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The pharmacist role in dermatologic care
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Currents in Pharmacy Teaching and Learning 6 (2014) 92–105
Research
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The pharmacist role in dermatologic care Stephanie K. Fabbro, MDa, Eliot N. Mostow, MD, MPHb,c, Stephen E. Helms, MDb,c, Richard Kasmer, PharmD, JDd,e, Robert T. Brodell, MDf,g,h,* a
Division of Dermatology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH b Dermatology Section, Northeast Ohio Medical University, Rootstown, OH c Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, OH d Division of Academic Affairs, Northeast Ohio Medical University, Rootstown, OH e Department of Pharmacy, Northeast Ohio Medical University, Rootstown, OH f Department of Dermatology, University of Mississippi, Jackson, MS g Department of Pathology, University of Mississippi, Jackson, MS h Department of Dermatology, University of Rochester School of Medicine and Dentistry, Rochester, NY
Abstract Objective: Pharmacists play a crucial role in the management and education of patients with dermatologic disease. However, there is little formal dermatologic education provided in pharmacy school or post-graduate training. Additionally, dermatologists and pharmacists have identified boundaries to patient care that are largely due to weak communication between the two professions. To improve pharmacists’ dermatologic knowledge and interprofessional relations, the Dermatology Symposium for Pharmacists was developed. Methods: Pharmacists were recruited to participate in the symposium on a state level. Pre- and post-test survey questions were administered using an audience response system, which tested frequency of dermatology encounters in the pharmacy, pharmacist perceptions of dermatology, and case-based questions correlating with each lecture. Results: A total of 83 pharmacists attended the symposium, the majority of whom make at least one dermatological recommendation daily. Paired t-test assessed the differences between scores of pre- and post-test questions on dermatologic knowledge, which showed mean scores of 6.36 and 9.89 before and after the symposium (p r 0.0001), respectively. The symposium had a significant impact on attendees with 65% saying they were more likely to recommend over-the-counter skin care products and 89% feeling more comfortable with dermatology referral. Methods to improve interprofessional care were developed during the panel discussions. Conclusion: The pharmacists attending this symposium were enthusiastic about learning more regarding dermatologic disease. The use of case-based interactive learning permitted dermatology teachers to identify knowledge gaps for an audience with
Funding: Data were gathered using an audience response system at a symposium (A Dermatology Primer for Pharmacists: a dialog between Pharmacy and Dermatology Practitioners at Northeastern Ohio Medical University on November 5, 2011) that was supported by an unrestricted educational grant from Galderma. Disclosures: Drs. Brodell, Helms, and Mostow have received honoraria, served on advisory boards, and/or received investigative support from Galderma, the major sponsor of the symposia described in this article, but these relationships are not felt to have any relevance to the content of this article. Other disclosures—Eliot N. Mostow, MD, Stephen E. Helms, MD, and Robert T. Brodell, MD: Speakers Bureaus: Allergan, Galderma, GlaxoSmithKline, and Dermik; Consultant: Galderma, Sirius laboratories, and Medicis; Clinical Trials: Galderma, Allergan, and Dow; Investigator: Amngen. Investigative Review Board: This study was approved by the Northeastern Ohio Medical University Institutional Review Board on November 1, 2011. * Corresponding author: Robert T. Brodell, MD, Department of Dermatology, University of Mississippi, 2500 North State Street, Jackson, MS 39216. E-mail: [email protected] 1877-1297/14/$ – see front matter r 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cptl.2013.09.008
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whom they had no prior experience. We believe the symposium also improved the interprofessional relationship between pharmacists and dermatologists regionally. r 2013 Elsevier Inc. All rights reserved. Keywords: Dermatology; Interprofessional care; Medical education; Pharmacy
Introduction Pharmacists are often the initial source of advice regarding over-the-counter (OTC) treatment for many patients with mild dermatological diseases. They may choose to accept the responsibility of determining whether a patient might respond to OTC treatment or whether he/she should be referred to a primary care physician or dermatologist. In any event, they are an important member of the health care team.1,2 Pharmacists provided initial OTC treatment for 39% of those with dermatological conditions as shown by a recent survey.3 Patients are often satisfied with the dermatological recommendations made by pharmacists, and in certain settings, their efforts have been shown to be cost-effective.4 In Sweden, a national campaign to improve pharmaceutical care of patients with skin disease saved 5–10% for the total dermatology health cost burden when the assistance of pharmacists was employed.5,6 Further benefits may come from pharmacists discouraging the use of OTC products that would be unnecessary or harmful for a patient's individual condition, such as longterm use of OTC topical steroids.7 Conversely, the trend toward using technicians at retail settings and the increased prevalence of mail-order pharmacies may insulate the pharmacist from providing effective medication counseling regarding potential adverse reactions and prevent the promotion of medication adherence.8 There is very little scientific interchange between dermatologists and pharmacists in the United States and a paucity of academic opportunities for pharmacists to learn dermatology. The annual meetings of the American Pharmacists Association, the American College of Clinical Pharmacy, and the American Society of Consultant Pharmacists revealed minimal coursework on dermatologyrelated diseases and treatments over the years 2009–2011. Out of 40 continuing education (CE) online modules, the American Society of Consultant Pharmacists offered only one module for three continuing education credits on dermatological disorders of the elderly and no live CE opportunities on dermatology.9 The American College of Clinical Pharmacy, as part of their Updates in Therapeutics conference, offered a one-hour review course on dermatology for ambulatory care pharmacists, out of a total of 27 contact hours.10 Finally, the monthly continuing education journal US Pharmacist rarely publishes articles geared toward dermatology topics, such as dermatological drug interactions. Because of the wide variation in the depth and breadth of knowledge about skin disease among pharmacists, many
pharmacists have suboptimal training in treating patients with dermatologic disease, and many do not feel comfortable participating in dermatologic care. This could possibly be optimized if the dermatology community played a more active role in advising and educating pharmacists. Our task force of dermatologists and pharmacy professionals created a formal CE symposium entitled “A Dermatology Practicum for Pharmacists: a Dialogue between Pharmacists and Dermatology Practitioners” (Fig. 1). The pharmacists attending this program served concomitantly as subjects of this study to allow for assessment of general attitudes toward dermatologists, knowledge and skills in caring for dermatologic problems, and the type and quantity of the dermatology services that pharmacists provide. Methods The Northeast Ohio Medical university (NEOMED) Dermatology Primer for Pharmacists was a ten-hour long didactic symposium, taught by academic dermatologists from private practice settings specifically for pharmacists to fulfill the following objectives:
Discuss basic dermatologic concepts to allow pharmacists to effectively triage patients for appropriate OTC treatment vs. referral to a physician. Enhance pharmacists' knowledge of appropriate treatment as well as possible adverse reactions and interactions of dermatologic drugs. Attempt to clarify barriers and possible improvements to the current interprofessional relationship between dermatologists and pharmacists.
Using the Ohio State Board of Pharmacy Database, 4000 pharmacists in northeast Ohio were invited to the conference using electronic symposium e-mail flyers and mailed printed brochures (Fig. 1). All pharmacists within the geographic region were included in the invitation to the symposium regardless of their setting of practice. The symposium flyer was also available on the NEOMED website. Seven lectures were developed on what were thought to be the most clinically relevant topics to pharmacists as established by prior literature review. These included the following: dermatologic medication adherence, the importance of vehicle in topical treatment, Herpes infections, warts, urticaria, eczema/psoriasis, and skin and skin structure infections (SSSIs). Two case-based test questions were presented before and after each of the eight clinical lecture topics to document any short-term
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Fig. 1. Program brochure.
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improvement in dermatology-specific information. Discussion sessions led by a dermatologist and two practicing pharmacists were incorporated into the program after each set of two lectures (Fig. 1). The primary objectives of the symposium were measured by pre-test and post-test surveys that were given, as well as questions on dermatologic knowledge before and after each lecture. The pre-test survey was administered at the beginning of the symposium, immediately following the introduction speech. The post-test survey was administered after the last lecture and panel discussion of the day. These surveys were composed de novo by the creators of the symposium and were used to collect data on pharmacists' experience, knowledge, and confidence in dermatology and interpersonal relationships with dermatologists (Addendum 1). An audience response system (ARS) with an individual remote control for each attendee was used to collect answers to questions posed to the group. The responses of the group were projected in real time following each question to provide information for self-assessment as well as guidelines for teaching. The pharmacists were given approximately eight seconds to answer each question; subsequently, group results were displayed. The pre-test survey consisting of 28 questions: eight questions relating to the pharmacists' frequency of dermatology encounters within the pharmacy, four questions regarding the dermatologist–pharmacist relationship, that included pharmacists' perceptions of the field of dermatology, and 16 case-based questions. The post-test survey consisted of 29 questions: nine questions focusing on the potential for improvement in the relationship between dermatologists and pharmacists, and the same 16 casebased knowledge questions that were included in the pretest survey were repeated. The entire symposium was audio and video recorded to gather qualitative data from topics raised and questions asked during the discussion sessions. Additional survey data were collected after the completion of the symposium to evaluate teaching effectiveness in each lecture.
