Advanced Clinical Practice in the General Practice setting

Helen Kilminster is a pharmacist in General Practice in Worcestershire. Helen discusses her advanced practice journey in General Practice.

No one’s fooling anyone here. Advance Clinical Practice isn’t a new concept. However the title is now embraced by varying healthcare professionals from pharmacists to physiotherapists. With all practitioners demonstrating at master level clinical skill, leadership, education and research.

 My battle to reach the end of Master in Advanced Clinical Practice is soon, a small matter of a research methods module and a 15,000 word dissertation. Doodle right? Pfft! Each module has really pushed me academically and my personal resilience to the absolute maximum. I keep asking myself “why? Is it really, really, really worth it?”

 The short answer is yes. Absolutely. The bottom line and the reality for me is I love caring for people. Patients are incredibly unique. I knew this prior to working in General Practice but now I have a newfound appreciation for this fact. No two appointments are the same, each clinic session beings its own challenges and uncertainty. Just when I think I have accepted the breadth of what General Practice has to offer, the end of same day can leave me feeling like I’ve survived complex labyrinth. The variation in patient cases is exciting but mentally exhausting. All too often one appointment reads as a simple ailment or a stable long-term condition to manage. The truth is, once than consultation door closes, you never know what to expect. Examples of such paradigm shifts that I’ve encountered are a ‘migraine’ that now surfaces as a TIA, a known patient with diverticulitis booked to discuss ‘changes in bowel habit’ now I’m suspecting some degree of heart block.

 I’ve worked in hospital and I’ve experienced working in urgent care but my perception of General Practice has completely changed since working in it and seeing for myself increasing numbers of some very sick patients presenting into practice, when in fact their conditions have been life threatening. Being an ACP has prepared me to be bold enough face into all possibilities. I don’t feel I’m the most intelligent pharmacist but I know I work hard. The ACP pathway hasn’t just been about synthesising information but contextual experience gained from utilising new skills and knowledge and applying them into practice. Fundamentally I’m developing into autonomous clinician but a safe clinician. Recognising early warning signs and symptoms that would alert me to refer on but also being pragmatic when making clinical decisions within my competency.

 Having a logical, systemic approach to the exploration of patient’s presenting complaint and sequential comprehensive, a holistic history take is taught extensively and practised over time. I would say I’m still learning from my peers and upon my reflections. The fear of being complacent and missing something pertinent sometimes overspills my anxiety tolerable levels. It is important to create mind space, time to reset and recover, time to consider could I have done something differently? Peer-to-Peer review can be really useful and having a good supportive multidisciplinary network is really empowering. At the end of the day, I’m still a pharmacist, people look to me for advice and guidance over medicines but I’m able to showcase evidence-based practice and implement patient-centred care plans.

 Our attention to detail serves us well as pharmacists. It’s important to consider the processes we operate in and understand our patients’ journey throughout their healthcare. ACPs can be seen as rebels in the workforce, highlighting inefficiencies and challenging services for quality improvements. Perhaps more of a rebel WITH a cause. Change is a concept that can fragment a workforce; people react and respond differently to change. For some people, sometimes referred to as ‘laggards’, will never adopt to the change. Important to acknowledge attitudes can change and it is our leader’s responsibility to encourage others to overcome barriers for a good change to happen. ACPs are leaders, not necessary through hierarchy but lead people and drive innovation forward. Leadership can be taught; the biggest lesson for me was taking an honest account of my own strengths. Criticising and analysing my weaknesses and limitations is far easier and I could write a list in seconds.

 True leadership unpins advanced clinical practice at every cornerstone of progress. To meet the healthcare needs of our modern society the workforce of the NHS must work collaborating together, generalists and specialists, different disciplines, across different sectors. Everyone can add value; being an advanced clinical practitioner doesn’t necessary mean more value but different value, ensuring delivery of excellence in patient care at every contact. The concise definition of an advanced clinical practitioner still needs to formally acknowledged consistently for all professional bodies as well as forming clear consistent standards for all.

 The ACP pathway may not be for all pharmacists but if you think it could be the right direction for your career progression, be bold and be brave. I have loved being a pharmacist at every stage of my career. I feel privileged to have worked in various pharmacy settings. Had someone described my future role 12 years ago when I embarked this profession as a newly qualified pharmacist, I would have laughed at what I thought was impossible for a pharmacist like me. Though I have yet to finish to my Masters, I feel like I have accomplished so much outside my comfort zone. I am immensely proud to be a pharmacist on this pathway. My knowledge and competencies as broaden to horizons that I never thought I could achieve. Despite the times of struggles and the times of conflicting internal feeling of competence and self-doubt, I would still venture this pathway all over again tomorrow. The sense of altruism is overwhelming and the positive impact my role has on patients, their families, their carer and the dynamics of the practice workforce as been all worth it.

