Pharmacy Inside Jobs: ophthalmology pharmacist — transcription

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Alex: Hello and welcome to Pharmacy Inside Jobs, The PJ Pod series which aims to inspire you to take the next step in your career.

Whether you’re a seasoned pharmacy professional or just starting out, our goal is to provide insights into the increasingly diverse roles that exist within the profession.

In each episode, we are joined by a guest to explore their career journey and hear about the opportunities, challenges and rewards that their current role brings.

We’ll also find out what skills they needed to succeed and how you could follow in their footsteps, should you feel so inclined.

I’m your host Alex Clabburn, and in this episode, we welcome Ed Hindle, who manages the ocular inflammation therapeutics service at Moorfields Eye Hospital.

Ed started his career at Moorfields as a trainee 16 years ago and following registration was able to secure a permanent role as a rotational pharmacist at the hospital. He’s since progressed through various ophthalmic focused roles and is now an advanced specialist pharmacist, heading up a pharmacy-led service for patients with a sight-threatening inflammatory eye disease — the largest service of its kind in the UK.

I started by asking Ed to tell us what he finds most interesting about working in the ophthalmology specialty.

Ed: The eye is a very unique organ in the body from a drug delivery perspective. So, you’ve got the drug ocular barrier, which is similar to the drug brain barrier. So, the way you deliver medicines in the eye is different compared to how you treat a lot of other diseases. When I first started, it was on the cusp of lots of the AMD drugs being developed. So, whilst I’ve worked at Moorfields, it has been a really exciting time from a drug development perspective and watching — for example — the size of the eye chapter in the BNF expand. It’s an area of medicine where there is a need for more pharmacist support than there was — for example — twenty years ago. And a lot of the therapies are more complex, and they require more complex monitoring. The logistics can be more complex. So, I think it’s a really interesting and exciting time to be involved in ophthalmology from a pharmacy perspective. 

Alex:  It sounds like you’ve gone straight into a specialist area with the eye. How was that transition for you coming out of the MPharm? Obviously, you cover a lot of ground as in your initial training and education. Was it much of a challenge to move into a specialist area? Was there any specific training you had to do? 

Ed: So, in the MPharm undergraduate, you cover — for example — glaucoma and some ophthalmic aspects, but it’s very much smaller parts of the degree. So, you’re not exposed to a huge amount of education to do with the eye. Well, certainly when I studied my MPharm. So, most of the training that I received at Moorfields is on-the-job training, and it’s developed through experience. So, I’ve done a clinical diploma, but it’s not specific to the eye. It’s general pharmacy. I also did an independent prescribing course that was specific to uveitis, which is the area that I practice in. And when you do the independent prescribing course, you set your own scope of practice, and you have local supervisors who guide you through that course and through the disease-specific areas. 

Alex: So, in terms of your current role then, it sounds like there’s quite a strong clinical component to the job you’re doing right now. It would be good to just hear about your work with patients, really, the patient load that you have, what sort of conditions you’re seeing and where you’re fitting in with the wider MDT. 

Ed: So, the ocular inflammation therapeutic service, it’s set up to manage and monitor patients who are using second-line immunosuppressant medicines.  And you may think, ‘Why, do you use these immunosuppressant medicines in ophthalmology?’ And the majority of these medicines are used to treat uveitis, which is an inflammation of the middle layer of the eye. That inflammation can either be at the front of the eye, it can be at the middle of the eye, or it can be at the back of the eye. So, if you’ve got inflammation at the front of the eye that’s normally treated with topical steroid eye drops. If the inflammations at the back of the eye, those eye drops don’t penetrate the eye to get to the back of the eye to where they’re needed. So, for inflammation at the back of the eye — posterior uveitis — you need to use systemic medicines. So, we tend to start people on relatively high doses of oral steroids. And then when those steroids are tapered down, you often need to introduce second-line immunosuppressant agents. So, the medicines that we introduce are things like mycophenolates, methotrexate, azathioprine, cyclosporine. And that’s where our team comes in, because all of these medicines have the potential to cause systemic side effects.

Alex: And which side effects specifically?

They may cause renal impairments, they may cause hepatic impairments, they could cause blood dyscrasias. So, the purpose of our team is to make sure that patients who are starting these medicines have all the blood tests that need to be completed and checked before they start. So, we make sure the patients have a liver function test, a renal profile, a full blood count. We also need to make sure that patients don’t have any underlying, potentially undiagnosed viral infections as well. So, we check people to make sure they don’t have Hep B, Hep C, HIV, as well as we can check to see if patients have had TB in the past, because these medicines can cause all of these underlying infections to reactivate.

