I work as the renal pharmacist at Hull University Teaching Hospitals. I also manage a clinic with consultant oversight for patients diagnosed with autosomal dominant polycystic kidney disease (ADPKD) — an inherited condition that causes small fluid-filled sacs to develop in the kidneys.
The aim of the clinic is to ensure safe and effective use and monitoring of tolvaptan (JINARCÂ®), a selective vasopressin 2-receptor antagonist, approved by the National Institute for Health and Care Excellence to slow down the growth of cysts in the kidney and preserve renal function for longer. This pharmacist-led clinic has been running for about 18 months.
08:00 — start
Today is Monday and, because the renal ward does not have a dedicated pharmacist during weekends, this means that there is a lot of catching up to do from all the acute medical and renal admissions over the weekend. I quickly, but comprehensively, review the new patients and ensure that I have recommendations (where appropriate) ready for the clinician ward round.
Ward rounds on Mondays start at 09:00 after an in-depth handover from the weekend. Depending on my work schedule, I either join the ward round or continue to review the drug charts and medications for patients admitted over the weekend or who were transferred from other wards for ongoing renal issues. If I have a preregistration trainee shadowing me, it is a great opportunity to go through the pharmaceutical care needs and considerations for these new patients. Often, I will assign one or two patients to the trainee to review and use the subsequent discussion as a teaching session.
Today, I did not attend the ward round but I have been informed by the team which patients are due for discharge. I dispense the newly prescribed medications for these patients on the ward, provide medication education to patients being discharged, and devise a follow-up plan for them in primary care/community. However, completing all three tasks for all patients sometimes proves difficult and, depending on the needs of each patient, I may only have time to prioritise one or two of the tasks.
I review a patient in clinic, who was referred to me by a consultant for education on tolvaptan to ensure they are fully informed about their treatment. I explain the need for tolvaptan therapy, how it works, how to take it and the potential side effects. I also explain my commitment to them and my expectations from them in terms of adherence to treatment and voicing any concerns. I provide the patient with my email address so they are able to reach me directly, instead of via the renal department, pharmacy department or hospital switchboard. I explain to the patient that because they are newly started on tolvaptan, they will need to attend a follow-up appointment with me every month for the first 18 months and then every 3 months thereafter.
Today is a relatively long appointment. Consultations can be as short as 15 minutes but can extend to 45 minutes depending on the complexity of the patient.
When I first started managing the tolvaptan clinic, I found it useful having a standard process checklist to refer back to, in case I forgot anything owing to nerves. Before seeing each patient, I would read their notes from the previous consultation, make a list of questions I needed to ask, and note the observations I needed to assess, including blood pressure, weight and anything else relevant.
Now that I have developed good working relationships with my patients beyond their ADPKD diagnosis, we talk about more than just their treatment. Having developed such a good rapport with them means I no longer require a checklist. If I have any concerns, I am able to refer to my clinical supervisor/mentor, Sunil Bhandari, a renal consultant at the trust and honorary professor at Hull York Medical School.
During late afternoons, I usually update guidelines, draft protocols or review renal pharmacy-related queries from within and outside our trust. My most recent query was from a GP enquiring about which antibiotic to prescribe for a patient with stage 4 chronic kidney disease, who has been diagnosed with a urinary tract infection.
Today, I am working on a protocol for appropriate calcium supplementation for patients undergoing a parathyroidectomy and drafting abstracts for review by my clinical supervisor. His constructive feedback has been extremely valuable and forces me to think more critically when reviewing research allowing me to develop this skillset.
One such abstract Bhandari and I submitted was to the European Renal Association—European Dialysis and Transplant Association conference which was scheduled to be held in Milan in June 2020. The renal department was ready to fund my trip but, owing to the COVID-19 pandemic, the conference was held virtually instead.
Patients diagnosed with ADPKD who are managed with tolvaptan need to have their liver function tests and other biochemical profiles monitored monthly for the first 18 months of treatment. I review the results to ensure there are no unexplained deviations from baseline. By late afternoon, the blood results are usually ready to view on our patient management system. I notice an unexpected finding in the blood results for several patients and draft an email to Bhandari, summarising my concerns and possible actions.
I have a very good working relationship with my clinical supervisor, who responds to my email within an hour, offering constructive advice on how to proceed.
17:30 — finish
Before I go home for the day, I type up clinic letters to the GPs of patients whom I saw earlier in the day and contact patients to let them know of any changes to treatment.
Overall, I love what I do. The support from my clinical supervisor and the renal department has been invaluable. Likewise, my line manager and chief pharmacist are very keen on education and training, accommodating all reasonable requests I have.
Are you interested in a similar role?
- My role is NHS Agenda for Change Band 8A. To be successful in such a role requires completion of a postgraduate clinical pharmacy diploma and independent prescribing qualification as a minimum;
- Do not wait for permission. If you see any opportunity to improve the service in your department, write a proposal discussing a plan of improvement. It may not be suitable initially but refine it and refine it again. Ask a senior team member to review it and, after several iterations, submit it and be patient. Progress may be slow but never give up;
- Continue your learning. Do not stop studying after gaining your diploma and independent prescribing qualification. If you have the opportunity, acquire an additional certificate in any area of interest; it does not have to be pharmacy-related. Alternatively, focus on developing the skills required to do the job — for example, consultation or research skills. This will broaden your horizons and give you the ability to solve problems from a different perspective;
- Have a good work ethic. Be diligent with your work and do not take shortcuts. This is just as, if not more, important than any certificate you acquire. It is what you do when nobody is watching that really counts;
- Join a professional network. The Renal Pharmacist Group has been an immense resource and I highly recommend pharmacists new to renal pharmacy sign up with them.
Acknowledgements: Sunil Bhandari, renal consultant at Hull and East Yorkshire Hospitals NHS Trust and honorary professor at Hull York Medical School.