Tiffany Shin, clinical assistant professor in the KU School of Pharmacy, and pharmacy student Munjal Attawala had discussed a 40-ish-year-old man's many medical problems and medications well before he came to see resident Brett Hoffecker at Via Christi Family Medicine.

It was a long list. The man has pancreatitis, diabetes, and severe pain resulting in a slew of issues - difficulty eating, sleeping, and maintaining weight among them - and medications. Shin fires questions at Attawala as they discuss the case in her office.  

"Do we know what his pancreatitis is from?" she asks. Attawala, who had examined the man's records to prep for the session, replies, "I don't think so, but I can look," an answer he soon updates to "alcohol use."  

They run through other cases, including a bipolar pregnant woman - prompting discussion of anti-depressants and pregnancy - and of a teen with anxiety and thyroid issues who smokes marijuana. Shin pushes Attawala with queries about why another patient is on the blood thinner Warfarin, spurring him to dig deeper into the record until he finds the answer - "Oh, a heart-valve replacement. I feel like I need to go over my notes some more," he concludes.  

Since 2014, Shin and her students have been "embedded" in the clinic, with Shin consulting with doctors and patients and the fourth-year pharmacists-to-be doing rotations where they work not only with her, but with residents and their patients. It's an outgrowth of the trend toward interprofessional collaboration in health care training, which is welcomed by both educators and students.  

"We get knowledge from both a pharmacy perspective and a medical perspective," said Attawala. "The amount I've learned in 20 days has been incredible. This takes my training to another level."  

"It's really, really helpful. They catch a lot of things," said Hoffecker.  

Shin pairs students with different residents during the one-month rotation so they can see different methods. "Each doctor approaches things differently, and it also gives medical residents exposure to pharmacy."

"The residents are really good about teaching students," Shin said. "Our clinic has an environment of learning. Everyone is really on board with it."  

Shin herself is a resource for residents and patients. Doctors can refer patients with diabetes or complex drug regimens - often 20-plus medications - to her for counseling.  

As of late July of this year, 14 fourth-year students had gone through one-month rotations at the clinic. Attawala considered himself lucky, since he was the only student on rotation that month, which increased his learning opportunity.  

"One benefit is seeing health care from a different perspective," Shin said. "None of these students have experience in primary care or family medicine, except as a patient. So I think the students gain appreciation for what goes on in the clinic."  

Changing professions and training

Bob Emerson, the associate dean of the KU School of Pharmacy who is in charge of the Wichita pharmacy campus, said the collaboration is a sign of the changing nature of his profession. "Pharmacy has evolved from a focus on the product to a clinical emphasis, less on the dispensing and more on the medication management part."  

"It's going to make them better able to participate as members of the health care team as the practice model changes down the road to more of a patient management role," he said.  

The pharmacy school had a number of goals when it expanded to Wichita in 2011: increase the number of pharmacists for Kansas and its rural areas, expand students' clinical exposure to ambulatory and primary care, and promote interprofessional development.  

Emerson said a number of doctors at KU School of Medicine-Wichita were involved in the collaboration, including Rick Kellerman, Scott Moser, John Dorsch, Dean Garold Minns, and the heads of the residency programs at Via Christi and Wesley.  

"When we approached them about the idea of embedding faculty into their clinics, they were very receptive," Emerson said. "Everyone saw such benefit to this collaboration that there were never any insurmountable roadblocks."  

Going to school at the clinic

It's been a slow morning in the clinic as several patients are no-shows. Shin helps first-year resident John Grisham, a graduate of KU School of Medicine-Wichita, get signed up for K-TRACS, the state database for narcotics prescriptions and just one of many things Grisham is having to learn.  

Shin, Attawala, and Hoffecker delve into the case of the man with pancreatitis, diabetes, and pain. Attawala brings up something he and Shin discussed, the possibility of prescribing Actos to see if it can lessen or eliminate the man's need for insulin. "It can lower insulin resistance," Attawala said.  

They head in to see the man. They discuss his low energy and daily drug routine, while Attawala types in notes. Hoffecker observes that "you've got at least four things going on," reflecting the case's complexity.

The patient describes his sleep problem, and his desire to get better is clear in the vigor he shows describing the day he had the energy to go fishing. Attawala and the patient discuss Actos and what it could do - increase insulin utilization, lower glucose levels - and he explains that a different sleep medicine should help the man sleep for longer periods.  

The visit ends with a run-through of the updated medicine list, a prescription for starting some regular exercise, the setting of a two-week follow-up and the man's statement that "I hope it works. I want to live."

Later, recapping with Shin, Attawala mentions the man's energetic fishing discussion. "He is very receptive to making changes. Talking about goals made him feel better."  

Next up is a new mother, in for her daughter's two-week check. "You're doing great with her," Hoffecker said before demonstrating a well-baby check for Attawala.  

"Dr. Hoffecker is a really good teacher," Attawala said. "He didn't have to show me that."  

Having pharmacists in the clinic allows both doctors and pharmacists to learn not only about each other's expertise but also about one another.  

"I want pharmacy students to not be afraid to talk to doctors. I want them to see that pharmacists have the ability to help improve patient care with collaboration. The residents also learn that they don't need to do everything on their own, and that by asking for help they can better care for their patients."