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Nutrition Support Pharmacist Helps Physician Practice
Nutrition Support Pharmacist Helps Physician Practice Bruce Wachsman) PharmD) coordinates nutritional care for the patients offour gastroenterologists in Memphis) Tenn. by Vicki Meade
hen Lawrence Wruble, MD, decided in 1988 to ask nutrition support pharmacist Bruce Wachsman to join his thriving practice of four gastroenterologists, the reason was simple: "He knows far more about medications than any physician," Wruble says. Wachsman is one of fewer than 250 pharmacists who are certified by the Board of Pharmaceutical Specialties (BPS) in the area of nutrition support. At the Memphis Gastroenterology Group, he serves as coordinator of nutrition services, with overall responsibility for managing the enteral and parenteral feeding of the practice's patients.
W
Making Rounds
Attributes for Success • Strong knowledge of nutrition and drugs. • The ability to work independently. • A knack for getting along with other people. •
Good clinical judgment.
• Dedication to staying on top of a quickly changing field. • Knowledge of which products are most costeffective.
Vol. NS33, No. 10
October 1993
Although he shares offices with the four physicians , Wachsman spends most of his time across the street at Baptist Memorial Hospital, visiting up to 30 patients a day to see how their nutritional therapy is working and providing opinions on proper drug therapy. Typically, he starts his day at 8:00 am, making rounds in the intensive care unit (lCU). There, he monitors critically ill patients receiving IV hyperalimentation. "I monitor for tolerance--that is, the absence of adverse effects--and for efficacy--is [the product]
Nutrition support pharmacist Bruce Wachsman (right) consults with gastroenterologist Lawrence Wruble, MD.
AMERICAN PHARMACY
doing what it is supposed to do?" he says. Wachsman determines how many calories each patient needs and what percentage of those calories should be in the form of fat, carbohydrates, and protein, based on the patient's disease and organ functions. "I may need to adjust
Third Nutrition Support Exam Will Take Place in 1994 The next certifying examination for the specialty of nutrition support pharmacy will be given by the Board of Pharmaceutical Specialties (BPS) on Saturday, January 29, in San Antonio, Tex., and Philadelphia, Pa. The application deadline is December 10. Since 1992, when the exam was fIrSt given, 236 pharmacists have become board certified in nutrition support pharmacy. According to Beverly Holcombe, PharmD, vice chairman of the Specialty Council on Nutrition Support Pharmacy, pharmacists frrst became involved in the field about 20 years ago, when they compounded sterile parenteral nutrition products. Today, they handle direct patient-care responsibilities, she says, and assure that feeding formulations are properly prepared and administered. Nutrition support pharmacists typically nmction as part of a multidisciplinary team of nurses, physicians, dieticians, nutritionists, and other health care professionals. The American Society for Parenteral and Enteral Nutrition, in Silver Spring, Md., says that the following areas of responsibility fall within the scope of nutrition support pharmacy practice: • Assessing nutritional status. • Delivering parenteral or enteral nutrition. • Evaluating drug-nutrient interactions. • Monitoring nutrition support therapy. • Compounding parenteral nutrient admixtures. • Establishing and maintaining a nutrition support formulary. • Performing drug utilization reviews and quality assurance audits. • Preparing patients for parenteral nutrition at home. • Research and education. Other specialties that have been approved by BPS are nuclear pharmacy, with 234 board-certified practitioners; pharmacotherapy, with 263 board-certified practitioners; and psychopharmacy, which was approved in late 1992 and has not yet offered a certifying exam. BPS is currently considering a petition requesting that oncology pharmacy practice be designated a specialty. To obtain more information on any pharmacy specialty, or to request an application for the nutrition support certifying exam, contact the Board of Pharmaceutical Specialties, 2215 Constitution Ave., NW, Washington, DC 20037-2985. (202) 429-7591 or (800) 237-2742.
