Pharmacy in Transition: Physical Assessments

When Marilyn Flores enrolled at the Touro College of Pharmacy in 2016, she expected classes on medical terminology and pharmacokinetics. But among the newer requirements at the New York, New York, school is a physical assessment class in the second year, as universities respond to the evolving role of retail pharmacists. Flores had always pictured pharmacists working furiously behind the counter sorting pills.¹ But that traditional role is expanding with increasing opportunities.

Today’s patients expect more primary care services from their pharmacy, including having their blood pressure and heart rate checked, receiving flu shots, consulting with a pharmacist about symptoms, and even getting a physical exam.¹ Continuing education is also responding to this shift. The American Society of Health-System Pharmacists (ASHP) 2019 Summer Meetings & Exhibition in Boston, Massachusetts, explored best practices for physical assessments in an interactive workshop.²

PHYSICAL ASSESSMENTS FOR AMBULATORY PHARMACISTS

At the ASHP session, presenter Melanie A. Dodd, PharmD, PhC, BCPS, FASHP, established 3 major components of an examination: interview and health history, general survey and vital signs, and the physical exam itself. The examination, she said, is intended to identify a patient’s normal state and explore any variations by validating the patient’s complaint and symptoms. As Dodd outlined the physical exam of the entire body, she added that the interview and health history should determine the areas of concentration. Unlike a more comprehensive exam by a physician, she said, a pharmacist tends to do a more focused exam based on the patient’s concerns and symptoms. “If we don’t do a good job in that interview and health history, we may go down the wrong path and select the wrong physical exam to perform,” she said.

Techniques for the physical examination include inspection, palpation, percussion, and auscultation.

“Really, our hands are the best tools that we’ll use to be able to detect temperature and to be able to detect [firmness]. ‘Is it soft? Is it hard?’ Detecting shape, consistency—all of those things through palpation,” Dodd said.

After Dodd’s brief presentation, the attendees broke out into 4 sessions to practice and further explore areas of a physical examination: musculoskeletal, neurological, cardiovascular, and pulmonary.

At the musculoskeletal session, Dodd explained the sequence of checking joints, bones, and range of motion before assessing fall risks. Timing the patient while he or she walks 10 feet and returns provides a good indication of fall risk, she said, using the CDC’s STEADI (Stopping Elderly Accidents, Deaths & Injuries) resources to determine normal times based on an individual’s age. She also recommended several balance tests—standing in 4 positions for 10 seconds each—to determine a patient’s risk of falling.

The neurological session, led by Joe R. Anderson, PharmD, PhC, BCPS, explored basic assessments for the cranial nerves, such as using a penlight to check pupil dilation and the point of a paper clip to assess pain responses. Medications can cause or exacerbate some conditions, so awareness of the patient’s medications is vital to figure out if it’s a new condition or an adverse effect.

At the pulmonary session, Jamie Cavanaugh, PharmD, CPP, BCPS, provided opportunities to practice listening to a patient’s lungs using only hands. Instead of using a stethoscope, attendees placed their hands sideways on an individual’s back, between the shoulder blades. They were able to hear lung vibrations as the individual said “99.”

Finally, at the cardiovascular session, Betsy Shilliday, PharmD, CDE, CPP, BCACVP, FASHP, reviewed best practices for blood pressure and orthostatic measurements. Dodd recommended performing these tests at the end of the assessment, when a patient has been sitting for 5 minutes before the measurements are taken. She also stressed the importance of asking about the patient’s eating, drinking, smoking, and exercise habits for context about their cardiovascular health.

For each stage of the examination process, Dodd emphasized the need for a visual assessment: Is the patient out of breath? Does he or she have a curved posture? Is the patient alert?

SHIFTS IN THE PHARMACY FIELD

The physical assessment course at Touro College of Pharmacy is a hands-on class that teaches—through lectures and labs— basic exam techniques used in outpatient clinics and in retail and acute care settings. In an interview with Pharmacy Careers®, Henry Cohen, PharmD, MSc, the school’s dean, said it has become vital for pharmacists to know how to perform physical exams.

“The role of a pharmacist as a clinician is here,” Cohen said. This change is here to stay, he added, and the physical assessment course helps prepare students for that new reality.

As pharmacists advocate for provider status, they are expanding their role in patient outcomes. Not performing physical assessments would limit their capacity to document and bill for services.³

Assistant professor and course director Andrew Smith, PharmD, said that the class doesn’t cover nearly everything involved in performing a physical exam. And because pharmacists work in a variety of settings, not all graduates will use all the skills they learn. Smith specializes in critical care and emergency medicine, areas where physical exams are more complicated than those taught in his basic course.¹

Flores, now a fourth-year student pursuing a postgraduate residency in emergency medicine, told Pharmacy Careers® that she enjoys the hands-on experience and that it will prepare her for different work experiences. Although not all retail pharmacists utilize all these skills, Flores said, clinical pharmacists have many opportunities to educate patients and their families.

REFERENCES

• Touro College of Pharmacy. Let’s get physical: as pharmacy practice evolves, students learn to do physical exams. 2019 Dean’s Update. https://issuu.com/ touro3/docs/touro_college_of_pharmacy_deans_upd. Published July 24, 2019. Accessed August 28, 2019.
• Dodd MA, Anderson JR, Shilliday B, Cavanaugh J. Physical assessment for ambulatory care pharmacists. Presented at: American Society of Health-System Pharmacists 2019 Summer Meetings & Exposition; June 12, 2019; Boston, MA. Accessed June 12, 2019.
• Turingan EM, Bates JS, Amerine LB. Integration of physical assessment into pharmacy practice. Am J Health Syst Pharm. 2018;75(4):169-170. doi: 10.2146/ ajhp170274.