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Statistical analysis Data were analyzed using SPSS version 17. Results from the pre-test and post-test survey were analyzed in terms of paired t-test and point serial bisection to determine the degree of improvement in medical knowledge resulting from the symposium. The point serial bisection, a measure of how well the item distinguished the examinees who did well on the test overall from those who did not, was emphasized in the analysis. The data regarding pharmacists’ attitudes and experiences were largely analyzed only in terms of frequency. Results The conference was attended by 89 medical professionals (83 pharmacists and six physicians). Only pharmacists voted using the ARS. There was a mean of 53 respondents to each question with a range of 14–63 respondents. The demographics of the pharmacists were not measured or collected. Dermatology encounters within the pharmacy Among the eight questions assessing the prevalence of dermatological encounters within the pharmacy, 87.5% of pharmacists reported making OTC recommendations for dermatology products in the pharmacy during their career, with 68% making at least one OTC recommendation daily (Fig. 2). With regard to diseases treated in the pharmacy, 47% had made recommendations for all seven dermatologic diseases treatable by OTC products that were included in the lectures (acne, warts, herpes, psoriasis, poison ivy, fungal infections, and eczema), with most commonly treated diseases being fungal infections, acne, and eczema with 32%, 27%, and 27%, respectively (Fig. 3). A significant number (43%) of pharmacists reported referring a patient to a dermatologist or a primary care physician at least once a day. Significant dermatologic drug interactions or allergies
Fig. 2. The average number of skin care products recommended by each pharmacist in a typical eight-hour work day.
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to remember the brand name, while 24% replied that superior vehicles were the most likely motivating factor. Misinformation provided by unprincipled drug representatives was reported by 17% to lead to brand-name prescriptions.
Pharmacist cognitive improvement following symposium
Fig. 3. Dermatologic diseases most commonly treated by pharmacists.
were reported to dermatologists less commonly, with 67% of pharmacists encountering this only about once per year. Pharmacist education in dermatology As part of the pre-test questionnaire, 86% of the pharmacists reported that they had not attended a single dermatology lecture since graduating from pharmacy school. Pharmacy journals were the main source of dermatology information for 62% of pharmacists. Other commonly reported sources of information were the internet and pharmacy meetings (Fig. 4). Pharmacist views on dermatologist motivations Pharmacists overwhelmingly agreed that they could improve their service to patients by understanding how dermatologists approach disease processes and decide on treatment options. They believed it would be helpful to have more continuing medical education focusing on dermatology (95%), and only a small minority reported an adversarial relationship between pharmacists and dermatologists (8%). When pharmacists were asked about the motivations of dermatologists to prescribe brand-name products over generic drugs, 45% believed dermatologists found it easier
The medical knowledge of the pharmacists was variable. Overall, they chose the correct response 53.3% of the time. Pharmacists had greatest pre-test knowledge on the topic of patient adherence in dermatology and the least amount of pre-test knowledge on systemic steroid dosing. Item difficulty, a measure of the proportion of participants who answered a question correctly, was measured for both preand post-test items. The mean level of item difficulty for the pre-test questions was 0.489, indicating that almost half of the pharmacists answered the questions correctly on their first attempt (range 0–1). The post-test knowledge increased significantly with a mean correct response rate of 78.6%, and therefore, an item difficulty of 0.786, with a mean change in pre- to post-test item difficulty of 0.296. This indicates that almost 30% of the pharmacists who had first answered the questions incorrectly had mastered them by the completion of the symposium. The area with largest improvement of knowledge was dosage of systemic steroids, with pre- and posttest correct responses of 12.1% and 91.9%, respectively (Fig. 5). Subjectively, 42% of pharmacists believed they gained the most knowledge on the topic of the diagnosis and treatment of warts; other popular topics focused on herpes and eczema. Point serial bisection analysis was similar between the pre- and post-test items. A paired t-test was conducted to assess the differences between the raw scores of pre- and post-test. The results showed mean scores of 6.36 and 9.89 before and after the symposium, respectively (p r 0.0001).
Fig. 4. Primary sources of information on dermatologic drugs reported by pharmacists.
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Fig. 5. Pre- and post-test case-based questions answered correctly by pharmacist audience. Skin and Skin Structure Infections (SSSIs).
The confidence intervals between pre- and post-test values combined for each topic were also assessed and were found to be 32–65 and 68–87, respectively (Fig. 6). Qualitative data from audience during panel discussion Several topics were discussed during panel discussions (Fig. 7). The panel discussions included dialogs on improving interprofessional relationships between pharmacists and dermatologists and barriers to optimizing patient care that are further elaborated upon in the discussion. The majority of pharmacists view dermatologists in a positive light, though there were a few legitimate concerns raised regarding improving rapport by ensuring that both professional groups play equal roles in this dynamic relationship. Interestingly, more pharmacists agreed with the sentiment that there is an adversarial relationship between pharmacists and dermatologists after the symposium (pre-test 7.9% and post-test 12.3%).
respectively). Topics that were suggested for discussion for future symposia included dermatologic emergencies, most common reasons to make a dermatologic referral, and improving interprofessional relationships between pharmacists and dermatologists by understanding factors motivating their prescribing habits. Recommendations for future symposia included common internal medicine topics such as hypertension, diabetes, and anticoagulation.
Discussion The Dermatology Symposium provided a rare glimpse of pharmacists' views on dermatology education and their interprofessional relationships with physicians. Pharmacists attending the symposium demonstrated some dermatology
Overall reception Evaluative feedback about the symposium was exceedingly positive. The overwhelming majority of pharmacists agreed that the symposium aided them in closing knowledge gaps, motivated them to pursue further coursework in the topic of dermatology, and attend further symposia presented to pharmacists by clinicians (98%, 81%, and 83%, respectively). They also responded that they were more likely to recommend both OTC skin care products to patients and to make referrals to dermatologists or Primary Care Physicians (PCPs) for skin disease (65% and 89%,
Fig. 6. Pre- and post-test confidence intervals for the medical knowledge aspect of the survey (*p o 0.05).
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Fig. 7. Most frequently discussed topics at Panel Discussions during the Dermatology Symposium for Pharmacists. Health Insurance Portability and Accountability AcT (HIPAA).