Then we provide patients patient-specific counselling on the medicine that they’re going to start for their uveitis, so mycophenolate or methotrexate. And each of these medicines, which you usually use long-term, need ongoing safety blood checks. So, at the moment, we often need to do a blood test every two weeks for six weeks, then monthly for three months, and then quarterly for as long as the medicine’s used. So, our team makes sure that those blood tests happen when they’re supposed to happen and make sure that the correct tests are ordered. And we also make sure that those tests are reviewed, and if there’s any abnormalities detected, we have a patient-specific plan on how to manage those out-of-range tests.

We also have a patient helpline. So, when a patient starts an immunosuppressant medicine — quite a big thing for them — and they may have lots of questions that they haven’t necessarily asked at the consultation. So, we’re able to answer those questions independently of their ophthalmic appointments. If they develop a side effect, if they develop any infection, if they need advice, they’re able to contact us through those communication channels, and we can give them specific advice. The other thing we run is a biologic screening clinic. So, if the steroids that I mentioned at the beginning and the second-line agents aren’t effective at controlling the inflammation, we often then need to introduce a third-line agent. Things like biologics, things like adalimumab, infliximab, potentially other biologics as well, like tocilizumab, abatacept. And we run a pharmacy-led, screening and counselling clinic, which makes sure that patients who need to start these biologic medicines are started safely, they’re given all the information that they need, and that they are monitored effectively for as long as they’re using them. 

Alex: And so, the types of interactions you have with patients day-to-day, is that clinic-based or is there other ways that you’re physically seeing and consulting with patients? Or is it more that your role’s advisory to the MDT, you’re doing the patient-facing work? 

Ed: So, it’s both. So, we are highly integrated into the MDT, but the majority of our work is clinic-based. So, we see patients face-to-face in the clinic. There are some clinics which use lots of immunosuppressant medicines where we have a full-time presence in the clinic and when those patients are started on immunosuppressants, either myself or members of my team counsel the patients on how to start the medicine and conduct the ongoing monitoring. 

We also are able to do some of this independently of the clinic as well. So, there’s quite a large aspect which can be done remotely. So — for example — if a patient has a blood test which is out of range, we don’t need to bring them into the clinic to discuss this. We can contact them by phone — for example — and we can discuss out-of-range bloods, and we can give specific advice on what needs to happen next depending on the nature of the result. 

Alex: And how is your team structured? What’s the number of pharmacists that you’ve got working now at Moorfields? Has that changed in the time that you’ve been there? 

Ed: So, when the role was created, we had two pharmacists. There was myself and a band 7 pharmacist, but as the service has grown, we are seeing more patients. So, the size of the patient cohort has actually doubled in the past nine years. We’ve had excellent support from our chief pharmacist, Naheed Phul, who has helped us to grow our team to manage the increased patient numbers, and she’s been excellent at supporting the development of our team as well. So, we now have myself, and I manage two specialist pharmacists and also a specialist pharmacy technician. The two specialist pharmacists are now both enrolled on the ACP course. So that’s the advanced clinical practice course. It’s a three-year master’s course, which is run out of City University in London, and that gives these pharmacists clinical, practical skills to be more autonomous in how they manage the patients in clinic. And that’s a big development, and I think they will be the first ACP ophthalmology pharmacists in the UK. So that’s a big, exciting development to lead on at Moorfields. 

Alex: It does sound like you’ve got quite a lot of ownership, really, over the patient load that you’re responsible for. How does the team sit within the MDT? Do you work quite independently, or is it a bit more integrated than that?

Ed: So, we have a high degree of autonomy, but we’re very highly integrated into the clinical service. So, we sit predominantly within the uveitis service, and the uveitis service has weekly MDTs, which I normally join with. If I don’t join one, the ACP pharmacists will join. And in those MDTs, we discuss patients who are particularly complex, perhaps patients who have failed multiple agents and who have a high risk of permanent, irreversible vision loss. And then we’re able to provide input on what therapies we’re able to access. We can help with potential side effects, potential contraindications, or we can advise on what might be the best therapy option for that particular patient on an individual basis.

There are also some other niche indications where you might need to use immunosuppressant medicines in ophthalmology. There’s a condition called mucous membrane pemphigoid, where the front of the eye — the cornea — can become scarred. And there’s also indications where you may need to use things like mycophenolate and some biologics to treat that. So, we sit in the clinics where those patients are seen, and the patients that require those more specialist treatment interventions will sit with a consultant when the patient comes into the clinic, and we’ll review and we’ll provide our specialist medicines knowledge to the patients and to the consultant to help the patient get the best drug for them and get the most out the medicine that they’re using. 

Alex: And so, uveitis, is that a very common condition? Could you explain a little bit more about that? 

Ed: So, uveitis is a rare disease, but we see lots of patients with uveitis as often their care is concentrated at Moorfields. 

Alex: And what are the main symptoms of uveitis? What’s the impact on vision? 

