucky to work with some extraordinary community pharmacists who provided home medicines reviews and clinical reviews for nursing home clients.  These pharmacists entrusted me to pack webster packs, dispense scripts, counsel patients, deliver medicines, and serve customers.  I learnt so much about the quality use of medicines in the community setting, and this was to become beneficial in my future career. 

It was a hospital placement at Flinders Medical Centre that introduced me to hospital pharmacy, seeing pharmacists integrate with the medical team to provide patient care became a turning point for me.

Having never considered a career in hospital pharmacy, I was hooked.

From my preceptors, I learned the great value a clinical pharmacist can add to the interprofessional team in caring for patients and improving medicines outcomes, as they let me counsel patients and participate in the interprofessional ward rounds. This led me to apply for an internship at the same hospital and — after a rather terrifying job interview with a panel of seven directors of pharmacy including three previous SHPA clinical pharmacy award recipients — and a medal of merit recipient.

In South Australia, we certainly haven’t been short of fantastic role models and trail blazers in the world of clinical pharmacy practice.

My early days as a clinical pharmacist were scattered with great development opportunities, as I was entrusted to cover senior clinical pharmacists in various clinical roles from Medicines Information, to Oncology, and Manufacturing. I recall early on in my registration days being asked by my Director of Pharmacy, Vaughn Eaton, to undertake contract negotiations with several drug companies to decide on which proton pump inhibitor we would keep on our hospital formulary. I met with the drug reps, I reviewed the literature, and I negotiated drug prices. Something we now do at a statewide level, this was a great opportunity to learn about literature reviews, procurement processes, contract law, and cost analysis. Once the drug was added to the formulary, Vaughn then showed me how to load new drugs into our dispensing system, highlighting all the safety aspects built into the process. Many of these skills have been useful in my career, but clearly demonstrated the importance and value of giving learners an opportunity to give a new skill a go.

Clinical practice to start with was a rather overwhelming experience. I had 40–50 patients in a general medicine ward and I really had no idea where to start, how to prioritise my workload, and how to systematically go about many clinical pharmacy processes. Since this time, we have developed much clearer orientation, workplace-based training, and entrustable professional activities that guide new pharmacists in what is expected of them and provide a platform for support and feedback that guides future practice. Whilst I did eventually find my way — and learnt a lot along that journey — I would have really benefited from many of the tools and learning structures we have in place for the development of our early career pharmacists today.

I also remember my time at John Hunter Hospital fondly. I had the pleasure of working with some amazing pharmacists, who saw potential in me and entrusted me firstly with the first network wide intern program, then the clinical team, and in my last year there, as Deputy Director. What struck me about my experience in Newcastle was how integrated the pharmacy department was with other professions. I learnt so much from our medical and nursing colleagues in my time there as we worked on projects to improve medication safety, medicines utilisation, and patient outcomes. It was here that my research journey began when the Director of Anaesthetics, Ross Kerridge, rang me one day because he was getting tired of pharmacy calling him to clarify his pre-operative prescribing.  I invited him out for coffee as we talked through the problems with the perioperative model of care, and we designed a new model of care that involved pharmacists taking medication histories pre-operatively and prescribing these medicines ready for post-operative administration. Since that time, we have seen partnered charting revolutionise the delivery of clinical pharmacy services, and pre-operative pharmacist medication reviews become a standard of care.

The key to my professional learning in all of these examples is trust. Being trusted with increasing levels of independence to undertake activities has really provided me with enormous opportunities to grow and develop as a professional. Trusting others and allowing them to take responsibility for their decisions really allows them to learn in a meaningful way.

It is through trust we truly develop our future leaders.

There has been an increasing recognition, and ultimately reliance, on pharmacists in the clinical setting to reconcile medicines on admission and discharge and provide medicines reviews, counselling, and medicines lists.

We have seen a growth in our departments as hospitals have funded further pharmacist and pharmacy assistant positions, recognising the value we add to patient care. Patient complexity is increasing and patient length of stay is decreasing, creating more and more episodes of care that can benefit from the input of pharmacy. The last few years have seen other pressures on pharmacy, with staff moving into roles setting up electronic systems, vaccination clinics, and prescribing, we have seen a rapid expansion in the role of pharmacists. Behind the pharmacists that have taken up these roles we have seen pharmacy assistants and community pharmacists trained to fill the gaps.  The need for leadership and support with learning and research in our organisations has never been higher.

