Interview with a pharmacistOct 26, 2021
Both pharmacists and nurse practitioners play a critical role in medication management for patients.
But we don’t always understand what we can do for one another, which can lead to confusion, frustration, and missed opportunities. Finding ways to collaborate and build professional bridges, however, can improve outcomes for everyone.
In this week’s video, I talk with Miriam Ahmed, a pharmacist based in Canada who also runs the educational Instagram platform, @rxnotes. We dive into important topics like:
✅ Ways nurse practitioners can increase their comfort level prescribing medications
✅ Tips on mitigating common errors when dealing with medication management
✅ How to navigate medical guidelines for prescription medications
✅ And tons of questions from the audience
Check it out below!
(FYI: to slow down the audio speed, hit the gear symbol in the bottom right corner and change it to .75x or .5x. Closed captions are also located at the bottom R-hand corner of the video.)
Interview with a Pharmacist Transcript
Well, hey there.
It's Liz Rohr from Realworld NP.
You are watching NP Practice made simple the weekly videos
to help save you time, frustration and help you learn faster
so you can take the best care of your patients.
In this week's episode.
I am so pleased to share.
I did an interview with a pharmacist named Miriam.
She is a wealth of knowledge and just so lovely.
She has her own educational Instagram account for all clinicians
And we did an interview similar to the other specialist and
multidisciplinary interviews I've done so far with the primary
theme and focus being how can we collaborate better and what
we both wish we knew about each other pharmacists and primary
care providers and vice versa.
So we also answered questions from the audience, so definitely
stay tuned and listen to listen or watch our episode that
we recorded together.
I hope you enjoy it.
Well, thank you so much for being here with me.
Do you want to introduce yourself?
Tell me a little bit about yourself.
So my name is Miriam.
I'm a pharmacist working in Vancouver, Canada.
I work in a community independent practice, and I specialize
in mental health.
We work with a lot of the local mental health teams because
I'm a Canadian pharmacist in this interview, I won't really
touch on any insurance questions or discuss country specific
practice requirements, but I just want to share some general
advice about pharmacists and about what we do that is applicable
across the border.
And you also have an Instagram account that I Super love.
Do you want to tell us about that?
So I have an Instagram account.
It's just an educational platform where I share infographics
It's for use for any healthcare professionals, so nurse practitioners
can use it.
Nursing students, pharmacy students or even practicing professionals
can use it just to kind of review medication.
And I like just putting things into a nice, easy to look
at graphic and yeah, they're so beautiful.
They're so helpful.
What had you start your Instagram account?
I started in school in pharmacy school, and one of the main
reasons that I started it was I was creating these note packages
or graphics for myself for studying purposes.
I find sometimes the way that material is presented in school
is still quite old fashioned.
It's just very pieces from a textbook or screenshots of the
guidelines, and it was very hard to synthesize all that information.
So I started making these note packages, which would summarize
and make things easy to look at and understand.
So I can just look at a note package and get a lot of information
out of it instead of weeding through the different slides.
And that's when it started in pharmacy school and it just
kept going awesome.
That's really awesome.
And I know I've shared it on real world MP and people just
And I just want to recognize you because I know how much
work goes into holding an Instagram account, creating, like,
a little iceberg of, like, you see this much.
And then there's, like, all that extra.
So the theme of all the specialist interviews and multidisciplinary
interviews that I've done and will do, the theme is really
connecting specialties and disciplines so that we can all
take better care of our patients.
So that's the questions that I have for you today.
And then we also have questions that are sourced from the
audience that we went through together.
You and I.
So why don't we start with what is your favorite part about
being a pharmacist?
That's a great question.
I enjoy a lot of different parts of being a pharmacist, but
I think the best part for me is being a hub for the patient.
So I just feel like I'm the center of health care professionals
for the patient.
So I'm the go to person either from the patient themselves
or from other health care providers.
I feel like I'm collecting information from different sources.
I'm collecting the prescriptions from the patient specialist
along with their GP or NP.
And I have more of a general overview of the patient in that
way, sometimes, especially patients that see different specialists.
Those specialists are only focused on what they are prescribing
and what they're looking after for the patient.