knowledge in the pre-test, but it was evident that improvement is needed, and the post-test survey demonstrated that improvement is possible. Review of the literature revealed only minimal continuing education programs and relevant journal articles focusing on pathophysiology, prevention, patient education, and OTC treatment of the most common skin diseases directed to pharmacists. International efforts to improve web-based dermatology continuing medical education and teledermatology to aid pharmacists have increased in the last 5 years.16,17 These materials are generally created by pharmacists (RPh/PharmD), PhDs, or are collaborative efforts between dermatologists and pharmacists. We could identify no continuing education symposia in the United States where dermatologists teach pharmacists. The panel discussions brought rich qualitative data focusing on the concerns of pharmacists. Some pharmacists expressed their belief that dermatologists prescribe brandname drugs when they are not medically necessary and overuse the “dispense-as-written” tool, though the use of generic drugs in dermatology is rising and currently accounts for about 70% of dermatologic prescriptions.18 Although generic equivalents have been steadily increasing, eight of the top ten drugs by total number of prescriptions in dermatology are brand name.19 Focus group data also demonstrated that pharmacists believe that dermatologists often do not perceive them as equals and that their opinions are not valued.20 Pharmacists are also frustrated by the disproportionate nature of the relative frequency with which dermatologic diseases are encountered in the office compared to at the pharmacy, with pharmacists encountering more acute diseases and dermatologists encountering presentations that are more chronic. If developing a health care team is a professional and community goal, then providing pharmacists with information to enhance their competency in diagnosis and treatment of dermatological diseases is important. We believe this can be most effectively accomplished by forming a professional working relationship between pharmacists and dermatologists. This symposium demonstrated a willingness by
dermatologists to improve the clinical abilities of pharmacists through a continuing pharmacy education program and provided a forum to discuss methods to enhance team-based dermatologic patient care by triaging patients from the pharmacy to the dermatologist's office as part of a systems-based practice. Improving pharmacist–physician relations Analysis of focus group data demonstrates that pharmacists are the least integrated health care professionals despite their willingness to play a greater role. A lack of privacy and time constraints limit the ability of pharmacists to take a clinical history.8 Furthermore, a lack of educational materials and a fear of harming relationships with physicians or providing contradictory information to patients are often reported.21,22 Finally, the ability of pharmacists to educate patients is completely lost when dermatologists provide drug samples rather than a prescription.19 One reason for the lack of educational interchange between dermatologists and pharmacists may be related to conflicts of expectation that contribute to distrust. Pharmacists believe their key role is to educate patients about effectively utilizing their dermatologic drugs.23 However, instead, dermatologists expect pharmacists to make them aware of drug prices, watch for drug interactions, and make over-the-counter recommendations.24 Dermatologists are also frustrated with pharmacists' recommendation of inappropriate topical vehicles, the lack of counseling about sunscreen usage, and for late referrals to the dermatologist.11–15 We believe the respective professional roles could be better delineated. Pharmacists should predominantly evaluate acute inflammatory and infectious skin diseases while dermatologists manage chronic skin diseases and skin neoplasms.25 Additionally, some diseases, such as tinea pedis, are treated with comparable effectiveness by pharmacists and dermatologists, while others, such as acne, can be treated much more effectively with prescription options.9,24
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Emphasizing dermatology teaching within pharmacy curricula There is little emphasis on dermatology during pharmacy school training. While community pharmacists in Britain felt confident in advising patients about common skin problems, much less time was devoted to dermatology in the pharmacy vs. medical school curriculum. Our survey suggests that pharmacists spend less than 1% of their pharmacy school education in the study of dermatology, with no emphasis on dermatological diagnosis. Postgraduate dermatology education is predominantly obtained from pharmacy journals and, to a lesser extent, from distance learning, with no direct teaching from dermatologists.26 Pharmacists report stronger graduate training focusing on prescription drugs, over-the-counter drugs, and compounding.27 Since 63% of pharmacy consults are focused on six skin disease processes, a focused education curriculum provided by dermatologists could influence this deficiency. Limitations The study had some limitations that should be taken into consideration when interpreting the results. While 83
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pharmacists participated in the symposium, only six dermatologists attended as members of the faculty. The number of participants responding to some of the preand post-test questions using the ARS was lower than expected, with a mean of 53 respondents to each question. We feel this is likely due to the novelty of the ARS to many of the participants and, in some cases, the length of the questions. In the future, we would allow the participants more than eight seconds to respond to each question. Conclusion The NEOMED Dermatology Primer for Pharmacists successfully addressed a number of topics in dermatology for pharmacists in an interprofessional environment. It identified significant gaps in pharmacists' knowledge of skin disease, objectively enhanced pharmacists' knowledge of skin disease using problem-based interactive learning with an audience response system, and provided a forum that served as a basis for a healthier dermatologist– pharmacist relationship. The pharmacists reported an interest in attending future symposia presented by physicians in the field of dermatology and other clinical areas. The symposium also exposed pharmacist concerns about the
Addendum 1. Pharmacy Dermatology Primer Survey Questions
Pre-Test Questions 1.
2.
3.
4.
I have made recommendations for over-the-counter skin products to patients in the pharmacy. A. Yes B. No I have recommended over-the-counter skin-care products for the following skin conditions: acne, eczema/dry skin, herpes, psoriasis, warts, fungal infections, poison ivy. A. None B. 1 or 2 C. 3 or 4 D. 5 or 6 E. All of them. How many times in a typical week do you recommend a skin care product to a patient? A. None B. 1 or 2 C. 3 or 4 D. 5 or 6 E. 7 or more How many times in a typical week do you recommend the patient see a dermatologist or primary care physician for a skin problem? A. None B. 1 or 2 C. 3 or 4 D. 5 or 6 E. 7 or more
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5.
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For which of the following skin diseases do pharmacists most commonly recommend over-the-counter products? A. Acne B. Eczema C. Fungal infections D. Herpes E. Warts 6. Not counting this lecture, how many dermatology lectures, presented by a dermatologist, have you attended since graduating from pharmacy school? A. 0 B. 1 C. 2 D. 3 E. 4 or more 7. My primary source of information for prescribing dermatologic products is: A. Pharmacy journals B. Clinical dermatology journals C. Internet-based sources D. Pharmaceutical representatives E. Pharmacy meetings 8. On average, how many times do you contact/telephone a dermatologist to report a potentially significant drug interaction, allergy, or other issue that directly affects the care of a patient? A. Once per year B. Once every 6 months C. Once every month D. Once per week E. Several times per week 9. To the best of your knowledge, why do dermatologists prescribe brand-name topical products over generic drugs: A. Brand-name products sometimes have superior vehicles that improve efficacy or compliance B. Dermatologists are induced to prescribe brand-name products with gifts C. Dermatologists are misguided by unscrupulous drug representatives D. It is easier to remember the brand name E. Patients demand brand name products 10. Pharmacists can improve their service to patients if they know how dermatologists think. A. Yes B. No 11. Pharmacists could improve their service to patients if they have more continuing medical education in the field of dermatology. A. Yes B. No 12. There is an adversarial relationship between pharmacists and dermatologists: A. Yes B. No Pre/Post Wart Presentation 1. Which of the following is the best initial OTC option for a patient with a solitary 6-mm plantar wart? A) Daily use of 17% salicylic acid after filing B) Freeze with dimethyl ether (Freeze away™) C) Formaldehyde soaks D) Vinegar soaks E) Rub raw potato and bury it in the back yard Ans: A
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2.
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A patient complains of a painful wart on the right palm that has continually enlarged over the past year despite treatment with dimethyl ether freezing, 17% salicylic acid liquid, and 4 visits to the dermatologist. The warty lesion is 15 mm in diameter. The pharmacist should recommend: n ¼ 62 A) Ignoring the wart since it will eventually go away B) Retreating with the same OTC products C) Retreating with alternative OTC products D) Referring the patient back to the same dermatologist to confirm diagnose and plant treatment (or a second opinion) E) Treating with OTC oral cimetidine
Ans: D Pre/Post-Herpes Presentation 1. A frustrated patient asks the pharmacist for help with a “cold sore” on the right lower lip that recurs every 3–4 weeks associated with stress, sun exposure, and the menstrual cycle. Grouped vesicles and erosions are noted in a 15 10 mm area adjacent to the vermillion border of the right lower lip. The pharmacist should recommend: A) topical docosanol (Abreva™) three times daily B) lysine 1000 mg three times daily C) benzocaine 6.5%, phenol 0.45%, camphor 0.25%, menthol 0.25% liquid (Anbesol™) three times daily D) referral to a physician to consider acyclovir or related prescription product E) referral to a surgeon to excise the lesion Ans: D 2.
A 16-year-old girl who suffers from recurrent “cold sores” asks questions about whether her boyfriend can “catch herpes” from her. You should explain that: A) Cold sores, like canker sores, are not infectious B) Cold sores are only infectious during a visible attack C) Catching the virus at an early age will make her boyfriend immune from future attacks D) The potential for spread is reduced with oral anti-viral treatment E) The potential for spread is eliminated with oral anti-viral treatment
Ans: D Pre/Post Adherence Presentation 1. Dermatology compliance/adherence is: A) An insignificant problem since itchy patients use their medication B) Impossible to prevent C) A major reason patients with skin problems fail to get better D) A more significant problem with oral agents E) A poor excuse for ineffective drug treatment Ans: C 2.
