Friday, March 17, 2017

I've Felt the Burn, and Live to Tell About It

After 6 years of experience since completion of my residency training, I have felt a tremendous amount of growth. As I have said earlier, the more experience I gain, the more I respect those who have it, and realize how little I truly have. There is no hidden meaning or cryptic message. Rather than resisting advice or guidance, I now listen to someone who's been through it all and come out wiser. It's such an obvious epiphany but it took burnout and reflection for me to figure it out.

Yes, I felt burnt out. My early (still early, but who’s counting) career was spent relearning what I should have learned in pharmacy school, discovering what a pharmacist actually does (not the fairy tale described in school) and learning from mistakes. The final straw was actually FOAMed. But let me be clear: I do NOT blame FOAMed. My participation and consumption of blogs and podcasts has created a broader understanding of a plethora of topics that I would have otherwise not been exposed to. But, it also led me down a path of becoming frustrated with the philosophy of evidence-based medicine. At first, it was invigorating to learn the truth behind a dogma or clarify a prescribed doctrine. But an unintended consequence emerged and it began to seem that everything I thought I knew was probably wrong, what I was instructed as fact turned out to be opinion or misrepresentation of evidence, there was no point reading new literature since it's probably crap or biased and even if it was solid, nobody I work with is reading it. This lead to an endless cycle of defending my point of view to dogma or experience. Most of what I wrote or read became cynical, pointing out flaws without solid solutions and ultimately becoming regressive. This bled into my day-to-day work. After 6 years of practice, I did not expect to feel so defeated and to continue to have the same discussions, the same replies, and the same outcomes. I was close to giving up.

I certainly do not feel I am out of the hole yet, although I do feel I’ve seen the light at the end. It may seem simple, but how I got there was further reflection on what I love about my job. The two strongest elements of which are: the scientific method, and learning how things work. There are however, forces intended to help which actually hinder development and led to my burnout. My perception of FOAMed was one, but changing my perspective and attitude addressed my issues. But without addressing the remainder, I feel as though others may follow my path, or I may find myself back where I started. Those forces are pharmacy education and professional societies.

Scientific Method 

Similar to many children of the 80’s I grew up with amazing popular culture science figures. For me, Bill Nye was my man. I could point to all the usual things about how inspiring he was to me, or the exposure to science in general as reasons to fall in love with the field. But thinking back on it now, as an adult, I feel strongly drawn to the idea of observing - forming a question - designing an experiment to try to answer the question - observing a result - deriving a new question from this result - designing a new experiment, and so on. It’s a never-ending process. But in some perverted way, pharmacy school imprinted an attitude that some results of this process are good or bad - right and wrong - and (most importantly) that the cycle is finite. Personal biases and attitudes poisoned the process and halted any further exploration of a study conclusion. For example: learning rate versus rhythm control for atrial fibrillation. Rate control = good; rhythm control = bad, and so sayeth the guidelines. However, looking further into the research and guidelines themselves - additional questions arose, and the research cycle seemed to stop rather than ask foster lines of question flowing into investigations with the same rigor.

My perception of literature as either being good or bad led me to form emotional connections with a given therapy, or strategy. So when the idea was challenged, I recoiled and felt insulted or attacked rather than embracing a new idea and challenging my hypothesis. This attitude permeates through the profession. In essence, I lost what I loved about the process of scientific investigation. Piling on top, a number of FOAMed contributions, including my own, furthered my nihilistic, or at the very least, cynical attitude.

Although I cannot fully describe how it happened, I knew why I needed to change and snap out of this dark place. It was like looking down two paths: one that was an easy slide down into this self deprecating, sarcastic pit - or - a sheer cliff, straight up, towards embracing the scientific method. Approaching each question now, not with fear of finding out something else I thought I knew turns out to be totally wrong, but embracing the idea that I may have a new exciting question to further investigate through research of my own or reading other supporting or refuting evidence. However, the most crucial component is that this cycle is infinite. Embracing that, has provided me with some inner peace and invigoration to keep learning.

Also, I stopped pretending I knew everything. I shook off the shame of hearing a voice echoing from preceptors and faculty, “You don’t know this?! You have to know this!”