And I just feel like I kind of centralized that and just
being very accessible to both the patient and to their healthcare
providers. So we have the patient policy asking questions
about multiple different medications, and we have specialists
calling asking about what the GP is doing or vice versa and
just having all that information and being a hub for the
patient. It's very nice, totally.
And I love that point.
I love that conception and that description of your role,
because I think that's one of the things that I realized
more and more because I've been an MP for about six years,
and I think I had no idea what all the other disciplines
did. And I recently did an interview with a physical therapist,
my own personal one that I worked with because of an injury.
And it's just like this whole different world of hidden gems.
I feel like pharmacists are really hidden gems in our healthcare
field. And I just love hearing about everything you have
to share, of course, but not at that point because it's like
when we talk about the frustration that some of us have with
the continuity of care and with specialists.
And I've noticed that a lot where I just think of so many
patients where it's like I've prescribed a medication and
then they see their cardiologist and then there's two different
sets of meds, and it's like, what are they taking?
And so you're the front lines for that.
That's just so beautiful.
That's exactly an example of what happens what we've seen
cardiologists prescribe like a different dose, and then the
MP's prescribing a different dose.
And we have to explain that you guys might want to communicate
Usually it's just a lack of documentation.
So sometimes the cardiologist makes a change.
And that's not really in the documents.
So when the patient's general practitioner, NP, or whoever's
renewing the medications, they're just going based off of
So we're just like, hey, the cardiologist actually updated
this, and usually they're very grateful for letting us them
I always am.
And I think that's like, especially as a newer nurse practitioner
I worked in maybe.
And I don't know how it works in Canada, but in the US there
are 340 B pharmacies that are specialty.
Sorry, they're community outpatient pharmacies that have
government grant funding so that we can supply medications
at a lower price for patients.
And they are usually affiliated with that health center.
So I don't know if that's maybe not the 340 B component,
but the fact that you're in a community setting.
I just think if any nurse practitioners watching this or
primary care providers, rather watching this can really remember
that they especially if you're tied to a specific community
Like, what a phenomenal resource that pharmacist is, even
if it's like a local CVS or other drugstore that people are
using. Patients usually like to use the same one.
And still develop relationships with those people, even if
you're not directly affiliated with them.
I think as a new grad, I got very aware of the different
specialists and pharmacists and all that stuff all the hot
pharmacies people like to use.
So you can tell those relationships over time.
And like you said, that's your favorite part is being that
So it's great to reach out.
I think sometimes new grads, especially, are hesitant to
reach out to other providers.
But I want to segue into the kind of theme of this, which
is connection between our specialties, but also what do you
wish? One of the things that I love learning about is what
other providers wish we knew as primary care providers.
And again, maybe this is different in the US versus Canada.
But if you could generally answer, what would you say is
something you or some things.
And this might segue into the questions that people submitted.
What are some things you wish primary care providers knew
or some of the pet peeves you have?
So I think that one of the biggest myths or misconceptions
is the role of a pharmacist just being behind the counter.
Maybe they have an image of counting pills, even in some
TV shows, when people go to the pharmacy, that's what the
pharmacist is doing even today.
That's still the image of pharmacist.
And it's just not accurate at all anymore.
So pharmacists actually don't usually do the technical skills
of counting a filling of compounding.
So we have pharmacy technicians or assistants to help with
that. And so pharmacists have used more of their clinical
knowledge to check the Therapeutics of the prescription.
And so that's one of the things that we wish that primary
care providers understood was that we're clinical practitioner
just like they are.
So we're not just filling medications or sticking labels
on anything that pharmacists have expert knowledge.
We're just working with medications all the time.
And so either we have that information on the top of our
head or if we don't know something, we know where to easily
get accurate, direct information from or where to look into
So pharmacists are a great resource to use for that.
So either you call them and they know the answer right away
or they're able to look into it and get back to you.
And yeah, just that we're available to talk about anything
medication related, whether it's drug interactions, adverse
effects, even the efficacy, which medication is best for
That's what we learn in school.
And that's what we practice when we're checking prescriptions
So that's the main role of a pharmacist.
And I think that's so unfortunate about I think healthcare
There's so many, like media portrayals that are just giving
everybody a lot of injustice.
I appreciate you saying that.
And I think just to share from personal experience.
And I have a follow up question, actually.