Ans: A
Improving adherence/compliance is possible with: A) A health care team approach B) Handouts C) An emphasis on all possible side effects D) Proper supervision by a mother E) Limiting prescription medications to one per patient
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Pre/Post-Topics in Topical Dermatology 1) The prescription is written for branded fluticasone propionate 0.05% LOTION. This product is not in stock. A quick call to the physician leads to approval for a generic OINTMENT that is in stock. Even though you have approval, which of the following should be considered? A) Location: the treated area is covered by clothing that could be damaged by the ointment base B) Location: The patient is black and plans to use it in the scalp C) Effectiveness: Ointments are less effective than lotions D) Side effects: Stinging is more likely with an ointment E) Refills: An additional refill is needed since the ointment will not spread as easily as the lotion Ans: A 2)
A patient's scalp psoriasis is improving while they are using a topical steroid, but they report that they hate the ointment they are using because it “mats” their hair. You agree to phone the physician for the patient. Any of the following, EXCEPT ONE, might be excellent choices. A) Dermasmoothe scalp oil (at night and washed out in the morning) B) A thermolabile foam such as LUXIQ® or OLUX® C) An emollient cream such as Temovate-E or other steroid with Dimethicone in its base D) A spray such as Clobex spray or Kenalog spray E) Betamethasone lotion such as Diprolene lotion
Ans. C Pre/Post-Urticaria Presentation 1) Which of the following H-1 and H-2 antihistamines is least likely to cross the blood–brain barrier? A) Hydroxyzine B) Cetirizine C) Fexofenadine D) Cimetidine E) Levocetirizine Ans: E 2) Which of the following does not have antihistamine properties? A) Diphenhydramine B) Doxepin hydrochloride C) Doxycycline D) Loratadine E) Ranitidine Ans: C Pre/Post-Antibiotic for Skin and Skin Structure Infections 1) A patient has been treating her “cold sore” for 10 days with her usual antiviral ointment as well as an OTC antibiotic ointment but it has become more red, indurated, crusted, and itchy. What is your diagnosis? A) Resistant Herpes simplex virus B) Bullous Impetigo C) MRSA secondary infection D) Allergic contact dermatitis E) Tinea faciale Ans: D 2)
A patient who scratched his leg while washing his car 5 days ago has noticed a progressively enlarging red patch spreading around it over the past 24 hours. It is sore and has not responded to OTC antibiotic
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ointments. He had a Tetanus shot 1 year ago. He denies fever but just “does not feel up to par.” He asks for your advice. He should do which of the following? A) Use warm soaks, continue his ointment and elevate his leg B) Use hydrogen peroxide and “triple antibiotic ointment” C) Take acetaminophen and wait for a day or two and call his physician if not improving D) Call his doctor or go to an Urgent Care or ER facility E) Take “left over” antibiotic he has at home and call his doctor if not better in three to four days Ans: D Pre/Post-Topical Steroids for Eczema and Psoriasis 1) Which of the following topical medications produces the best long-term results for a patient with seborrheic dermatitis of their face? A) Clobetasol lotion B) hydrocortisone butyrate emollient cream C) Ketoconazole cream D) Clindamycin lotion E) Benzoyl Peroxide/Clindamycin in a hydrogel base Ans: C 2)
A 70-year-old man shows you several clusters of papulovesicles on the right side of his forehead. They started 2 days after cleaning up leaves in his yard and have been present for 24 hours. It felt itchy initially but became very painful and is not responding to OTC “poison ivy” gel. You should suggest: A) Cold water compresses and topical antibiotic TID B) Topical Calamine lotion TID C) Topical Diphenhydramine D) Seek medical attention now E) Cold water compresses and 1% Hydrocortisone cream TID
Ans: D Dermatology Practicum Post-Test Questions: 1. My ability to effectively recommend over-the-counter skin care products has been improved as a result of the Dermatology Practicum. A. Yes B. No 2. I anticipate I will recommend more over-the-counter skin care products as a result of the Dermatology Practicum. A. Yes B. No 3. I anticipate I will refer more patients to the dermatologist or their primary care physician as a result of the Dermatology Practicum. A. Yes B. No 4. As a result of the Dermatology Practicum, the likelihood I would attend a symposium presented by clinicians (at ——————) is: A. Increased B. Decreased C. The same 5. Pharmacists can improve their service to patients if they know how dermatologists think. A. Yes B. No
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6.
7.
8.
9.
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There is an adversarial relationship between pharmacists and dermatologists: A. Yes B. No Did you succeed in closing a knowledge gap as a result of this course? A. Yes B. No In which area did you close a knowledge gap? A) Warts B) Herpes C) Adherence D) Topical Dermatology E) Urticaria F) Systemic Steroids G) Skin and Skin Structure Infections F) Topicals in eczema and psoriasis Did this program motivate you to learn more about dermatology through future independent reading or coursework? A. Yes B. No
physician–pharmacist relationship and provided a basis for further discussion and research to best harness the skills of pharmacists in team-based medical care. References 1. Committee on Quality Healthcare in America. Crossing the Quality Chasm: A New Health System in the 21st Century. 1st ed, Washington, DC: National Academy Press; 2001. 2. Nutting PA, Miller WL, Crabtree BF, et al. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7 (3):254–260. 3. Marks R. Who will advise patients about matters dermatological in the new millennium? Arch Dermatol. 2000;136(1):79–80. 4. Kilkenny M, Yeatman J, Stewart K, Marks R. Role of pharmacies and general practitioners in the management of dermatological conditions. Int J Pharm Pract. 1997;5(1):11–15. 5. Plunkett A, Lau P, Stewart K, Marks R. Skin conditions in the pharmacy: consumer satisfaction and economic conditions. Int J Pharm Pract. 2001;9(1):9–14. 6. Hammarstrom B, Wessling A, Nilsson JL. Pharmaceutical care for patients with skin diseases: a campaign year at Swedish pharmacies. J Clin Pharm Ther. 1995;20(6):327–334. 7. Rogers PJ, Wood SM, Garrett EL, et al. Use of nonprescription topical steroids: patient's experiences. Br Assoc Dermatol. 2005;152(6):1193–1198. 8. Linnblad AK, Kjellgren KI, Ring L, Maroti M, Serup J. The role of dermatologists, nurses and pharmacists in chronic dermatological treatment: patient and provider views and experiences. Acta Derm Venereol. 2006;86(3):202–208. 9. Chamberlin, RW. American College of Consult Pharmacists. Module 06: Dermatological Disorders. 〈http://education.ascp. com/gpr/node/133〉. Updated March 10, 2010. Accessed September 25, 2013.
10. American College of Clinical Pharmacy. ACCP's Updates in Therapeutics 2011. 〈http://www.accp.com/meetings/ut11/〉. Updated April 17, 2011. Accessed September 25, 2013. 11. Marks R, Plunkett A, Merlin K, Jenner N. Atlas of Common Skin Diseases in Australia. Victoria, Australia: St Vincent's Hospital, Department of Dermatology; 1999. 12. Casper KA, Mehta BH. Healthy skin for women: a review of common conditions and therapies. J Am Pharm Assoc. 2002;42 (2):206–216. 13. Pray JJ, Pray WS. Teenagers and acne: the role of the pharmacist. US Pharm. 2003;28(6):17–23. 14. Mehta R. Topical and transdermal drug delivery: what a pharmacist needs to know. InetCE 221-146-04-054-H01. 〈http://www.inetce.com/articles/pdf/221-146-04-054-H01.pdf〉. Accessed September 25, 2013. 15. Vender R. The management of itchy skin. Skin Ther Lett. 2006;1(2):1–3. 16. Manahan MN, Soyer HP, Nissen LM. Teledermatology in pharmacies: a pilot study. J Telemed Telecare. 2011;17(7):392–396. 17. Naldi L, Manfrini R, Martin L, Deligant C, Dri P. Feasibility of a web-based continuing medical education program in dermatology: the DermoFAD experience in Italy. Dermatol. 2006;213(1):6–11. 18. Bhosle M, Balkrishnan R, Dewan T, Yelverton CB, Feldman SR. The rise of the generic drug market and its implications for dermatology. J Dermatolog Treat. 2005;16(5-6):295–298. 19. US Department of Health and Human Services. ASPE Issue Brief: Expanding the Use of Generic Drugs. December 1, 2010. 〈http://aspe.hhs.gov/sp/reports/2010/genericdrugs/ib.pdf〉. Accessed September 25, 2013. 20. Rochester CD. Drug interactions in dermatology: are they just skin deep? US Pharm. 2007;32(4):HS29–HS39. 21. Coleman CL. Examining influences of pharmacists' communication with consumers about antibiotics. Health Commun. 2003;15(1):79–99. 22. Sodergard BM, Baretta K, Tully MP, Linnblad AK. A qualitative study of health-care personnel's experience of a
S.K. Fabbro et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 92–105 satellite pharmacy at a HIV clinic. Pharm World Sci. 2005;27 (2):108–115. 23. Ring L, Linnblad AK, Kjellgren KI, et al. Living with skin diseases and topical treatment: patients' and providers' perspectives and priorities. J Dermatol Treat. 2007;18(4):209–218. 24. Araujo OE, Desantis DA, Doering PL. Survey of the professional interrelations between dermatologist and pharmacist. Drug Intell Clin Pharm. 1986;20(11):876–880.
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25. Yeatman J, Kilkenny M, Stewart K, Marks R. Advice about management of skin conditions in the community: who are the providers? Aust J Dermatol. 1996;27:540–547. 26. Hafejee A, Coulson IH. Community pharmacists' role in managing common skin problems. Br J Dermatol. 2006;155(6):1293–1307. 27. Eedy DJ, English JS, Coulson IH. Updates from the British Association of Dermatologists annual meeting, 5-8 July 2005, Glasgow, U.K. Br Assoc Dermatol. 2006;154(6):1028–1045.