 

A day in the life of a Pharmacist trainee Advanced Clinical Practitioner (tACP)

 

Ravinder Singh Cholia is a trainee Advanced Clinical Practitioner Pharmacist at Barking, Havering and Redbridge (BHR) University Hospital Trust. He talks us through a day in the life of a pharmacist trainee ACP.

 

Right, let’s set the DeLorean for 1^st March 2016, let’s go…..back to the pharmacy. Que theme tune. If Marty Mcfly travelled back one year and asked me “Ravinder, what’s an urgent care pharmacist?” I would have replied something similar to “I haven’t got a clue.”

Ask me now and I could be close to writing a paper on it!

Back to the present day. My life as an urgent care pharmacist. Location: Queens Hospital emergency dept (ED), Romford. Time: 8am: I’m in the ED handover, listening, learning, and contributing to a multidisciplinary team. Our team includes consultants, nurses, pharmacists, paramedics, community treatment teams, ambulatory care units…the list, fortunately, goes on. I then meet my mentor, an experienced ED and primary care GP for a quick chat and catch up on the previous day as well as the day ahead. A few smiles and jokes always help start the day well.

I then hit the shop floor and pick the next patient to be seen. This isn’t an MUR or a regular consultation you would “normally” have with a pharmacist. It’s something new, unique and exciting for the profession. My patients will be seen by an advanced clinical practitioner in training who just so happens to be a pharmacist (who, by the way, has a habit of not letting you go without a thorough review of medicines hidden in his consultations).

I walk into the busy waiting room, patients gasp and hold their breath waiting and hoping that their name is on my lips, (no, this isn’t a romantic). Glazed eyes, I can’t help empathize with them but the show must go on, one patient at a time. Let’s do this.

“Mr Smith” I call out and as sure as in any community pharmacy Mr Smith himself leaps up to collect his winning lottery ticket but in this case a consolation prize, a consultation with me.

“My name is Ravinder, and I’m am trainee advanced clinical practitioner, you’ll be seeing me first today and then a doctor” In the cubicle I will take a thorough history, conduct a thorough physical examination and request relevant blood tests as well as radiological scans if required. If I feel the patient needs cannulating then I can also do this as well as prescribe fluids and drugs. Having these additional skills as well as being and independent prescriber means Mr Smith gets all the care he needs from one highly trained professional. He is welcome to ask questions and is made to understand that we are making decisions about his care together. After I have noted my differential diagnoses I will present my findings to a senior clinician, be they a registrar, my mentor or a consultant at which point we discuss my findings and decide on what should be the best course of action. Does Mr Smith need to be referred to surgeons for appendicitis or does he need maxillofacial surgeons for his facial injury? Do we need to conduct a portable ultrasound of his gall bladder or shall we send for a CT scan of the head to rule our subarachnoid haemorrhage? Before any decision is made the senior clinician will also conduct a thorough history and examination with my patient to reaffirm my diagnosis. If they concur then I am pleased I am on the right track; if they do not then this is a positive thing – it means this is a learning point and that is what I like most, learning.

At the end of the consultation I let Mr Smith know that I am also a pharmacist, so far I haven’t received any raised eyebrows – and why should I? It’s a handshake and a “thank you very much Dr” “I’m not a-” I reply but by then it’s too late and in his eyes he has received at least the same great care as he expects from a Dr. My title doesn’t define me. The level of care I give defines me.

Mr Smith is just one patient in one area of the ED. I will see many patients throughout the day, anything from a tonsillitis with GPs to a full arrest in resuscitation. I am fortunate enough to be allowed to take some ownership of my learning and taken advantage by working in all areas of the ED, following the patient journey from steaming and triage to majors and resus. My first resus involved a consultant asking me to do chest compressions – not as easy as it is on a manikin although the Bee Gees did help me keep time.

To eventually and hopefully become a master of my trade I spend one day a week at university learning about physiology, examination techniques, complexities of different body systems as well as clinical reasoning with diagnoses. This is coupled with a practice portfolio and a lot of blended and self-directed learning at home. All of this is working toward a PGDip/MSc. I have a practice facilitator/mentor as well as support from the pharmacy management team, the lead ED consultant and ACP leads as well as all the ED staff. HEE are also integral to my support network and are met with regularly.

My moto gets me through the day, “A&E stands for Anything & Everything and there is something to learn from everyone.”

So, if I was given the opportunity by Marty Mcfly to give me a glimpse of the future I would hope that there were a lot more pharmacists in my role. As a profession we can do anything with the right mindset.  Would I take Marty up on his offer? No, I don’t believe I would. My destination is set and it’s the journey that matters to me. Right now I’m enjoying the journey too much.

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