But personal experience.
I've talked with pharmacists about challenges with antibiotic
choice allergies and drug interactions and anticoagulation
management and choices and stuff like that.
So I've had a lot of great experiences working collaboratively.
But I guess is there a way that is optimal to reach out to
pharmacist? What would you prefer?
What would be like, the best case scenario of developing
a relationship if they weren't, whether or not they were
tied to a specific clinic, the pharmacist and the clinician.
I think that unfortunately, there are barriers in the pharmacy
world as well about creating these relationships.
And that's mostly that you're probably this is generalization.
But you're probably not going to be able to have such a solid
relationship, like a back and forth with pharmacists working
in large, busy corporate pharmacies just because they're
just so busy, they have so many roles and responsibilities
in their pharmacy that they don't really have the time or
ability to branch out or reach out other than what's necessary.
So if a medication error on the prescription comes up, they're
obviously going to reach out and get that sorted.
But beyond that, those pharmacists might not be the best
because of the time limitations they have.
But other than that, I think that you can create good relationships
with more of the smaller pharmacies independent pharmacies.
That's at least what I've experienced here in Canada.
So the independent pharmacies usually are able to have direct
lines of the pharmacy and some of the ways that you can start
creating a relationship is just maybe by adding little notes
on your prescriptions.
And I really like this.
I learned this from actually some entities that I work with
here. They kind of write just when they sent in a new ramapril
dose, for example.
And it's not ramapril ten.
And they just put, like, an arrow increased dose.
And now I know that it was purposely increased, and I don't
have to phone or call or Fax back saying, oh, why is there
Even just saying prior authorization, completed or submitted.
Now, I don't have to follow up.
I know it's done and just waiting for that.
So that's been really nice.
That's something I learned from the MPs I've worked with
here. And I think that's a good way to start.
That's really awesome.
And actually, that's one of the things that when I was in
school, the person I trained with with pediatric medication.
Specifically, I would write a note being saying their weight
And like, for Amoxicillin, for example, like, 90 milligrams
per kilogram in the notes to the pharmacist was like, whatever
kilograms. I'm not good with those off the top of my head.
However, kilograms they were.
And then in parentheses, it would be like, 90 Megs per gig
per day or whatever.
And then I'd send that off, and then I'd be like, fingers
crossed. This is helpful.
Yeah, that definitely would be helpful choices.
I always get nervous with men dosing.
So I'd always like to put that in, like, please call me if
It's good practice, especially for little kids.
A dose error can be very bad.
So if we get a prescription that doesn't have the kilograms,
we're usually calling the parent, saying, how much does their
We just need to double check with those funny story.
Like, I remember calling a dad and they're like, I don't
know at all.
I have to contact them all.
That definitely happens, especially as they get a little
And like, their last time they were weighed was that their
physical a year ago.
And it's like, okay.
Yeah, I don't know.
But something around there, it's not over there.
But I guess leading into that, I feel like this kind of ties
into one of the questions that were submitted.
And the question is, what are the most common medication
errors that you see in primary care?
And obviously it's probably location dependent.
But I imagine even internationally, we all practice similar
And so what do you feel like some are the most common medication
errors and any strategies that you recommend to help with
I think one of the most common medication errors we kind
of mentioned, actually how there's discrepancy and some of
Usually this happens as we discuss when someone sees a different
provider and a different prescription comes in and the primary
care provider doesn't have that updated information so usually
updated doses after medication changed or if medications
have been added or actually being omitted.
So sometimes I've seen patients go into a hospital.
Maybe they had extreme hypoglycemia.
So a bunch of their diabetes medications were actually stopped.
And then when they come back in community, the primary care
provider didn't get that update and they were prescribed.
That's something that we always follow up.
We say in hospital, this was actually discontinued because
Do you want to continue?
Usually it's because they didn't know that.
I would say to help mitigate that try to keep getting updated
medication lists from the patient.
Maybe if they use the same pharmacy, it would be even easier.
Just ask the pharmacy to send the most recent updated list
and also updating your electronic Mars.
I find that sometimes providers just click print and the
same error is stuck for prescription after prescription after
prescription. And I've had to write a nice note to someone
saying, Please, I'm just like, please update your electronic
Mark because this is the third something like that, and it
works. Yeah, they ended up updating.