AMERICAN PHARMACY
the assessment daily, depending on how the patient's disease is progressing and on laboratory indicators of nutritional status," he says. He usually spends about two hours in the ICU and spends another two to three hours on the nonacute floors. "These patients are often up and walking around, and they're able to communicate more, so I chat with them," Wachsman says. "I explain what I'm doing, and most of them fmd it pretty interesting to know that the formula they're getting intravenously really provides all of their nutritional needs and that they can survive that way indefmitely." On most days, in addition to making rounds on his own, Wachsman accompanies the physicians in the practice as they make rounds. "We visit those receiving nutrition as well as those who aren't, and we learn from each other. I may throw out some principle about drug therapy, and they may teach me something about gastroenterology that I didn't know." At any time during the day, Wachsman may be called on to do nutritional work-ups for new patients to determine what sort of regimen they need, if any, and to write a prescription to start the feeding. If necessary, he orders the placement of a nasogastric tube, or, for IV feedings, a catheter into the chest. Wachsman works closely with the hospital pharmacy staff. "I want to be sure there is no confusion about the formulas we're ordering, so I encourage them to page me at any time, during the day or at home," Wachsman says. Unlike most nutrition support pharmacists, he does not function as part of an established multidisciplinary team. He does, however, consult regularly with experts such as speech pathologists and dietitians-who may, for example, help Wachsman decide whether a patient with a swallowing disorder is able to try regular food. Nearly every month, Wachsman serves as preceptor to a medical resident or pharmacy student. They accompany him on rounds to learn the fmer points of nutritional assessment and monitoring. His day may also include attending educational conferences at the hospital or at the nearby University of Tennessee Medical Center.
A Personal Interest Many of the patients Wachsman sees have cancer. Other common problems include inflammatory bowel disease; pancreatitis; and neurological disorders, such as stroke, that have impaired the patient's ability to swallow. Wachsman, who takes a personal interest in his patients, recalls in particular a 36-year-old truck driver with a long history of ulcerative colitis who was admitted to the hospital when his symptoms suddenly became worse. Pan-colitis was diagnosed, and the gastroenterologists decided that the patient should have a colectomy, Wachsman explains. "Because he was apprehensive about the surgery, I tried to October 1993
Vol. NS33, No. 10
give him support. Unfortupharmacist who specializes nately, he developed compliin nutrition." Wachsman is cations that required an asset not only because he additional surgery. What has extensive scientific and would normally have been practical knowledge of only a week or two in the drugs, Wruble explains, but hospital turned into three also because he knows months. But we got him which are the most costthrough it with a lot of emoeffective. And because tional support and meticuWachsman spends most of his time in the hospital, he lous provision of nutrition. I can detect and respond saw him not long ago and he quickly to rapid changes in a looked great; he was a new patient's nutritional status, man." says Wruble. The ability to work directly with patients is the part of his job that he likes most, A Unique Position Wachsman says. Attributes in a Growing Field that bring him success in his position -aside from a strong "It's a compliment to the knowledge of nutrition and profession that these physicians realized how valuable pharmaceuticals-are the this position would be," ability to work independent- In his office at Memphis Gastroenterology Group, Wachsman prepares recommendations for feeding a patient. Wachsman says. "We don't ly, a knack for getting along know of any other gastroenwith all kinds of people, good clinical judgment, and terology practice that has a position like this one." dedication to staying on top Beverly Holcombe agrees of developments in a fastthat Wachman's position is paced field. unique. As vice chairman of He keeps in touch with the other 12 nutrition support pharmacists in the Memphis BPS's Specialty Council on Nutrition Support Pharmacy, she area through the local chapter of the multidisciplinary Amerikeeps tabs on trends in the specialty. Most nutrition support pharmacists are employed by hospitals, she notes, and an can Society for Parenteral and Enteral Nutrition (ASPEN), and ever-increasing number-as many as 28%, according to a regularly attends national ASPEN conferences. recent survey-work in home health care. Although she is unsure how many pharmacists other than Having an Expert Available those certified by BPS serve in a nutrition support capacity, BPS projects that 100 pharmacists per year will seek certificaWachsman graduated from the University of Cincinnati tion as nutrition support specialists, she says. College of Pharmacy in 1977 and became interested in nutri"It's defmitely a growing area, and why I think it will contion support pharmacy when he prepared total parenteral tinue to grow is because nutrition support is a relatively large nutrition bottles as a hospital pharmacist. He went back to component of home health care," Holcombe says. "Home school for a PharmD from the University of Texas Health Scihealth care is the fastest-growing area of health care today, ence Center at San Antonio, and completed a one-year nutriand the companies that provide home services are hiring a tion support residency in 1986. lot of pharmacists. " He was a clinical pharmacist on staff at Baptist Memorial "Personally, I think it's an exciting area of the health sciwhen the physicians at Memphis Gastroenterology Group ences," adds Holcombe, who is a nutrition support pharmaasked him to join their practice. cist with the University of North Carolina Hospitals in Chapel "I think the advantage they saw was the ability to expand Hill. "You see a variety of patients and you're truly a part of their practice into the area of nutrition, to have an expert the health care team. It's really on the cutting edge of pharcoordinate the program for them, and to have the knowlmacy." edge of a clinical pharmacist available at all times," Wachsman says. According to Wruble, the decision to hire Wachsman "had Vicki Meade is associate editor, American Pharmacy. more to do with his unique capabilities than simply having a Vol. NS33, No. 10
October 1993
AMERICAN PHARMACY
hen Lawrence Wruble, MD, decided in 1988 to ask nutrition support pharmacist Bruce Wachsman to join his thriving practice of four gastroenterologists, the reason was simple: "He knows far more about medications than any physician," Wruble says. Wachsman is one of fewer than 250 pharmacists who are certified by the Board of Pharmaceutical Specialties (BPS) in the area of nutrition support. At the Memphis Gastroenterology Group, he serves as coordinator of nutrition services, with overall responsibility for managing the enteral and parenteral feeding of the practice's patients.