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Research
http://www.pharmacyteaching.com
The pharmacist role in dermatologic care Stephanie K. Fabbro, MDa, Eliot N. Mostow, MD, MPHb,c, Stephen E. Helms, MDb,c, Richard Kasmer, PharmD, JDd,e, Robert T. Brodell, MDf,g,h,* a
Division of Dermatology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH b Dermatology Section, Northeast Ohio Medical University, Rootstown, OH c Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, OH d Division of Academic Affairs, Northeast Ohio Medical University, Rootstown, OH e Department of Pharmacy, Northeast Ohio Medical University, Rootstown, OH f Department of Dermatology, University of Mississippi, Jackson, MS g Department of Pathology, University of Mississippi, Jackson, MS h Department of Dermatology, University of Rochester School of Medicine and Dentistry, Rochester, NY
Abstract Objective: Pharmacists play a crucial role in the management and education of patients with dermatologic disease. However, there is little formal dermatologic education provided in pharmacy school or post-graduate training. Additionally, dermatologists and pharmacists have identified boundaries to patient care that are largely due to weak communication between the two professions. To improve pharmacists’ dermatologic knowledge and interprofessional relations, the Dermatology Symposium for Pharmacists was developed. Methods: Pharmacists were recruited to participate in the symposium on a state level. Pre- and post-test survey questions were administered using an audience response system, which tested frequency of dermatology encounters in the pharmacy, pharmacist perceptions of dermatology, and case-based questions correlating with each lecture. Results: A total of 83 pharmacists attended the symposium, the majority of whom make at least one dermatological recommendation daily. Paired t-test assessed the differences between scores of pre- and post-test questions on dermatologic knowledge, which showed mean scores of 6.36 and 9.89 before and after the symposium (p r 0.0001), respectively. The symposium had a significant impact on attendees with 65% saying they were more likely to recommend over-the-counter skin care products and 89% feeling more comfortable with dermatology referral. Methods to improve interprofessional care were developed during the panel discussions. Conclusion: The pharmacists attending this symposium were enthusiastic about learning more regarding dermatologic disease. The use of case-based interactive learning permitted dermatology teachers to identify knowledge gaps for an audience with
Funding: Data were gathered using an audience response system at a symposium (A Dermatology Primer for Pharmacists: a dialog between Pharmacy and Dermatology Practitioners at Northeastern Ohio Medical University on November 5, 2011) that was supported by an unrestricted educational grant from Galderma. Disclosures: Drs. Brodell, Helms, and Mostow have received honoraria, served on advisory boards, and/or received investigative support from Galderma, the major sponsor of the symposia described in this article, but these relationships are not felt to have any relevance to the content of this article. Other disclosures—Eliot N. Mostow, MD, Stephen E. Helms, MD, and Robert T. Brodell, MD: Speakers Bureaus: Allergan, Galderma, GlaxoSmithKline, and Dermik; Consultant: Galderma, Sirius laboratories, and Medicis; Clinical Trials: Galderma, Allergan, and Dow; Investigator: Amngen. Investigative Review Board: This study was approved by the Northeastern Ohio Medical University Institutional Review Board on November 1, 2011. * Corresponding author: Robert T. Brodell, MD, Department of Dermatology, University of Mississippi, 2500 North State Street, Jackson, MS 39216. E-mail: [email protected] 1877-1297/14/$ – see front matter r 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cptl.2013.09.008
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whom they had no prior experience. We believe the symposium also improved the interprofessional relationship between pharmacists and dermatologists regionally. r 2013 Elsevier Inc. All rights reserved. Keywords: Dermatology; Interprofessional care; Medical education; Pharmacy
Introduction Pharmacists are often the initial source of advice regarding over-the-counter (OTC) treatment for many patients with mild dermatological diseases. They may choose to accept the responsibility of determining whether a patient might respond to OTC treatment or whether he/she should be referred to a primary care physician or dermatologist. In any event, they are an important member of the health care team.1,2 Pharmacists provided initial OTC treatment for 39% of those with dermatological conditions as shown by a recent survey.3 Patients are often satisfied with the dermatological recommendations made by pharmacists, and in certain settings, their efforts have been shown to be cost-effective.4 In Sweden, a national campaign to improve pharmaceutical care of patients with skin disease saved 5–10% for the total dermatology health cost burden when the assistance of pharmacists was employed.5,6 Further benefits may come from pharmacists discouraging the use of OTC products that would be unnecessary or harmful for a patient's individual condition, such as longterm use of OTC topical steroids.7 Conversely, the trend toward using technicians at retail settings and the increased prevalence of mail-order pharmacies may insulate the pharmacist from providing effective medication counseling regarding potential adverse reactions and prevent the promotion of medication adherence.8 There is very little scientific interchange between dermatologists and pharmacists in the United States and a paucity of academic opportunities for pharmacists to learn dermatology. The annual meetings of the American Pharmacists Association, the American College of Clinical Pharmacy, and the American Society of Consultant Pharmacists revealed minimal coursework on dermatologyrelated diseases and treatments over the years 2009–2011. Out of 40 continuing education (CE) online modules, the American Society of Consultant Pharmacists offered only one module for three continuing education credits on dermatological disorders of the elderly and no live CE opportunities on dermatology.9 The American College of Clinical Pharmacy, as part of their Updates in Therapeutics conference, offered a one-hour review course on dermatology for ambulatory care pharmacists, out of a total of 27 contact hours.10 Finally, the monthly continuing education journal US Pharmacist rarely publishes articles geared toward dermatology topics, such as dermatological drug interactions. Because of the wide variation in the depth and breadth of knowledge about skin disease among pharmacists, many
pharmacists have suboptimal training in treating patients with dermatologic disease, and many do not feel comfortable participating in dermatologic care. This could possibly be optimized if the dermatology community played a more active role in advising and educating pharmacists. Our task force of dermatologists and pharmacy professionals created a formal CE symposium entitled “A Dermatology Practicum for Pharmacists: a Dialogue between Pharmacists and Dermatology Practitioners” (Fig. 1). The pharmacists attending this program served concomitantly as subjects of this study to allow for assessment of general attitudes toward dermatologists, knowledge and skills in caring for dermatologic problems, and the type and quantity of the dermatology services that pharmacists provide. Methods The Northeast Ohio Medical university (NEOMED) Dermatology Primer for Pharmacists was a ten-hour long didactic symposium, taught by academic dermatologists from private practice settings specifically for pharmacists to fulfill the following objectives:
Discuss basic dermatologic concepts to allow pharmacists to effectively triage patients for appropriate OTC treatment vs. referral to a physician. Enhance pharmacists' knowledge of appropriate treatment as well as possible adverse reactions and interactions of dermatologic drugs. Attempt to clarify barriers and possible improvements to the current interprofessional relationship between dermatologists and pharmacists.
Using the Ohio State Board of Pharmacy Database, 4000 pharmacists in northeast Ohio were invited to the conference using electronic symposium e-mail flyers and mailed printed brochures (Fig. 1). All pharmacists within the geographic region were included in the invitation to the symposium regardless of their setting of practice. The symposium flyer was also available on the NEOMED website. Seven lectures were developed on what were thought to be the most clinically relevant topics to pharmacists as established by prior literature review. These included the following: dermatologic medication adherence, the importance of vehicle in topical treatment, Herpes infections, warts, urticaria, eczema/psoriasis, and skin and skin structure infections (SSSIs). Two case-based test questions were presented before and after each of the eight clinical lecture topics to document any short-term
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Fig. 1. Program brochure.
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improvement in dermatology-specific information. Discussion sessions led by a dermatologist and two practicing pharmacists were incorporated into the program after each set of two lectures (Fig. 1). The primary objectives of the symposium were measured by pre-test and post-test surveys that were given, as well as questions on dermatologic knowledge before and after each lecture. The pre-test survey was administered at the beginning of the symposium, immediately following the introduction speech. The post-test survey was administered after the last lecture and panel discussion of the day. These surveys were composed de novo by the creators of the symposium and were used to collect data on pharmacists' experience, knowledge, and confidence in dermatology and interpersonal relationships with dermatologists (Addendum 1). An audience response system (ARS) with an individual remote control for each attendee was used to collect answers to questions posed to the group. The responses of the group were projected in real time following each question to provide information for self-assessment as well as guidelines for teaching. The pharmacists were given approximately eight seconds to answer each question; subsequently, group results were displayed. The pre-test survey consisting of 28 questions: eight questions relating to the pharmacists' frequency of dermatology encounters within the pharmacy, four questions regarding the dermatologist–pharmacist relationship, that included pharmacists' perceptions of the field of dermatology, and 16 case-based questions. The post-test survey consisted of 29 questions: nine questions focusing on the potential for improvement in the relationship between dermatologists and pharmacists, and the same 16 casebased knowledge questions that were included in the pretest survey were repeated. The entire symposium was audio and video recorded to gather qualitative data from topics raised and questions asked during the discussion sessions. Additional survey data were collected after the completion of the symposium to evaluate teaching effectiveness in each lecture.
