What made you decide to go into HIV care?
In 1994, I graduated with a B.S. in pharmacy from Memorial University in Newfoundland and completed a hospital pharmacy residency program in pediatrics in Toronto. I practiced in the areas of pediatrics and infectious disease for four years. I went back to complete a Pharm.D. program at Ferris State University and, since graduating in 2001, I have been working in an outpatient HIV clinic.
When I was working in an infectious disease rotation prior to getting my Pharm.D., I had a few HIV patients, and those experiences made me realize the complexities of antiretrovirals and the positive impact a pharmacist can make upon these patients.
How long have you been preparing medications for people living with HIV?
I don't dispense medications. As a clinical pharmacist in an HIV clinic, I focus on patient education regarding their antiretroviral regimens, adherence and resistance. There are more HIV clinical pharmacists now. It is a new role for pharmacists in the last 10 or 12 years. I work with the patients in managing antiretroviral side effects, and I work with the infectious disease physicians to create optimal drug regimens. We always take into consideration potential drug interactions even though we are not necessarily filling all their prescriptions. There are a lot of drug interactions, and it's my job to educate the patients about when to take their meds, how to take them and prepare the patients for any expected side effects. In addition, I work as the clinical research coordinator for our clinic. I'm also an adjunct at Ferris State University. Students shadow me for a day on one of my hospital rotations or for a month on my HIV rotations.
When did you decide on pharmacy school?
I decided to pursue pharmacy school when I was in 11th grade.
Does your most successful work come as a result of working in a team environment?
Yes. In our clinic, other than the clinical pharmacist, we have infectious disease physicians, nurses who are also case managers, a nurse practitioner, social case managers, a mental health counselor, housing specialist and a dietitian. Having a multidisciplinary team allows us to view the patients from various facets and make medical decisions based on all the available information.
Why do you think people with HIV nominated you as their favorite pharmacist?
I'm not quite sure. I try to make sure my patients know everything about their medications, such as what the potential drug interactions are, and I try to fully inform them about the importance of adherence. I guess it may be that I care about them. I provide a 24/7 access via pager for the patients, so if they experience side effects, they have someone to contact on weekends when the clinic is closed.
Is there anything special you try to do for people living with HIV when they come to pick up their medications?
I see all the patients for a one-hour medication counseling session. I always ask them how they feel about taking medication so I can assess the patient's commitment level, which is critical for adherence. I review topics such as basic HIV life cycle, antiretroviral mechanisms of action, goals of therapy, regimen characteristics, storage, solutions for when there has been a missed dose, side effects and a plan of action.
My plan of action is very patient specific, but we always offer a pillbox. Some patients don't like using it, but we always offer it. If a patient says that they just can't remember, we have watches that beep when you have to take your meds. We have had a lot of success with the watches. Just sitting down with the patients and talking about their life will reveal many hurdles. Is it the size of the pill? Or the time of day? Or that they just can't remember?
For patients who do not understand English, I print pictures of their filled pillbox, allowing them to fill their pillbox on their own. I always print information about their personal regimen and HIV resistance. By providing my phone number, as I previously mentioned, I am their emergency contact, and that gives them a sense of relief that there is someone they can contact if they run into trouble. I give verbal rewards to any difficulties that a patient has had to struggle through.
What is your patient demographic?
Our clinic has around 650 patients, with 550 on them on meds. Everyone at our clinic has HIV, and the majority are white men. We have diversity, though, with 25% women, 30% black and African, 10% Hispanic, and a handful of Asian and Native American patients. The Africans are a unique patient group. Grand Rapids has an organization that sponsors people from Africa to come here and live. Most come here to live, but they are also students, and some are seeking asylum. Depending on their current status, we start them on medications, but we may wait until they are ready. The treatment is harder to assess with these patients because depending on what kind of HIV they have (HIV-1 in America) they may not be able to take many of the drugs available here. There is a whole class of drugs that don't react to HIV-2, and we aren't always sure which they have. We can start with a certain regimen, but they may be resistant. Some patients are Clades B, which also plays a role in terms of finding the right medications. The response to medications and the chance of resistance increase once their regimen has started.
Do you find any patient demographic especially challenging?
Some people seem to have a lot of distrust regarding health care providers. I have had patients who needed to start medications, but had a fear of starting because they had heard from a family member that the meds don't work in African Americans. These patients need a lot of reassurance that these meds do work in all populations. I had a longtime survivor who didn't want to take the medication AZT (zidovudine, Retrovir) because he had a friend who died after taking it. So there are a lot of fears and misconceptions that I have to help patients put to rest until they feel ready to take their meds.
If I were to follow you for a week, what would I observe you doing?