W
Making Rounds
Attributes for Success • Strong knowledge of nutrition and drugs. • The ability to work independently. • A knack for getting along with other people. •
Good clinical judgment.
• Dedication to staying on top of a quickly changing field. • Knowledge of which products are most costeffective.
Vol. NS33, No. 10
October 1993
Although he shares offices with the four physicians , Wachsman spends most of his time across the street at Baptist Memorial Hospital, visiting up to 30 patients a day to see how their nutritional therapy is working and providing opinions on proper drug therapy. Typically, he starts his day at 8:00 am, making rounds in the intensive care unit (lCU). There, he monitors critically ill patients receiving IV hyperalimentation. "I monitor for tolerance--that is, the absence of adverse effects--and for efficacy--is [the product]
Nutrition support pharmacist Bruce Wachsman (right) consults with gastroenterologist Lawrence Wruble, MD.
AMERICAN PHARMACY
doing what it is supposed to do?" he says. Wachsman determines how many calories each patient needs and what percentage of those calories should be in the form of fat, carbohydrates, and protein, based on the patient's disease and organ functions. "I may need to adjust
Third Nutrition Support Exam Will Take Place in 1994 The next certifying examination for the specialty of nutrition support pharmacy will be given by the Board of Pharmaceutical Specialties (BPS) on Saturday, January 29, in San Antonio, Tex., and Philadelphia, Pa. The application deadline is December 10. Since 1992, when the exam was fIrSt given, 236 pharmacists have become board certified in nutrition support pharmacy. According to Beverly Holcombe, PharmD, vice chairman of the Specialty Council on Nutrition Support Pharmacy, pharmacists frrst became involved in the field about 20 years ago, when they compounded sterile parenteral nutrition products. Today, they handle direct patient-care responsibilities, she says, and assure that feeding formulations are properly prepared and administered. Nutrition support pharmacists typically nmction as part of a multidisciplinary team of nurses, physicians, dieticians, nutritionists, and other health care professionals. The American Society for Parenteral and Enteral Nutrition, in Silver Spring, Md., says that the following areas of responsibility fall within the scope of nutrition support pharmacy practice: • Assessing nutritional status. • Delivering parenteral or enteral nutrition. • Evaluating drug-nutrient interactions. • Monitoring nutrition support therapy. • Compounding parenteral nutrient admixtures. • Establishing and maintaining a nutrition support formulary. • Performing drug utilization reviews and quality assurance audits. • Preparing patients for parenteral nutrition at home. • Research and education. Other specialties that have been approved by BPS are nuclear pharmacy, with 234 board-certified practitioners; pharmacotherapy, with 263 board-certified practitioners; and psychopharmacy, which was approved in late 1992 and has not yet offered a certifying exam. BPS is currently considering a petition requesting that oncology pharmacy practice be designated a specialty. To obtain more information on any pharmacy specialty, or to request an application for the nutrition support certifying exam, contact the Board of Pharmaceutical Specialties, 2215 Constitution Ave., NW, Washington, DC 20037-2985. (202) 429-7591 or (800) 237-2742.
AMERICAN PHARMACY
the assessment daily, depending on how the patient's disease is progressing and on laboratory indicators of nutritional status," he says. He usually spends about two hours in the ICU and spends another two to three hours on the nonacute floors. "These patients are often up and walking around, and they're able to communicate more, so I chat with them," Wachsman says. "I explain what I'm doing, and most of them fmd it pretty interesting to know that the formula they're getting intravenously really provides all of their nutritional needs and that they can survive that way indefmitely." On most days, in addition to making rounds on his own, Wachsman accompanies the physicians in the practice as they make rounds. "We visit those receiving nutrition as well as those who aren't, and we learn from each other. I may throw out some principle about drug therapy, and they may teach me something about gastroenterology that I didn't know." At any time during the day, Wachsman may be called on to do nutritional work-ups for new patients to determine what sort of regimen they need, if any, and to write a prescription to start the feeding. If necessary, he orders the placement of a nasogastric tube, or, for IV feedings, a catheter into the chest. Wachsman works closely with the hospital pharmacy staff. "I want to be sure there is no confusion about the formulas we're ordering, so I encourage them to page me at any time, during the day or at home," Wachsman says. Unlike most nutrition support pharmacists, he does not function as part of an established multidisciplinary team. He does, however, consult regularly with experts such as speech pathologists and dietitians-who may, for example, help Wachsman decide whether a patient with a swallowing disorder is able to try regular food. Nearly every month, Wachsman serves as preceptor to a medical resident or pharmacy student. They accompany him on rounds to learn the fmer points of nutritional assessment and monitoring. His day may also include attending educational conferences at the hospital or at the nearby University of Tennessee Medical Center.