How Things Work 

The second piece fits directly into this scientific view: I love to learn about how things work. This was a leading factor pushing me towards engineering when I was a kid in high school. Although I’m glad to end up in pharmacy, there are just as many mechanisms of drugs, disease and the body to understand and feed my interest. But I had no idea to the degree with which a deep and thorough knowledge of fundamental mechanisms plays into understanding everything else to come in medicine and pharmacy. I mean, of course I should have known, but I was a naive cocky little shit.

If the scientific method is my door through pharmacy/medicine, physiology and pharmacology are the keys. They must go hand in hand. When one holds onto a therapeutic dogma like loop diuretics in acute pulmonary edema, pharmacology (with physiology) is the prevailing logic. Yet, I find it challenging to have discussions with residents or other professionals who forget these fundamentals, and end up relying on what is dictated in the guidelines or what they remember from a teacher or preceptor. What’s worse is that we are now teaching the guidelines in school rather than teaching fundamentals. For any students, or residents out there- you will have a very difficult time with me (or anyone else) if you can’t talk to me about what beta-blockers have to do with calcium. Sure, you’ll get by in professional life, but there will come a stopping point. I could care less what CHEST says. If you know the pharmacology and pathophysiology, and can challenge your ideas with primary literature, I guarantee you can predict what the guidelines will say. Furthermore, you’d be able to predict how they would change in the future.

Embracing this method, admitting that I don’t know everything, and continually building and maintaining a foundation in fundamental concepts is where I find myself now. However, it isn’t easy (nor should it be), but it feels as though professional CE or BCPS CE hinders, rather than helps, in my view. But I’ll get to that in a moment.

Education and Organizations 

Burnout is no joke. I had no idea it was happening, but I’m glad to have recognized it and had the luxury of working through it. I fully appreciate how burnout can be different to different individuals, but for pharmacy - particularly young pharmacists within 5 years of finishing residency - we, as a profession, are at tremendous risk of losing great minds. After finishing residency, the professional societies have little to offer (at least for me) in real professional development and guidance. The furious pace of 2 years of residency is not sustainable through the length of a career. Yet, nobody stops to tell anyone that. Nor do we help those new to practice how to develop healthy learning habits. And I’m not talking CE. CE is useless and everyone knows it. That includes BCPS CE. For example, since completing residency, I have attended numerous national professional pharmacy conferences, but the content at each remains the same. Someone (including myself who has presented nationally) read a few papers that they did not write, and is now telling you about them. It’s a glorified book report and offers little room for debate and opinion outside of the norm. While I’ve been frustrated by the lack of innovation and controversy, I know feel even more concerned. Largely by asking this question: Where are the pharmacists doing innovative, controversial, thought provoking or practice challenging research? And why aren’t the presenting here? The hopeful answer is that they’re presenting at “better” medical conferences, but I fear they actually don’t exists at all.

It is challenging to bring up concerns or alternative views for fear of repercussion, because I feel as though having an alternative view will be labeled “unprofessional.” But this model makes sense in a way when considering the figures of our profession and thus the target audience. According to data from the Bureau of Labor Statistics, there were approximately 297,000 pharmacists in 2014 in the USA. Of which 105,000 belonged to one of our two major professional organizations: APhA and ASHP (almost a 60/40 split, respectively). While it is next to impossible to find membership data, I would wager that for ASHP, more than 50% of their 43,000 members are either in school or within 5 years of finishing school (i.e. residents or new pharmacists) with the remainder being members of boards, and advanced leadership positions, and faculty/preceptors who get their memberships paid for. So directing education at 0-5 year level experience is logical, easy to do and requires very little intellectual currency. Contracting young speakers, throwing a little cash at them and a nice feather on their CV makes a recipe for professional development (again, I did this, and benefited from it). But keeping those interested and continuing their development from 5-10 years, then 10-20 years, and engaging those with 20+ years experience to give lectures, present arguments and facilitate debate is hard to do. A similar pattern is playing out in academia as well - turning it into an entry-level position (again, myself included - I had no business being in the classroom with less than 5 years experience). This lonely island of too experienced to benefit from novice lectures, having questions, or seeking discussion that is ‘controversial’ but not experienced enough to have wisdom, is a threat to the profession. And it’s worse than I think it may be.