We have also been introduced to the concept of burnout. The constant changing landscape has placed pressures on our workforce to adapt and change, both at work and at home. It has impacted on our ability to do the things that really matter, to maintain perspective, manage stress, have face to face contact with our support networks, and remain healthy. Many of us have had increasing amounts of time where we are simply treading water, trying to keep on top of the urgent and important things that are constantly thrown at us.

Now is a time where it is critical that our leaders take the opportunity to lift their heads up and consider how things like communication, empathy, flexibility, and connectedness can contribute to a culture of wellbeing at work.

My key wellbeing learnings from the pandemic include but are not limited to:

  1. Dysfunctional technology contributes to inefficiency and also burnout
  2. Nothing replaces face to face conversation when facing challenges — it is really hard to develop good relationships and common goals via a scheduled Teams meeting — and those coffee catch ups and water cooler conversations are critical to understanding what is actually happening in the workplace
  3. Self-care isn’t necessarily about eating well and exercising. For me it was important to set boundaries, like not watching the news where each evening they would report on the latest ICU COVID-19 casualties many of whom I had been involved in their care.

Now as the smoke clears, I believe it is time for us to take a reset — look at all the things we do and re-evaluate. There are only limited resources, and limited time in the day. From a legislative perspective, there are only three things that define us as pharmacists: dispensing, prescribing, and vaccinating. Even these tasks can be done by other professions. So, what defines us as a profession, and how do we add the most value in improving patient outcomes?

I believe partnered charting is an excellent use of pharmacist time. Working in an interprofessional team contributing at the point of decision-making early in patients’ admissions ensures patients start their hospital stay with evidence-based medicines use. We need to support the pharmacists working in these areas with interprofessional led, workplace-based training and assessment to support their development, and trained pharmacy assistants who can provide support with administrative and patient centred roles. Working independently of the interprofessional team is just plain inefficient and ineffective. 

We need to look at other entry points into hospital and support partnered charting in these settings too, such as the pre- and perioperative settings. Building relationships with the anaesthetists, nurses, and surgeons to optimise medicines use post-operatively. Regular participation in ward rounds with our interprofessional team will keep us involved in decision-making around medicines use and monitoring. Being present when the team are present with extended hours, seven days a week. This will require we re-think our Key Performance Indicators, and how we measure our ‘output’. Documenting medication histories and discharge medication lists is not enough, we need to be proactively contributing to optimising medicines use for our patients, and this doesn’t always mean more medicines. We need to lift our heads up from our computer screens (or paper) and stop being reactive to the problems we are constantly emailed, phoned, paged, or messaged about on Whatsapp, and start integrating with our teams and actively apply our specialist skills and knowledge to patients.

Integrating with our teams, cultivating specialist knowledge and skills, and allowing our patients and other professions to develop trust in us takes time. Every time we rotate a pharmacist to a new area, we may be giving them an opportunity to learn something new, broaden their skill base, and develop new relationships, but we need to balance this with a potential loss of mastery, efficiency, relationships, and trust. Rotation is the adversary to strong interprofessional relationships, clinical research, and specialisation. 

That brings me to the topic of specialisation. In my career I have had the absolute pleasure to work with a wide range of pharmacists who have developed specialised skills across a range of areas. I too have developed specialised skills and knowledge in some specific and general areas of practice.  Specialisation allows an individual to contribute meaningfully to patient care, improving the efficiency with which clinical reviews, therapeutic drug monitoring, deprescribing, counselling, teaching, and clinical research can occur.

Perhaps the less recognised value that specialisation adds is job satisfaction. Developing a network of colleagues you work with, contributing meaningfully to patient care, the sense of achievement you experience each day being able to utilise your skills and knowledge to make a difference all contribute to job satisfaction. In a world where burnout is common, these aspects of our work are critical in keeping us engaged in the workplace.

For some of you, none of this is new thinking but not everyone is on the same page, and some of this will require a significant commitment to enable the behaviour and culture change that is required to embed this across hospitals across the country. So, congratulations and well done to the innovators and early adopters who have led this revolution, we have many people to bring along on this journey to see a real diffusion of innovation.