Ed: So, the symptoms of uveitis depend on where the inflammation is in the eye. So, at the front of the eye, you might get pain, you might get some blurring of vision. But our practice, where the immunosuppressant medicines are used, is all posterior uveitis, so inflammation at the back of the eye. And the symptoms there are very different. So, it’s usually painless, but you get visual symptoms, so you may get things like floaters or blurry vision, or you may get patches with vision without good clarity. For posterior uveitis, that’s generally the most severe type of uveitis, or it can be the most severe type of uveitis. And some types of posterior uveitis — if left untreated or suboptimally treated — can lead to total irreversible vision loss. So that’s the outcome that we’re trying to avoid in all of our patients, and we can usually do this by getting people access to the right treatments following their diagnosis. 

Alex: So, I guess when it comes to uveitis, we’re talking about quite a rare condition, with new therapies and potentially not always perfect practice guidelines. Is it the case that you’re having to create your own evidence and forge your own path here to figure out what best practice looks like for patients? 

Ed: Yeah, certainly to some extent. So, there are no national guidelines on how the medicines that we use to treat uveitis are used. So, we have in-house guidance that was originally developed in conjunction with the Bristol Eye Hospital and the medical eye unit at St. Thomas’s, and we’re currently updating those guidelines now. And those guidelines will be shared with other hospitals as well, as a guide to best practice on how to safely start and continue these medicines. And in terms of evidence, yes, we are involved in generating research questions for areas of knowledge which we don’t currently have, and we are trying to answer those questions through looking at our experience with our patients and publishing that data.

That data can also be used for commissioning purposes as well. One of the limitations in ophthalmology is the lack of commissioning policies for specialist medicines. This is partially due to a lack of data. So, if we have the data to demonstrate effective outcomes with some of these new medicines, we can use those to develop commissioning policies to ensure that these medicines are able to be accessed not just for our patients at Moorfields, but also nationally as well. 

Alex: So beyond managing patients and supporting the MDT, are there any other activities that you’re engaged in? I’m thinking here of things like QI projects or research. You mentioned that there’s a strong research component at Moorfields. Is that something you and your team are able to engage in? 

Ed: Absolutely, yes. So, Moorfields is one of the largest research centres in the world for ophthalmology. Because uveitis is a rare disease, there are still lots of unknowns about some of the medicines that we use compared to other disease states like rheumatology and dermatology. So, I and my team are involved in developing research questions that try to answer some of those unknowns as well. So, every year, we send posters to ARVO, which is the Association of Research in Vision and Ophthalmology, and it’s the largest eye research conference in the world. It’s held every year in the US. So, this year, we submitted five posters to ARVO, which focus on drug, dose, side effect tolerability questions for the drugs, which we use in uveitis, which we haven’t been able to find the answer to from perhaps other disease areas like rheumatology. 

Alex: Amazing. So really filling in gaps in the evidence base and contributing to wider impact, I suppose. How does that type of work fit in with day-to-day clinical activities? Do you have protected time for those sorts of projects, or is it more a question of trying to make time, as and when you can? 

Ed: So, we have to try and make time where we are able to do so, but it’s a very, very busy service. So, Moorfields is a tertiary referral centre, so you see patients from all over the UK, who have complex uveitis. Often those patients have been referred from other specialist ophthalmic centres. And there’s a uveitis clinic on twice a day. So, it’s a very, very busy environment to work in, but it’s important that we are able to allocate ourselves time to answer some of these questions which we don’t know. So, we need to dedicate our time to the research components as well. Absolutely. 

Alex: It really feels like there’s a strong amount of expertise development within your role and your career so far and obviously within the hospital itself. Is there anything that you could share on that front, really. What it’s like to work in a site that is having a broader impact going beyond the local population and nationally, and potentially internationally as well? 

Ed: Yeah, absolutely. So, we work closely with the medical eye unit at St. Thomas’s. We have a group of patients who need biologic infusions. So, those patients are managed jointly with Moorfields and with medical eye units at St. Thomas’s. We also have very close links with UCLH. There’s a group of patients who have uveitis, but they also have background rheumatology disease as well. So, we have a monthly MDT with the rheumatologists at UCLH. Further afield, we work with uveitis centres up and down the country, as and when the need arises. I mentioned that we have a weekly MDT. Some of those MDTs, we throw open to other centres as well. So — for example — if the consultants in Belfast have a particularly complex uveitis case that they wish to discuss, they’ll contact myself, and I’ll arrange for that case to be discussed at the uveitis MDT at Moorfields. So, we collaborate very closely with local hospitals and also hospitals nationally as well, yes.