My work includes counseling patients about their medications. I cover the basics of HIV, how the drugs work and the goals of therapy. I review the regimen characteristics (dosing, frequency, etc.) and the common side effects. I also cover rare side effects if they may be life threatening (such as Abacavir [Ziagen] hypersensitivity reaction). I help manage side effects, provide options for therapy for patients' physicians based on resistance test data, drug interactions and antiretroviral history. I also coordinate any clinical studies we have at McAuley and provide drug and HIV information to the clinical staff.
A couple of half-days every week I'm in the clinic, looking at laboratory reports to make sure the meds aren't harming the patient. If there are issues, before the doctor sees the patient I will sit down with them to express my concerns, and then after the doctor sees them, I advise them on adherence or what they can do to remember to take their medications on time. I focus on the new patients, because the older patients have the information driven into their heads by their nurses. All the patients have had a number of people talking to them about their medications. A very unmotivated patient will have a hard time taking the medications, and sometimes we never see him/her again. I had a patient -- I would fill his pillbox and then eventually he began to fill it himself. He was on a weekly schedule, and he started missing pickups so we would call him, but he had other problems like losing his housing. It's been about two years, and he just recently resurfaced -- at least he has come back.
On the other days, I talk to patients and see how they are working out and how the medications are fitting into their lives. I don't want their lives to revolve around the medications and I look to somehow integrate the meds into their already established schedules. For someone who has been on medications for a while the meetings don't last that long. I spend a lot of time on paperwork because we are Ryan White funded. There are plenty of other non-scheduled visits if a patient has a side effect and he/she comes in for a blood draw.
I spend time researching drug interactions and prepare any updates or developments in the world of HIV for the staff. I also coordinate the clinical research, which takes up a lot of time when patients are enrolling. I get paperwork ready to send to the drug companies, and I prepare for the study itself, which has to be approved by an IRB (Institutional Review Board).
What is the best thing about your job?
Patient care. I enjoy meeting with patients and educating them about the medications they are going to take, as well as helping them overcome barriers to adhering to their antiretrovirals.
What is the worst thing about your job?
What is the biggest challenge you face as a pharmacist?
Keeping up with the rapidly evolving HIV literature.
What do you think is the biggest risk factor for HIV?
Complacency, because I think that people have forgotten about this virus and feel that since there are many drugs to treat HIV, they can be less vigilant in practicing safe sex. Many of us remember the early '80s, and the number of people who were dying of AIDS then. The younger generation doesn't see the same threat and is not practicing safe sex.
What do you think are the biggest problems people with HIV face today?
Resistance to antiretrovirals is the biggest problem that will someone living with HIV encounters. With non-adherence to these medications, resistance may develop, leading to a change in the patient's medication regimen, which in turn limits their future options. The spread of the resistant virus is also a problem, because it limits the number of drugs for newly diagnosed patients. Once you have resistance, the medications don't work anymore. The higher doses make people sick, but now we are using smaller doses in conjunction with other drugs, at least three at a time, to make the regimens more manageable for the patients.
What is the most memorable thing you have learned from people living with HIV?
I just do my job, teaching patients and helping them out, but I am able to have an impact on some people and achieve a personal level of interaction. One patient had a side effect of a buffalo hump with medication that wasn't working and he was so appreciative of what we did for him. He would always send a card and small gift because he was so appreciative of our attention. I can identify with my patients being ill. I was diagnosed with bone cancer in 1981 when I was nine, and they had to amputate my right leg. I had chemotherapy. The experience limits me in some ways. Because of it, I'm not into a lot of sports. I think being sick got me interested in health care. During my rotations for the Pharm.D. program, I chose infectious diseases because we had three or four HIV patients and I realized what a pharmacist could contribute to their care, with all the side effects and interactions. A lot of patients are afraid and focus on why they fear the drugs -- for example, they had a friend who died after taking a certain drug -- but there is always hope.
How do you maintain a positive outlook and avoid burning out?
This is difficult for me, but I try to separate my work from my home life and not take work home. Though I'm not always successful! For the longest time, work has been my life. I got engaged about two years ago. Tom is very understanding of my need to work. He'll go off and do something else. I realized at one point that I can't keep bringing work home. I try to plan it out; when he works at night I will use that as an opportunity to also work. It's great that he understands because, if he didn't, things would be a lot different, but I have the responsibility to keep up on the information on developments in drug interactions with HIV medications that's out there.
If you weren't a pharmacist, what would your profession be?
Not sure, probably an astronaut.
What was your first reaction when you were told about this award?
I was very flattered that someone would nominate me for this award. I still don't know who it is. I was told it was an anonymous nomination.
Would you like to dedicate this award to anyone?
My fiancé, Thomas Skula, who understands the importance of my work and the long hours; and he never complains.
Where did you grow up?