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Statistical analysis Data were analyzed using SPSS version 17. Results from the pre-test and post-test survey were analyzed in terms of paired t-test and point serial bisection to determine the degree of improvement in medical knowledge resulting from the symposium. The point serial bisection, a measure of how well the item distinguished the examinees who did well on the test overall from those who did not, was emphasized in the analysis. The data regarding pharmacists’ attitudes and experiences were largely analyzed only in terms of frequency. Results The conference was attended by 89 medical professionals (83 pharmacists and six physicians). Only pharmacists voted using the ARS. There was a mean of 53 respondents to each question with a range of 14–63 respondents. The demographics of the pharmacists were not measured or collected. Dermatology encounters within the pharmacy Among the eight questions assessing the prevalence of dermatological encounters within the pharmacy, 87.5% of pharmacists reported making OTC recommendations for dermatology products in the pharmacy during their career, with 68% making at least one OTC recommendation daily (Fig. 2). With regard to diseases treated in the pharmacy, 47% had made recommendations for all seven dermatologic diseases treatable by OTC products that were included in the lectures (acne, warts, herpes, psoriasis, poison ivy, fungal infections, and eczema), with most commonly treated diseases being fungal infections, acne, and eczema with 32%, 27%, and 27%, respectively (Fig. 3). A significant number (43%) of pharmacists reported referring a patient to a dermatologist or a primary care physician at least once a day. Significant dermatologic drug interactions or allergies
Fig. 2. The average number of skin care products recommended by each pharmacist in a typical eight-hour work day.
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to remember the brand name, while 24% replied that superior vehicles were the most likely motivating factor. Misinformation provided by unprincipled drug representatives was reported by 17% to lead to brand-name prescriptions.
Pharmacist cognitive improvement following symposium
Fig. 3. Dermatologic diseases most commonly treated by pharmacists.
were reported to dermatologists less commonly, with 67% of pharmacists encountering this only about once per year. Pharmacist education in dermatology As part of the pre-test questionnaire, 86% of the pharmacists reported that they had not attended a single dermatology lecture since graduating from pharmacy school. Pharmacy journals were the main source of dermatology information for 62% of pharmacists. Other commonly reported sources of information were the internet and pharmacy meetings (Fig. 4). Pharmacist views on dermatologist motivations Pharmacists overwhelmingly agreed that they could improve their service to patients by understanding how dermatologists approach disease processes and decide on treatment options. They believed it would be helpful to have more continuing medical education focusing on dermatology (95%), and only a small minority reported an adversarial relationship between pharmacists and dermatologists (8%). When pharmacists were asked about the motivations of dermatologists to prescribe brand-name products over generic drugs, 45% believed dermatologists found it easier
The medical knowledge of the pharmacists was variable. Overall, they chose the correct response 53.3% of the time. Pharmacists had greatest pre-test knowledge on the topic of patient adherence in dermatology and the least amount of pre-test knowledge on systemic steroid dosing. Item difficulty, a measure of the proportion of participants who answered a question correctly, was measured for both preand post-test items. The mean level of item difficulty for the pre-test questions was 0.489, indicating that almost half of the pharmacists answered the questions correctly on their first attempt (range 0–1). The post-test knowledge increased significantly with a mean correct response rate of 78.6%, and therefore, an item difficulty of 0.786, with a mean change in pre- to post-test item difficulty of 0.296. This indicates that almost 30% of the pharmacists who had first answered the questions incorrectly had mastered them by the completion of the symposium. The area with largest improvement of knowledge was dosage of systemic steroids, with pre- and posttest correct responses of 12.1% and 91.9%, respectively (Fig. 5). Subjectively, 42% of pharmacists believed they gained the most knowledge on the topic of the diagnosis and treatment of warts; other popular topics focused on herpes and eczema. Point serial bisection analysis was similar between the pre- and post-test items. A paired t-test was conducted to assess the differences between the raw scores of pre- and post-test. The results showed mean scores of 6.36 and 9.89 before and after the symposium, respectively (p r 0.0001).
Fig. 4. Primary sources of information on dermatologic drugs reported by pharmacists.
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Fig. 5. Pre- and post-test case-based questions answered correctly by pharmacist audience. Skin and Skin Structure Infections (SSSIs).
The confidence intervals between pre- and post-test values combined for each topic were also assessed and were found to be 32–65 and 68–87, respectively (Fig. 6). Qualitative data from audience during panel discussion Several topics were discussed during panel discussions (Fig. 7). The panel discussions included dialogs on improving interprofessional relationships between pharmacists and dermatologists and barriers to optimizing patient care that are further elaborated upon in the discussion. The majority of pharmacists view dermatologists in a positive light, though there were a few legitimate concerns raised regarding improving rapport by ensuring that both professional groups play equal roles in this dynamic relationship. Interestingly, more pharmacists agreed with the sentiment that there is an adversarial relationship between pharmacists and dermatologists after the symposium (pre-test 7.9% and post-test 12.3%).
respectively). Topics that were suggested for discussion for future symposia included dermatologic emergencies, most common reasons to make a dermatologic referral, and improving interprofessional relationships between pharmacists and dermatologists by understanding factors motivating their prescribing habits. Recommendations for future symposia included common internal medicine topics such as hypertension, diabetes, and anticoagulation.
Discussion The Dermatology Symposium provided a rare glimpse of pharmacists' views on dermatology education and their interprofessional relationships with physicians. Pharmacists attending the symposium demonstrated some dermatology
Overall reception Evaluative feedback about the symposium was exceedingly positive. The overwhelming majority of pharmacists agreed that the symposium aided them in closing knowledge gaps, motivated them to pursue further coursework in the topic of dermatology, and attend further symposia presented to pharmacists by clinicians (98%, 81%, and 83%, respectively). They also responded that they were more likely to recommend both OTC skin care products to patients and to make referrals to dermatologists or Primary Care Physicians (PCPs) for skin disease (65% and 89%,
Fig. 6. Pre- and post-test confidence intervals for the medical knowledge aspect of the survey (*p o 0.05).
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Fig. 7. Most frequently discussed topics at Panel Discussions during the Dermatology Symposium for Pharmacists. Health Insurance Portability and Accountability AcT (HIPAA).
