Insights Into Small and Rural Hospital Pharmacy Practice

Pharmacy opportunities, either after graduation or during residency training, are often selected in relation to previous exposure or local geographic preferences. Many colleges of pharmacy are located in urban areas and do not offer rotations in smaller community hospitals due to lack of preceptors or longer commuting distances.Recognition of alternative clinical practice options is therefore key to growing our professional impact in rural communities, especially because most of these facilities do not require a pharmacy residency or previous hospital experience and may offer a transitional career path from other pharmacy settings, such as home infusion, retail, or specialty pharmacy.

Small, rural facilities are also good stepping stones | Image credit: merrimonc | stock.adobe.com

About 46 million individuals live in rural areas, and in 2025, 35% (1796) of all community hospitals in the country were designated as rural.^1,2 Based on 2019 data, 47% of rural hospitals have 25 beds or fewer, and 18% have between 25 and 50 beds.³ These facilities are usually located in sparsely populated areas where a typical drive to an urban or midsize hospital may take up to an hour. However, many of these sites offer good salaries and a low cost of living with frequently attractive landscapes or within driving distance of larger cultural and economic centers.

As a pharmacist who started in a small, rural hospital in Illinois after my residency, I cannot be less than grateful for the experience it gave me to develop myself professionally and exercise greater influence in clinical initiatives than I would have had in a more established pharmacy within a larger facility. Although it was nearly 20 years ago, I came to a place where the pharmacy essentially functioned as a dispensing hub with the only clinical activity limited to pharmacokinetic consultations. There were no automated dispensing cabinets; a limited stock night drug room; an intravenous (IV) hood in an open, uncertified room; and as a director, I was also a staff pharmacist 70% of the time. The pharmacy was open only from 7 am to 6 pm during the week and 7 am to 4:30 pm on weekends, with alternating call schedules.

Many facilities with less than 50 beds also don't have a 24-hour pharmacy and rely on telepharmacy services from larger neighboring or system hospitals, or companies such as Cardinal Rx or Pipeline Rx. However, that provides a tremendous opportunity for an onsite pharmacist to perform a thorough clinical review during the day. For example, although it is more commonplace now even in small facilities, during my first year in a small, critical access hospital, I introduced an automatic renal dosing program; IV to oral conversion based on accepted criteria for antibiotics and gastrointestinal medications; and built the first antibiogram, to be followed by periodic culture review and antibiotic streamlining recommendations. I created a tool for high-alert medication review after hours and monitored relevant labs during the day. Because reviewing 20 patient profiles is not the same as looking at more than 80 patients per day, I was able to observe and correct duplicate therapy, polypharmacy, or screen for medication combinations that are prone to cause adverse events such as hyperkalemia or bleeding. After I trained my colleagues to recognize similar situations and perform automatic protocols as part of their evaluation and job description, I gained confidence in taking students for rotations and advocating for further professional involvement, such as the development of order sets to match clinical guidelines.

Although there were barriers to overcome in my first year related to physician satisfaction and rapport with select providers, eventually I was trusted with more in-depth clinical questions and allowed my staff to be more empowered in making clinical recommendations and bringing potential issues to my attention. There are various concierge services that a staff pharmacist in a small hospital can perform and which I did to the extent time allowed, including discharge counseling on high-risk medications, anticoagulation monitoring, clinic assistance if adjacent to the hospital, pain management, polypharmacy reduction initiatives with individual providers, brown-bag sessions for outpatients, or participation in code blue responses. I even participated in a local radio program and discussed treatment options for osteoporosis. Many patients in rural areas have multiple comorbidities, including chronic diseases, and may lead a different lifestyle than some of their urban or suburban counterparts. Some of these factors may be influenced by a lack of socioeconomic mobility, ingrained habits, or lack of purchasing options in local stores, sometimes referred to as food deserts. In many cases, the level of health literacy is low, and finding an appropriate way to engage the patient is a challenge that requires motivational interviewing techniques.

The training and knowledge pharmacists possess will allow them to be trailblazers in a rural setting more than in a larger institution where some protocols may already exist and there are more individuals involved in approving process changes. There is going to be resistance at first, so proceed slowly and carefully, with respect and consideration of all the stakeholders. Make a convincing presentation to senior management and find a progressive provider or a champion who can relate information to their peers. Talk to other pharmacy staff members about the culture and easiest ways to connect with providers or nurses. I have found that the openness, goodwill, and mutual trust are more prominent in smaller, rural facilities where the employees have stayed for many years and know each other both professionally and socially.

Based on personal experience, smaller facilities may be preferable for someone who enjoys variety and is inclined more to general medicine practice, as opposed to more specialized areas, which are typically reserved for larger teaching hospitals. Small, rural facilities are also good stepping stones to transitioning to a larger, midsize hospital later in one’s career, as you don't have to worry much about speed and productivity but mostly can concentrate on the task at hand. Small, rural hospitals teach pharmacy professionals to wear multiple hats yet give them enough time to dig for details when needed. Most of these facilities are still within a reasonable drive from a larger town, which allows for more outlets during days off, whether for recreational activities, dining, or cultural events. Due to close collaboration with other disciplines, such as nursing, relationship-building is emphasized. That in turn increases job satisfaction and creates an impetus for innovative ideas that can further advance one's practice.If you have the ability to choose outside the metropolitan area and travel, small and/or rural hospitals present a great opportunity for self-development and actualization.

REFERENCES

1. Rural Classifications – What is Rural? US Department of Agriculture Economic Research Service. Updated January 8, 2025. Accessed March 3, 2025. https://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/what-is-rural

2. Fast Facts on US Hospitals, 2025. Accessed March 3, 2025. https://www.aha.org/statistics/fast-facts-us-hospitals

3. Fast Facts: US Rural Hospitals. 2019. Accessed March 3, 2025. https://www.aha.org/system/files/media/file/2021/05/infographic-rural-data-final.pdf