Yeah, that is like a pet peeve of mine.
And I understand it's really hard when you have 15 minutes
visits and they're going really fast.
But if your Med list is like and again, if you're listening
to the podcast, I have my hands wide apart a really long
list of meds.
If you have hydroxy and hydrolyze, those are Med name.
That's another one that comes to mind of Med errors.
But if you have multiple doses, Metropolis all on the same
list, that is just such high risk for error.
And not many people do that.
But that's like it is a priority because medication errors
are significant in terms of actual harm to people.
Yeah, I was just trying to send it from asking the pharmacy
to send it to the hospital, because that's another frustration,
just in healthcare in general is that the EHRs or Mrs don't
always match up between health center and hospital and pharmacy
But that's a great idea.
Just trying to keep your notes of what the patient is on
just as clean as possible.
So like, as you were saying, different doses, like just delete
the old dose.
Just try to have the most current medication list that would
help reduce errors.
And another thing you were mentioning, like, hydroxyzine
Usually when prescriptions are printed or sent directly to
Privacy, it's Typed out.
So those errors don't happen.
But for another common error or something that we have to
follow up on is illegible handwriting.
So for handwritten prescriptions, I know it's like always
Pharmacist have to read these messy handwriting, but it's
actually very inconvenient, and it can be significantly dangerous.
So sometimes I'm looking and I send it like, we have four
pharmacists working and we're just passing this prescription.
And like, what is this?
And we just have to turn on our Detective mode and ask the
patient what was going on.
If it's an infection, we're like, okay, now we can narrow
it down to some sort of antibiotic, so we usually figure
it out, but it can be dangerous, because if it's something
general, the patient doesn't have information and you make
the wrong guess of what that messy handwriting is.
So I think that just at least having the drag name in some
sort of legible handwriting would help.
Like you said, everyone's rushed.
So you're scribbling at the end of the 15 minutes appointment,
getting ready for the next patient, but just at least having
the main drag name legible would be very helpful.
And I think that speaks to again.
And it's really hard.
We're only individuals working in a system that doesn't always
All of us are.
And so one thing I certainly endeavored to do, and I'm not
100%. I'm not perfect.
I try to make sure that my patients have a Med list, whether
it's your end of visit summary, depending on the practice
of the primary care clinic or something like some sort of
written list, especially if they have multiple chronic medications.
I really try to make sure that that is a practice that they
start because not every patient carries one.
Some patients carry one in their wallet, and at least they
can. Even if they don't understand their meds or know their
meds, they have a list.
I think that's hopefully one practice we can all try to work
better on in terms of this issue.
But yeah, I want to pop over to some more of the questions
from the audience.
Actually, that speaks to another question here.
So this is from an NP student and saying that I guess I can
read the question.
I often renew medications under my preceptor guidance, and
there are multiple Med interaction alerts that pop up.
We typically accept them and send the scripts in which this
person is worried about when they're practicing on their
own, how they suggest a primary care nurse practitioner or
PA that's applicable to any primary care clinician efficiently
manages these warnings in a timely way.
What are your thoughts about those pop ups in the EHR?
I love the system at the same time.
So we also have the system that we use.
We also have those pop ups.
I find that it's like you said, love and hate relationships,
because sometimes if they're popping up for silly things,
you kind of get alert fatigue, which can just be as dangerous
as not having any alerts.
So alert fatigue is basically when there are so many alerts
for every little thing that you just tend to ignore all of
them. You're just like blindly clicking through.
So I'm not sure how the systems are set up, but ideally to
have the alert for a certain level of interactions and above.
So if there's a gradient scale, like minor, medium major.
I would set up for medium major, for example, especially
If there could be, like, a double alert for us, we have it's
So the red alerts are the ones that we really look at.
So that's one thing and another is just to have kind of a
general understanding of the interactions.
So it kind of makes you quickly understand what I need to
monitor or do I need to change the therapy.
So especially since it's coming from a student MP.
So this is something that they can do while studying.
For example, if an interaction for an antipsychotic comes
up, you can have an understanding that they're both working
in the CNS.
So the interaction is probably something to do with they're
both increasing the side effects of each other versus, like,
Claritromycin, plus an agent with QT prolongation.