knowledge in the pre-test, but it was evident that improvement is needed, and the post-test survey demonstrated that improvement is possible. Review of the literature revealed only minimal continuing education programs and relevant journal articles focusing on pathophysiology, prevention, patient education, and OTC treatment of the most common skin diseases directed to pharmacists. International efforts to improve web-based dermatology continuing medical education and teledermatology to aid pharmacists have increased in the last 5 years.16,17 These materials are generally created by pharmacists (RPh/PharmD), PhDs, or are collaborative efforts between dermatologists and pharmacists. We could identify no continuing education symposia in the United States where dermatologists teach pharmacists. The panel discussions brought rich qualitative data focusing on the concerns of pharmacists. Some pharmacists expressed their belief that dermatologists prescribe brandname drugs when they are not medically necessary and overuse the “dispense-as-written” tool, though the use of generic drugs in dermatology is rising and currently accounts for about 70% of dermatologic prescriptions.18 Although generic equivalents have been steadily increasing, eight of the top ten drugs by total number of prescriptions in dermatology are brand name.19 Focus group data also demonstrated that pharmacists believe that dermatologists often do not perceive them as equals and that their opinions are not valued.20 Pharmacists are also frustrated by the disproportionate nature of the relative frequency with which dermatologic diseases are encountered in the office compared to at the pharmacy, with pharmacists encountering more acute diseases and dermatologists encountering presentations that are more chronic. If developing a health care team is a professional and community goal, then providing pharmacists with information to enhance their competency in diagnosis and treatment of dermatological diseases is important. We believe this can be most effectively accomplished by forming a professional working relationship between pharmacists and dermatologists. This symposium demonstrated a willingness by
dermatologists to improve the clinical abilities of pharmacists through a continuing pharmacy education program and provided a forum to discuss methods to enhance team-based dermatologic patient care by triaging patients from the pharmacy to the dermatologist's office as part of a systems-based practice. Improving pharmacist–physician relations Analysis of focus group data demonstrates that pharmacists are the least integrated health care professionals despite their willingness to play a greater role. A lack of privacy and time constraints limit the ability of pharmacists to take a clinical history.8 Furthermore, a lack of educational materials and a fear of harming relationships with physicians or providing contradictory information to patients are often reported.21,22 Finally, the ability of pharmacists to educate patients is completely lost when dermatologists provide drug samples rather than a prescription.19 One reason for the lack of educational interchange between dermatologists and pharmacists may be related to conflicts of expectation that contribute to distrust. Pharmacists believe their key role is to educate patients about effectively utilizing their dermatologic drugs.23 However, instead, dermatologists expect pharmacists to make them aware of drug prices, watch for drug interactions, and make over-the-counter recommendations.24 Dermatologists are also frustrated with pharmacists' recommendation of inappropriate topical vehicles, the lack of counseling about sunscreen usage, and for late referrals to the dermatologist.11–15 We believe the respective professional roles could be better delineated. Pharmacists should predominantly evaluate acute inflammatory and infectious skin diseases while dermatologists manage chronic skin diseases and skin neoplasms.25 Additionally, some diseases, such as tinea pedis, are treated with comparable effectiveness by pharmacists and dermatologists, while others, such as acne, can be treated much more effectively with prescription options.9,24
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Emphasizing dermatology teaching within pharmacy curricula There is little emphasis on dermatology during pharmacy school training. While community pharmacists in Britain felt confident in advising patients about common skin problems, much less time was devoted to dermatology in the pharmacy vs. medical school curriculum. Our survey suggests that pharmacists spend less than 1% of their pharmacy school education in the study of dermatology, with no emphasis on dermatological diagnosis. Postgraduate dermatology education is predominantly obtained from pharmacy journals and, to a lesser extent, from distance learning, with no direct teaching from dermatologists.26 Pharmacists report stronger graduate training focusing on prescription drugs, over-the-counter drugs, and compounding.27 Since 63% of pharmacy consults are focused on six skin disease processes, a focused education curriculum provided by dermatologists could influence this deficiency. Limitations The study had some limitations that should be taken into consideration when interpreting the results. While 83
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pharmacists participated in the symposium, only six dermatologists attended as members of the faculty. The number of participants responding to some of the preand post-test questions using the ARS was lower than expected, with a mean of 53 respondents to each question. We feel this is likely due to the novelty of the ARS to many of the participants and, in some cases, the length of the questions. In the future, we would allow the participants more than eight seconds to respond to each question. Conclusion The NEOMED Dermatology Primer for Pharmacists successfully addressed a number of topics in dermatology for pharmacists in an interprofessional environment. It identified significant gaps in pharmacists' knowledge of skin disease, objectively enhanced pharmacists' knowledge of skin disease using problem-based interactive learning with an audience response system, and provided a forum that served as a basis for a healthier dermatologist– pharmacist relationship. The pharmacists reported an interest in attending future symposia presented by physicians in the field of dermatology and other clinical areas. The symposium also exposed pharmacist concerns about the
Addendum 1. Pharmacy Dermatology Primer Survey Questions
Pre-Test Questions 1.
2.
3.
4.
I have made recommendations for over-the-counter skin products to patients in the pharmacy. A. Yes B. No I have recommended over-the-counter skin-care products for the following skin conditions: acne, eczema/dry skin, herpes, psoriasis, warts, fungal infections, poison ivy. A. None B. 1 or 2 C. 3 or 4 D. 5 or 6 E. All of them. How many times in a typical week do you recommend a skin care product to a patient? A. None B. 1 or 2 C. 3 or 4 D. 5 or 6 E. 7 or more How many times in a typical week do you recommend the patient see a dermatologist or primary care physician for a skin problem? A. None B. 1 or 2 C. 3 or 4 D. 5 or 6 E. 7 or more
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5.
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For which of the following skin diseases do pharmacists most commonly recommend over-the-counter products? A. Acne B. Eczema C. Fungal infections D. Herpes E. Warts 6. Not counting this lecture, how many dermatology lectures, presented by a dermatologist, have you attended since graduating from pharmacy school? A. 0 B. 1 C. 2 D. 3 E. 4 or more 7. My primary source of information for prescribing dermatologic products is: A. Pharmacy journals B. Clinical dermatology journals C. Internet-based sources D. Pharmaceutical representatives E. Pharmacy meetings 8. On average, how many times do you contact/telephone a dermatologist to report a potentially significant drug interaction, allergy, or other issue that directly affects the care of a patient? A. Once per year B. Once every 6 months C. Once every month D. Once per week E. Several times per week 9. To the best of your knowledge, why do dermatologists prescribe brand-name topical products over generic drugs: A. Brand-name products sometimes have superior vehicles that improve efficacy or compliance B. Dermatologists are induced to prescribe brand-name products with gifts C. Dermatologists are misguided by unscrupulous drug representatives D. It is easier to remember the brand name E. Patients demand brand name products 10. Pharmacists can improve their service to patients if they know how dermatologists think. A. Yes B. No 11. Pharmacists could improve their service to patients if they have more continuing medical education in the field of dermatology. A. Yes B. No 12. There is an adversarial relationship between pharmacists and dermatologists: A. Yes B. No Pre/Post Wart Presentation 1. Which of the following is the best initial OTC option for a patient with a solitary 6-mm plantar wart? A) Daily use of 17% salicylic acid after filing B) Freeze with dimethyl ether (Freeze away™) C) Formaldehyde soaks D) Vinegar soaks E) Rub raw potato and bury it in the back yard Ans: A
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2.
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A patient complains of a painful wart on the right palm that has continually enlarged over the past year despite treatment with dimethyl ether freezing, 17% salicylic acid liquid, and 4 visits to the dermatologist. The warty lesion is 15 mm in diameter. The pharmacist should recommend: n ¼ 62 A) Ignoring the wart since it will eventually go away B) Retreating with the same OTC products C) Retreating with alternative OTC products D) Referring the patient back to the same dermatologist to confirm diagnose and plant treatment (or a second opinion) E) Treating with OTC oral cimetidine
Ans: D Pre/Post-Herpes Presentation 1. A frustrated patient asks the pharmacist for help with a “cold sore” on the right lower lip that recurs every 3–4 weeks associated with stress, sun exposure, and the menstrual cycle. Grouped vesicles and erosions are noted in a 15 10 mm area adjacent to the vermillion border of the right lower lip. The pharmacist should recommend: A) topical docosanol (Abreva™) three times daily B) lysine 1000 mg three times daily C) benzocaine 6.5%, phenol 0.45%, camphor 0.25%, menthol 0.25% liquid (Anbesol™) three times daily D) referral to a physician to consider acyclovir or related prescription product E) referral to a surgeon to excise the lesion Ans: D 2.
A 16-year-old girl who suffers from recurrent “cold sores” asks questions about whether her boyfriend can “catch herpes” from her. You should explain that: A) Cold sores, like canker sores, are not infectious B) Cold sores are only infectious during a visible attack C) Catching the virus at an early age will make her boyfriend immune from future attacks D) The potential for spread is reduced with oral anti-viral treatment E) The potential for spread is eliminated with oral anti-viral treatment
Ans: D Pre/Post Adherence Presentation 1. Dermatology compliance/adherence is: A) An insignificant problem since itchy patients use their medication B) Impossible to prevent C) A major reason patients with skin problems fail to get better D) A more significant problem with oral agents E) A poor excuse for ineffective drug treatment Ans: C 2.