A Personal Interest Many of the patients Wachsman sees have cancer. Other common problems include inflammatory bowel disease; pancreatitis; and neurological disorders, such as stroke, that have impaired the patient's ability to swallow. Wachsman, who takes a personal interest in his patients, recalls in particular a 36-year-old truck driver with a long history of ulcerative colitis who was admitted to the hospital when his symptoms suddenly became worse. Pan-colitis was diagnosed, and the gastroenterologists decided that the patient should have a colectomy, Wachsman explains. "Because he was apprehensive about the surgery, I tried to October 1993
Vol. NS33, No. 10
give him support. Unfortupharmacist who specializes nately, he developed compliin nutrition." Wachsman is cations that required an asset not only because he additional surgery. What has extensive scientific and would normally have been practical knowledge of only a week or two in the drugs, Wruble explains, but hospital turned into three also because he knows months. But we got him which are the most costthrough it with a lot of emoeffective. And because tional support and meticuWachsman spends most of his time in the hospital, he lous provision of nutrition. I can detect and respond saw him not long ago and he quickly to rapid changes in a looked great; he was a new patient's nutritional status, man." says Wruble. The ability to work directly with patients is the part of his job that he likes most, A Unique Position Wachsman says. Attributes in a Growing Field that bring him success in his position -aside from a strong "It's a compliment to the knowledge of nutrition and profession that these physicians realized how valuable pharmaceuticals-are the this position would be," ability to work independent- In his office at Memphis Gastroenterology Group, Wachsman prepares recommendations for feeding a patient. Wachsman says. "We don't ly, a knack for getting along know of any other gastroenwith all kinds of people, good clinical judgment, and terology practice that has a position like this one." dedication to staying on top Beverly Holcombe agrees of developments in a fastthat Wachman's position is paced field. unique. As vice chairman of He keeps in touch with the other 12 nutrition support pharmacists in the Memphis BPS's Specialty Council on Nutrition Support Pharmacy, she area through the local chapter of the multidisciplinary Amerikeeps tabs on trends in the specialty. Most nutrition support pharmacists are employed by hospitals, she notes, and an can Society for Parenteral and Enteral Nutrition (ASPEN), and ever-increasing number-as many as 28%, according to a regularly attends national ASPEN conferences. recent survey-work in home health care. Although she is unsure how many pharmacists other than Having an Expert Available those certified by BPS serve in a nutrition support capacity, BPS projects that 100 pharmacists per year will seek certificaWachsman graduated from the University of Cincinnati tion as nutrition support specialists, she says. College of Pharmacy in 1977 and became interested in nutri"It's defmitely a growing area, and why I think it will contion support pharmacy when he prepared total parenteral tinue to grow is because nutrition support is a relatively large nutrition bottles as a hospital pharmacist. He went back to component of home health care," Holcombe says. "Home school for a PharmD from the University of Texas Health Scihealth care is the fastest-growing area of health care today, ence Center at San Antonio, and completed a one-year nutriand the companies that provide home services are hiring a tion support residency in 1986. lot of pharmacists. " He was a clinical pharmacist on staff at Baptist Memorial "Personally, I think it's an exciting area of the health sciwhen the physicians at Memphis Gastroenterology Group ences," adds Holcombe, who is a nutrition support pharmaasked him to join their practice. cist with the University of North Carolina Hospitals in Chapel "I think the advantage they saw was the ability to expand Hill. "You see a variety of patients and you're truly a part of their practice into the area of nutrition, to have an expert the health care team. It's really on the cutting edge of pharcoordinate the program for them, and to have the knowlmacy." edge of a clinical pharmacist available at all times," Wachsman says. According to Wruble, the decision to hire Wachsman "had Vicki Meade is associate editor, American Pharmacy. more to do with his unique capabilities than simply having a Vol. NS33, No. 10
October 1993
AMERICAN PHARMACY