Yes, burnout is being ignored, but what’s worse, in my opinion, is that the reality of what an actual pharmacist does is starkly in contrast to what professional organizations think we do. This constant pushing of furthering practice, by those who do not practice or have insufficient practice, is a measuring stick to which we assess our careers. The ever-moving goal posts to which we measure professional success adds onto the brutality of professional life as a pharmacist. After long, expensive education, entering into thankless employment with poor external gratification for a job well done makes deriving fulfillment difficult to do. This assessment will always land me falling short of misguided expectations, and thus feeding into burnout.

The expectation becomes: Doing A, B and C is nice and all, but you should be A, B and C, plus X, Y, and Z since that is what our profession needs. The push du jour is pharmacists' prescribing of medications. Even if I could prescribe, I wouldn't because I do not fully comprehend every aspect that entails diagnosis. Furthermore, our education is insufficient to do so in safe and productive manner. I’d rather be the expert in everything to do with medication, and provide that experience to the team who is making those diagnoses, and ultimately prescribing. Personally, I like that method better. But what I’m being told by professional organizations is that that attitude is wrong. To me, we have no business prescribing while drug errors occur in the capacities that they do on a regular basis in medicine. Once medication errors are 0 (or near zero) then we can make sure that each and every person taking a medication is on the correct drug, correct dose, correct route, frequency, fully understands why they take it, and ensure the risks are accounted for, no unnecessary medications, and on and on - then we can talk about prescribing. It’s not a sexy view of pharmacy. But I'm not here for the sexiness.

But there I go again, being cynical and not offering solutions. After seeing burnout, and living to tell about it, I know I must offer at least something to start the discussion. I cannot continue to pretend that I agree with the direction of the profession. To change course, stop political contributions and PAC spending by our organizations used to lobby for provider/prescriber status and redistribute the money and effort to facilitate professional education and fund post-graduate education for those qualified to seek it. Why I believe this is several-fold:
  1. There is a clear disaster in demand for residency-trained pharmacists, and demand for residencies - but insufficient residency positions. The obvious consequence is that good candidates are losing out just because of the sheer odds (nearly a 2:1 ratio of candidates to positions) of landing a position. What’s more concerning, is that eventually, these smart students will look to pharmacy and ask themselves: six figure debt, and (at least) 8 years of training, for this? Or choose medicine/law/PA/anything else. Pharmacy schools are in fact losing applicants year by year, and we will feel it soon. 
  2. Any political spending should be directed towards revising CMS pass-through funding to include PGY-2 residencies, not just PGY-1. The ball was fumbled at the 1-yard line here and needs to be picked up. 
  3. To push our profession forward, I believe in demonstrating capability, rather than mandating a function. Thus, education (including post-graduate residencies) and continuing professional development is fundamental. I cannot prescribe, however, I feel as though through hard work, building of trust and a professional relationship, I can still achieve the same outcome for patients. Furthermore, there has been more than one circumstance where a physician has brought up additional questions I did not consider which ultimately led to a different treatment path. 
  4. Board certification must be meaningful. The certificate looks great on my wall (it's actually not, it's in a bag, in a closet). But with or without it, I still make the same amount of money, can have the same job, perform the same activities - but I have to pay a "maintenance fee," and recertification credit. It (BCPS) either becomes the standard for practice (bye-bye NAPLEX), or the two are merged to create a new standard. This is an easy task if more are able to go through a residency program. 
  5. We forget about those who have > 10 years experience, and how the proposed change in practice would isolate, rather than engage them. With poor quality, and really no incentive to seek challenging CE, many pharmacists feel intimidated by the changing professional landscape. We should feel ashamed by that, not sweep it under the rug.
I may be wrong. However, I remembered I have the desire to develop questions/hypothesis, design solutions/investigations and observe outcomes. Most importantly, not fear the potential that my opinion may change based on new discussion or new facts.