Ans: A
Improving adherence/compliance is possible with: A) A health care team approach B) Handouts C) An emphasis on all possible side effects D) Proper supervision by a mother E) Limiting prescription medications to one per patient
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Pre/Post-Topics in Topical Dermatology 1) The prescription is written for branded fluticasone propionate 0.05% LOTION. This product is not in stock. A quick call to the physician leads to approval for a generic OINTMENT that is in stock. Even though you have approval, which of the following should be considered? A) Location: the treated area is covered by clothing that could be damaged by the ointment base B) Location: The patient is black and plans to use it in the scalp C) Effectiveness: Ointments are less effective than lotions D) Side effects: Stinging is more likely with an ointment E) Refills: An additional refill is needed since the ointment will not spread as easily as the lotion Ans: A 2)
A patient's scalp psoriasis is improving while they are using a topical steroid, but they report that they hate the ointment they are using because it “mats” their hair. You agree to phone the physician for the patient. Any of the following, EXCEPT ONE, might be excellent choices. A) Dermasmoothe scalp oil (at night and washed out in the morning) B) A thermolabile foam such as LUXIQ® or OLUX® C) An emollient cream such as Temovate-E or other steroid with Dimethicone in its base D) A spray such as Clobex spray or Kenalog spray E) Betamethasone lotion such as Diprolene lotion
Ans. C Pre/Post-Urticaria Presentation 1) Which of the following H-1 and H-2 antihistamines is least likely to cross the blood–brain barrier? A) Hydroxyzine B) Cetirizine C) Fexofenadine D) Cimetidine E) Levocetirizine Ans: E 2) Which of the following does not have antihistamine properties? A) Diphenhydramine B) Doxepin hydrochloride C) Doxycycline D) Loratadine E) Ranitidine Ans: C Pre/Post-Antibiotic for Skin and Skin Structure Infections 1) A patient has been treating her “cold sore” for 10 days with her usual antiviral ointment as well as an OTC antibiotic ointment but it has become more red, indurated, crusted, and itchy. What is your diagnosis? A) Resistant Herpes simplex virus B) Bullous Impetigo C) MRSA secondary infection D) Allergic contact dermatitis E) Tinea faciale Ans: D 2)
A patient who scratched his leg while washing his car 5 days ago has noticed a progressively enlarging red patch spreading around it over the past 24 hours. It is sore and has not responded to OTC antibiotic
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ointments. He had a Tetanus shot 1 year ago. He denies fever but just “does not feel up to par.” He asks for your advice. He should do which of the following? A) Use warm soaks, continue his ointment and elevate his leg B) Use hydrogen peroxide and “triple antibiotic ointment” C) Take acetaminophen and wait for a day or two and call his physician if not improving D) Call his doctor or go to an Urgent Care or ER facility E) Take “left over” antibiotic he has at home and call his doctor if not better in three to four days Ans: D Pre/Post-Topical Steroids for Eczema and Psoriasis 1) Which of the following topical medications produces the best long-term results for a patient with seborrheic dermatitis of their face? A) Clobetasol lotion B) hydrocortisone butyrate emollient cream C) Ketoconazole cream D) Clindamycin lotion E) Benzoyl Peroxide/Clindamycin in a hydrogel base Ans: C 2)
A 70-year-old man shows you several clusters of papulovesicles on the right side of his forehead. They started 2 days after cleaning up leaves in his yard and have been present for 24 hours. It felt itchy initially but became very painful and is not responding to OTC “poison ivy” gel. You should suggest: A) Cold water compresses and topical antibiotic TID B) Topical Calamine lotion TID C) Topical Diphenhydramine D) Seek medical attention now E) Cold water compresses and 1% Hydrocortisone cream TID
Ans: D Dermatology Practicum Post-Test Questions: 1. My ability to effectively recommend over-the-counter skin care products has been improved as a result of the Dermatology Practicum. A. Yes B. No 2. I anticipate I will recommend more over-the-counter skin care products as a result of the Dermatology Practicum. A. Yes B. No 3. I anticipate I will refer more patients to the dermatologist or their primary care physician as a result of the Dermatology Practicum. A. Yes B. No 4. As a result of the Dermatology Practicum, the likelihood I would attend a symposium presented by clinicians (at ——————) is: A. Increased B. Decreased C. The same 5. Pharmacists can improve their service to patients if they know how dermatologists think. A. Yes B. No
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There is an adversarial relationship between pharmacists and dermatologists: A. Yes B. No Did you succeed in closing a knowledge gap as a result of this course? A. Yes B. No In which area did you close a knowledge gap? A) Warts B) Herpes C) Adherence D) Topical Dermatology E) Urticaria F) Systemic Steroids G) Skin and Skin Structure Infections F) Topicals in eczema and psoriasis Did this program motivate you to learn more about dermatology through future independent reading or coursework? A. Yes B. No
physician–pharmacist relationship and provided a basis for further discussion and research to best harness the skills of pharmacists in team-based medical care. References 1. Committee on Quality Healthcare in America. Crossing the Quality Chasm: A New Health System in the 21st Century. 1st ed, Washington, DC: National Academy Press; 2001. 2. Nutting PA, Miller WL, Crabtree BF, et al. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009;7 (3):254–260. 3. Marks R. Who will advise patients about matters dermatological in the new millennium? Arch Dermatol. 2000;136(1):79–80. 4. Kilkenny M, Yeatman J, Stewart K, Marks R. Role of pharmacies and general practitioners in the management of dermatological conditions. Int J Pharm Pract. 1997;5(1):11–15. 5. Plunkett A, Lau P, Stewart K, Marks R. Skin conditions in the pharmacy: consumer satisfaction and economic conditions. Int J Pharm Pract. 2001;9(1):9–14. 6. Hammarstrom B, Wessling A, Nilsson JL. Pharmaceutical care for patients with skin diseases: a campaign year at Swedish pharmacies. J Clin Pharm Ther. 1995;20(6):327–334. 7. Rogers PJ, Wood SM, Garrett EL, et al. Use of nonprescription topical steroids: patient's experiences. Br Assoc Dermatol. 2005;152(6):1193–1198. 8. Linnblad AK, Kjellgren KI, Ring L, Maroti M, Serup J. The role of dermatologists, nurses and pharmacists in chronic dermatological treatment: patient and provider views and experiences. Acta Derm Venereol. 2006;86(3):202–208. 9. Chamberlin, RW. American College of Consult Pharmacists. Module 06: Dermatological Disorders. 〈http://education.ascp. com/gpr/node/133〉. Updated March 10, 2010. Accessed September 25, 2013.
10. American College of Clinical Pharmacy. ACCP's Updates in Therapeutics 2011. 〈http://www.accp.com/meetings/ut11/〉. Updated April 17, 2011. Accessed September 25, 2013. 11. Marks R, Plunkett A, Merlin K, Jenner N. Atlas of Common Skin Diseases in Australia. Victoria, Australia: St Vincent's Hospital, Department of Dermatology; 1999. 12. Casper KA, Mehta BH. Healthy skin for women: a review of common conditions and therapies. J Am Pharm Assoc. 2002;42 (2):206–216. 13. Pray JJ, Pray WS. Teenagers and acne: the role of the pharmacist. US Pharm. 2003;28(6):17–23. 14. Mehta R. Topical and transdermal drug delivery: what a pharmacist needs to know. InetCE 221-146-04-054-H01. 〈http://www.inetce.com/articles/pdf/221-146-04-054-H01.pdf〉. Accessed September 25, 2013. 15. Vender R. The management of itchy skin. Skin Ther Lett. 2006;1(2):1–3. 16. Manahan MN, Soyer HP, Nissen LM. Teledermatology in pharmacies: a pilot study. J Telemed Telecare. 2011;17(7):392–396. 17. Naldi L, Manfrini R, Martin L, Deligant C, Dri P. Feasibility of a web-based continuing medical education program in dermatology: the DermoFAD experience in Italy. Dermatol. 2006;213(1):6–11. 18. Bhosle M, Balkrishnan R, Dewan T, Yelverton CB, Feldman SR. The rise of the generic drug market and its implications for dermatology. J Dermatolog Treat. 2005;16(5-6):295–298. 19. US Department of Health and Human Services. ASPE Issue Brief: Expanding the Use of Generic Drugs. December 1, 2010. 〈http://aspe.hhs.gov/sp/reports/2010/genericdrugs/ib.pdf〉. Accessed September 25, 2013. 20. Rochester CD. Drug interactions in dermatology: are they just skin deep? US Pharm. 2007;32(4):HS29–HS39. 21. Coleman CL. Examining influences of pharmacists' communication with consumers about antibiotics. Health Commun. 2003;15(1):79–99. 22. Sodergard BM, Baretta K, Tully MP, Linnblad AK. A qualitative study of health-care personnel's experience of a
S.K. Fabbro et al. / Currents in Pharmacy Teaching and Learning 6 (2014) 92–105 satellite pharmacy at a HIV clinic. Pharm World Sci. 2005;27 (2):108–115. 23. Ring L, Linnblad AK, Kjellgren KI, et al. Living with skin diseases and topical treatment: patients' and providers' perspectives and priorities. J Dermatol Treat. 2007;18(4):209–218. 24. Araujo OE, Desantis DA, Doering PL. Survey of the professional interrelations between dermatologist and pharmacist. Drug Intell Clin Pharm. 1986;20(11):876–880.
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25. Yeatman J, Kilkenny M, Stewart K, Marks R. Advice about management of skin conditions in the community: who are the providers? Aust J Dermatol. 1996;27:540–547. 26. Hafejee A, Coulson IH. Community pharmacists' role in managing common skin problems. Br J Dermatol. 2006;155(6):1293–1307. 27. Eedy DJ, English JS, Coulson IH. Updates from the British Association of Dermatologists annual meeting, 5-8 July 2005, Glasgow, U.K. Br Assoc Dermatol. 2006;154(6):1028–1045.