Like, now, you know that this is the QT prolonging, and I
probably need to switch.
So most of the times, if it's just two of the similar medications
that substantiate side effect of each other, it's just a
monitoring issue versus some of the other more serious drug
interactions, which maybe you can like, as you're studying,
you can make a list of those that you really study and understand
totally. And that's such a great point because it's like,
as much as I hate those pop ups, I learned a lot because
I got especially when I was on the job so that I can actually
rattle off a couple of them because I see them all the time.
So for as an example of what you said, like, UTC prolongation,
you start to notice.
That's definitely one of the ones that's going to pop up
or, like, statins and Fibrates might interact, like increased
risk of rabdomylicis or something.
Every single time you try to order it.
It's going to do that.
And so it's like, through those alerts, I've learned backdrom
and license pro.
I'm pretty sure I was hyperclemia.
I don't know.
But I just like, I felt like all these things that I anyway
on the job when you're studying and when you're on the job,
it is something that you just embody or like, oh, okay.
I'm going to watch out for this general thing because I ordered
all the time.
So that's really helpful.
Are there any tips that you have speaking and studying?
This is a submitted question.
Tips for memorizing drugs or drug classes.
So I think that Firstly, I just wanted to kind of suggest
that the goal is not to memorize all the drugs.
It's more to become familiar with them and understand what
you need to prescribe them, because that's more of the role
when to prescribe is basically when you're going to be dealing
But in terms of studying, I would say two group common drugs
together. So, for example, if you put all the ace inhibitors
together you notice they end with Prel, so they're ace inhibitors
and beta blockers.
They all end with all all and grouping medications together
can help and learning medications within the system that
they work in.
So learning gastro medications together, for example, that
But again, the goal is not necessarily to memorize, because
you can list from your head a bunch of medications.
It's not going to help you in practice.
And I still appreciate you saying that because one of the
posts I made on Instagram recently was about the practice
of medicine is that you learn, forget, relearn and repeat
it. It's just like it's like exactly what it was.
But something along those lines of like, you forget things
and then you relearn them and you hold onto those essential
pieces of like, okay, what is going to really hurt somebody,
right? And then it's like, what is applicable to practice?
What are the general holds I have in this understanding of
this medication or this class.
And then where do I go from there?
But I think there's a misconception, especially among newer
clinicians and students that we have to know.
It all right away.
And we're never going to forget it.
And I think things have become easier with information at
the tips of our fingerprints.
So there's even apps from up to date or other apps on your
phone or on your computer that you can look at, even with
the patients in the room.
So it's never about memorizing.
You have the ability to take a pause and to look into something.
Even without compromising how you look in terms of knowledge
to a patient, you can just explain that you want to double
check that this is the right medication for them.
It's just the way you phrase things, especially for you guys.
It might seem intimidating.
You don't want to say, oh, I don't know.
Actually, I have to look into it.
It's just rephrasing that to saying I just want to make sure
that this is the best medication for you.
So I'm going to just look into the medication a bit more
for just a minute.
And I love that line.
That's one of the hacks that I use.
And I used before as a new ground.
And and I still use it now.
It's just like the go to way to easily say that, right.
It's like I just want the best one for you.
And how good does that feel as a patient?
Like they're really thinking about my well being and what's
best for me that feels so different than, like, oh, I don't
The last question I have from the audience.
This is from a nurse practitioners practicing, I believe.
How can I learn to be comfortable prescribing medications?
I love this question.
The rest of the question says they're all new to me.
So, like, generally speaking, which ones should I avoid?
Neurodrugs for Parkinson's controlled substances, et cetera.
And just before you answer, I just want to normalize for
someone who's watching or listening that my first prescription
was for Ibuprofen, and it was terrifying.
This is all terrifying, even for over the counter medication.
So what would you say to that person?
I understand where this practitioner is coming from.
Being on your own is definitely scary.
Like for me, I was checking a lot of prescriptions under
the supervision of my pharmacy manager before I got license
and everything was fine because there's someone to double
check. And the first prescription that I checked on my own
was for Amoxiculin.
And it was terrifying, even though I could do this in first
year. But I understand because it becomes your responsibility
and it has real world effects.