St. John's, Newfoundland, Canada. I'm from the most eastern city in North America. I miss being that close to water. When you get off the airplane you can smell the salt. I try to go home about once a year.
What did you want to be when you were a kid?
After I started school, I wanted to be a teacher. I loved being able to get a concept through to students. Teachers always seem to be so creative, especially in younger grades where you plan arts and crafts. I have become a teacher, but not full time. I do presentations for doctors, nurses and graduating students on practical things that pharmacists should know and what they can do for the patients. My relationship with my students is very informal. I just want to make my class open and get a dialogue going with my students. I have heard that students like my lectures because they like my enthusiasm.
If I wasn't going to be a teacher, there was always garbage collecting. I remember when the garbage truck would come with three men, one to drive and two to pick up garbage. The two men would come and throw the trash in the truck and they would pull a lever that would push all the trash down. I told my mom that I wanted to be that person.
What kind of work do your parents do?
Dad is a college physics instructor and Mom is a statistics consultant.
Who have been the most influential people in your life, professional and personally?
There are two, the first being Rick Abbott, who was my first hospital pharmacy preceptor. When I first started, I wanted to go into cancer research (as I had cancer myself). I worked in a retail pharmacy and in research (half and half) and I liked working with patients so much more. The next summer I was in a hospital. Rick created a learning environment that increased my interest in hospital pharmacy. His enthusiasm about his job made me want to be in a hospital. I've also moonlighted in a retail setting.
The second person is a pharmacist who has worked in various facets of pharmacy and has excelled in all of them. She is currently the director of the school of pharmacy at Memorial University of Newfoundland, and her name is Linda Hensman. She taught me about the various areas of the pharmacy profession. She has moved into an administrative position now, but she was so enthusiastic about all the different things you could do as a pharmacist. She emphasized that you don't have to work retail all the time. You can work in a hospital. She also has an M.B.A., which at the time I was thinking about doing. She has done so much during her career, and I respect her role in the pharmacy community at home in Newfoundland.
When you are able to get some spare time, what are your hobbies?
I like to read. I read romance novels because they take me away from life into another world. I like ones that are about time travel or old England. I read them when I just need a break. I also like Robin Cook; he's a doctor who writes medical-based stories. I watch TV -- comedies, sitcoms, CSI, Medical Investigation. Once in awhile I will see a movie, although I don't like horror, I like sci-fi. Anything that has to do with space, but not Aliens, and action movies like Spiderman and comic-book-based movies like Daredevil and The Hulk. I also like taking long drives in the country, and collecting gemstones.
Do you have a partner? Pets?
I have a fiancé whom I will be marrying in September 2005 on a glacier in Alaska. I have stepchildren who visit every other weekend. We also have two dogs, a bichon frise and a miniature schnauzer.
Where do you live?
Grand Rapids, Mich. I've been here for five years and I came to Michigan to do my doctorate. I enjoy Grand Rapids because the people here are so friendly, and it is a city, but it's not as big as Detroit. There is so much to do here. There are parks, gardens and museums. I grew up in a much smaller city than this. I like to take long drives to see various places I haven't been before. In the fall, when the leaves change, my fiancé and I head up north, and we stop often to take in the scenery. There are a lot of places in Michigan that I haven't been to before, so the trips are rarely planned too far in advance; it really depends on where we want to go to at the time. The last road trip was a year ago. We went up north to a town called Dublin. There was a place where they made their own beef jerky, pork, chicken, turkey, ostrich, buffalo -- we stayed away from the gamier ones.
If you could live anywhere, besides where you live now, where would you locate yourself?
I would love to have the same practice as I do at McAuley, but at home in St. John's. I'd like to move back there, maybe when I retire. I see myself here for a very long time, as long as people need someone to look out for them. I do miss home. I miss icebergs in the summertime; on a sunny day it is a very beautiful sight. There are big chunks of glacier that float down from way up north. It looks more like snow floating on water. In 1996 there was a huge iceberg that floated quite close to the city, and I have one of my favorite pictures of it hanging at my desk. When the iceberg gets stuck, people go down to the harbor and take chunks off it. Occasionally, there will be a polar bear on an iceberg. If they get close enough to land, they will hop off. People have also found seals in downtown St. John's, and the forestry department has to come and take them somewhere safe.
What the best vacation you've ever had?
A sightseeing tour of California, with my mother's family in 1997. At the time, she had not seen her family for about 27 years.
What are you currently reading?
We can get used books at our Barnes and Noble for just a lone dollar, and they are usually in very good shape. That is one of the ways that I keep my work and home life separate. I sit in the Jacuzzi until it gets cold and I read.
What kind of music do you listen to?
Alternative rock; I mostly listen to the radio to and from work.