We also have the UK Ophthalmic Pharmacist Group as well. So, that is an online forum hosted on NHS Futures. I think there’s about 180, maybe 200 members at the moment. And it’s a free-to-join community of either pharmacists who are specific ophthalmic pharmacists or pharmacists who ophthalmology is a part of their job role, or just pharmacists or pharmacy technicians who have an interest in ophthalmology. There’s a very active online forum, so if people have a question, they can post their question onto the forum, and experts from up and down the country will try as best they can to answer those questions and provide support, advice, signposting, guidance, things like that. The OPG, they also have several in-person and virtual meetings per year, and they’re really useful events for pharmacy professionals who have an interest in ophthalmology to come together to discuss their practice, to share research ideas, to share things that are going well or things that can be improved in their centres, and we can all learn from each other. Historically, ophthalmology isn’t a specialty where there’s structured training. There’s not dedicated courses specifically for pharmacists who want to pursue a career in ophthalmology, and that’s something that the OPG have been working on as well, trying to develop a set of standards and potentially a curriculum that would allow pharmacists a more structured educational route and career progression. 

Alex: Is this a job that requires advanced clinical practice level of training, or are there a range of ways in? What’s the kind of availability of roles and what’s the entry point for different people potentially interested in this as an area of pharmacy? 

Ed: So, it very much depends on the organisation in which you are based. So, Moorfields is a large ophthalmic centre, and as a consequence, there are lots of specialist pharmacists in Moorfields who cover —for example — specialist glaucoma pharmacists, specialist antimicrobial pharmacists, specialist uveitis pharmacists. In different hospitals, it will depend on the size of the services that are involved. Some hospitals may have a pharmacist who covers ophthalmology, but they have lots of other duties as well. For example, head and neck surgery is often tagged on too.

Some of the larger centres may have a dedicated ophthalmology pharmacist who just does ophthalmology, and some of the even larger tertiary centres will have teams of ophthalmology pharmacists. So, it really depends on the hospital and the size of the services that they provide and also on the nature of the patients that are being treated as well. But I think as time progresses and we see more people use more advanced, more complex therapies in the eye. We’ll need to see the roles develop to accommodate those therapies. So, I think this is going to be an area of growth in ophthalmology up and down the country in all of the larger ophthalmic centres. 

Alex: And do you think any of that will filter down into primary care or even community practice? 

Ed: I think it will, yes. So — for example — you can now have OCT scans done at your high street optician, which is incredible. So, I think there will be a natural trickling down of what were once highly specialist services being rolled out more locally to people. 

Alex: So, we’re getting to the end of our time with you, Ed. It would just be great to hear what you see for yourself in five to ten years’ time, and any achievements, really, that stand out, so far from your career. Sounds like you’ve been involved in some amazing pieces of work and seeing the service grow at Moorfields. But is there anything that you’d like to share with people that just will leave us with a nice note to end on? 

Ed: So, there are currently no consultant pharmacists, credentialed pharmacists or credentialed posts in the UK. So, there’s a small group of expert pharmacists who are currently pursuing the credentialing of their positions to become consultant ophthalmic pharmacists. So, I think this is another really interesting and exciting development, and I think that makes the specialty more attractive to new or newer pharmacists as well. 

Alex: Yeah. Is that something you see potentially on the horizon for yourself? 

Ed: It is something that I am actively pursuing, yes. In the future, five years from now, it would be great to have consultant pharmacist roles, not just at Moorfields, but nationally as well in some of the other large ophthalmic centres in the UK. And I’m sure that is going to happen. Standouts for me while I’ve been at Moorfields, it was great, we had a publication in Eye, which was a really big achievement for us in the pharmacy team, professionally.

Personally, one of the highlights was that Moorfields does a clinical governance half day where the whole hospital attends an educational event at the Barbican, which is about 2,000 people. So, I was asked to speak at that twice, so that was quite a big audience of 2,000 people. That was a highlight for me personally. And it’s just been really good. You work with a really interesting, really clever, caring group of professionals, and it’s just a great environment to work in and to be a part of and to help patients get the best out of their treatments and out of their medications. 

Alex: So, I think that’s probably a good note end on, Ed. But thank you again for your time this afternoon and for joining us today.

Ed: Thank you very much.

Alex: I hope you enjoyed hearing from Ed about his experiences in ophthalmology. For me, it was striking to hear how working in a specialist trust has provided Ed with a platform to develop such a deep level of expertise, to the point where he’s able to influence practice on a national and international level, generate research that’s plugging gaps in the evidence base and progress professionally to the point where consultant-level credentialing is actively underway.

If you would like to talk to us on the podcast about your own job, you can email us at editor@pharmaceutical-journal.com

And I should say, whilst so far, we’ve spoken to space pharmacists, sports pharmacists and other niche specialities like ophthalmology for Inside Jobs, we’re also interested in hearing from pharmacists working in more traditional settings still doing interesting and inspiring work.

That’s all for this episode of Pharmacy Inside Jobs.

Thanks again to Ed for joining us and thanks to everyone for listening. I hope you’ll join us for the next one.

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