You're doing something to a patient and what you do can affect
them, hopefully positively.
That's the goal.
But making errors is definitely scary.
I would say to be comfortable prescribing medications would
be to read the guidelines, especially for the major diseases,
so they usually have easy to follow algorithms for diabetes,
hypertension, cardiovascular, asthma, COPD.
So it's usually quite simple to follow those.
The guidelines are based on best available evidence.
So I would suggest starting there first.
There's other resources, like up to date or some other whatever
therapeutic website that you like to go to.
They have lots of information about what they think is the
So I would go there and understand those also just understanding
and being okay with realizing that you might need to go outside
So you might actually need to not follow the guidelines for
specific patients, and you have to be okay with that.
I think that's what a lot of new grads or students struggle
with because you go through so much school where there's
a right answer and a wrong answer.
But in reality, there's not.
You have to go outside of the book.
So for example, a guideline might say, okay, first step is
to start this medication and you know that this patient is
going to experience side effects of this medication or there's
a drug interaction or something off the table.
And now you're going into more of an unknown land and you
have to be OK with that.
And it's kind of just stepping back and believing in yourself
and following up with that is that you have other resources.
You can look at other guidelines.
You can look at other information, but also you have other
health care professionals that you can go to, like, pharmacists.
So for example, the other day I was talking with Mt, actually,
and there was a person who had a multidrug resistant urinary
So the medication options were like, 1234.
And I think there were some allergies too.
And I was like, I'm just going to call a pharmacist.
I don't know.
I'm not really sure.
And then I think that person had to end up getting IV treatment
in the Er.
But that's like here we go.
Yeah, for sure.
You can just ask your local pharmacist, and this goes back
to creating relationships and establishing that interprofessional
collaboration. So if you have a favorite pharmacy or pharmacist
to go to, that could really help you when you're going off
book. Especially also just keep learning through continuing
education and newsletters, because there's always updates.
There are new medications, there are changes to guidelines.
And if you're following Liz, you're already on the right
stuff because she has great resources.
In terms of the second part of the question about drugs to
avoid. I would say that it's hard to avoid prescribing certain
drugs, like ever.
You're not going to say no to everyone because some patients
But just if you're worried about the effects of those medications,
then kind of establish and understand when you are going
to prescribe them to which patients and explain to the patients
when they do or do not need it.
So, for example, a lot of new clinicians, especially, are
wary about starting insomnia medications, whether it's like
a benzo or other insomnia medications, because they're worried
about them being dependent on it.
So I think a good practice is to actually establish a conversation
that this is the short term prescription.
I'm not going to keep renewing it because we're going to
find a better solution.
And I think that could help set expectations with the patient
without them thinking that they're just going to be on a
benzo or like, ambient for the rest of their life.
So setting those expectations can also help.
And again, if you're nervous, just call the pharmacist or
talk to someone to kind of go through what you're worried
I love that.
And I guess I want to throw in one other.
So I am obsessed with up to date as a resource.
Again, I'm not affiliated with them.
I just love them.
But then the other resource.
And I don't know if you use this.
This might be a US one, but it's called Prescribers Letter.
There's also Pharmacist letter, I guess, which is specific
to pharmacist, but it's a monthly newsletter that's, like
very quick updates about medications.
And they also have educational resources.
Again, because you're also clinicians, right?
Like you're not pilgrimage.
So there's a lot of education and that's a publication that
I Super love.
That's really helpful.
Just subscribing to those and getting those updates in your
email. Sometimes I just even learn things from the headlines
or from just like, the snapshot that you get in your alert
section. Like, okay, there's something new I'm going to look
into this, right?
But thank you so much.
This is so wonderful.
I'm so grateful to have you on the channel and on the podcast,
and I know that people are going to get a lot of benefit
I'm so happy to have been here.
So where can people find out more from you resources?
You have things like that.
So as we talked about in the beginning, so I have the RX
I'm also RX notes on Facebook and Twitter.
You can visit rxnows CA for the resources that I have the
And if you want to chat, just sent me a DM on Instagram.
I think that would be the best and easiest.
Well, thank you so very much.
Thank you for having me.
So that's it for today.
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Is that I really just don't share anywhere else.
Thank you so much for watching.
Hang in there and I'll see you soon.