By Brittny Medenwald, PharmD, with acknowledgements to Katleen Chester, PharmD, BCCCP, BCGP and Sunita Dergalust, PharmD, BCPS
At 19 years old, my best friend was involved a motorcycle crash. Her severe TBI caused her to stay in the neurocritical care (NCC) unit for 13 days. That experience started my path toward practicing in NCC.
As a first-year pharmacy resident, I had a strong desire to be back in the NCC unit. I chose my rotations hoping to manage NCC patients. I was disheartened that despite rotating through various adult and pediatric critical care units, internal medicine and emergency medicine, I had scarce exposure to neurology. When comparing second-year residency programs, I desired a program that was dedicated specifically to neurology. Yet despite my continuous interest in this practice area, I was not aware that pharmacy had recently recognized it as a specialty. Luckily, I stumbled across a neurology residency program at Grady Health, and the rest is history.
Although the exact year neurology emerged as a specialty in the medical profession is not clearly defined, glimpses of neurology specialists began emerging in the 1800s. The American Neurological Association, established in 1875, was the first national neurological society in the world. During the next five decades, the designation of neurology as a medical specialty was not met with overwhelming enthusiasm, as attempts to branch from internal medicine and uncouple from psychiatry were difficult. Ultimately, the first formal training program in neurology originated at Harvard Medical School in 1935, and the field has continued developing and identifying subspecialties, including NCC.
Similar to medicine, neurology is challenged in pharmacy school curriculums with separating itself from psychiatry, as these topics are often combined into a “Central Nervous System” module, leaving students with limited exposure to neurology and much less exposure to NCC.
In contrast, the timeline of clinical pharmacy practice in neurology has not paralleled that of medical practice. The first formal training program in neurology pharmacy originated at the opposite side of the country, at the West Los Angeles VA Medical Center, in 2006. Neurology pharmacy received recognition as a unique specialty by the American Society of Health System Pharmacists (ASHP) last year — 83 years after the conception of clinical pharmacy and 30 years after cardiology and psychiatry emerged as unique specialties. Thus, it is not surprising that most NCC pharmacists complete residency training in critical care, emergency medicine or internal medicine specialty programs. However, with strict program standards, experiences in neurology/NCC are often limited.
With exponential increases in literature, complex medication regimens and barriers to medication access, it has become clear that dedicated neurology pharmacy residency programs are necessary to continue providing advanced care within the specialty and subspecialties. This need was noticed by both Dr. Sunita Dergalust and Dr. Katleen Chester.
Dr. Dergalust is credited with the vision and implementation of the first second-year neurology pharmacy residency program in the country and now offers two resident positions. The interest for the first neurology pharmacy residency program originated from pharmacy learners. Within the first four years after implementation in 2000, Dr. Dergalust’s 6-week neurology rotation remained consistently scheduled with learners. Noticing and supporting this interest, Dr. Dergalust’s pharmacy director provided funding for the first neurology pharmacy residency program in the United States.
Dr. Katleen Chester followed by creating the second, ASHP-accredited neurology residency program in 2017. This program is the first at a comprehensive stroke center (CSC) and level 1 trauma center. Her interest in providing dedicated training in neurology came from multiple sources of motivation, including challenges she faced while transitioning out of an ED practice environment into a neuroscience center. Despite training in a well-established CC program, she had limited, formal training in neurology/NCC, in part because the institution was not a CSC and had no NCC. Fortunately her training provided the skills necessary to establish clinical pharmacy services upon opening of a dedicated neuroscience center. Stepping into that new role was not without challenges, as Dr. Chester found that many of the clinical scenarios and medications common to the neuroscience center were not ones she had not been exposed to during pharmacy school or post-graduate training.
Dr. Chester was further challenged with holding hybrid or cross-coverage responsibilities between all levels of neurology patient care. This too is not a unique challenge, but one that many other clinical neurology pharmacists have expressed experiences. Many NCC positions incorporate varying degrees of responsibilities across the spectrum of neurology care. Thus, Dr. Chester found overwhelming support and collegial assistance from colleagues with experience surrounding similar challenges. She realized that dedicated, post-graduate training would create a new generation of neurology pharmacists who have been immersed in experiences highlighting the unique challenges and medications of this specialized population.
It was because of the insight from Dr. Dergalust and Dr. Chester that I was able to fulfil my dream of becoming trained in neurology pharmacy. My experience has shown me that practicing pharmacy in the NCC setting requires a completely different clinical skill set than I had developed on other rotations. Neurology medications are quite complex in their administration, mechanism of action and therapeutic drug monitoring. What’s more, the timing of medication initiation can have drastic effects in a patient with a neurologic injury. Having trained in this setting, I have had increased exposure to neurology literature and am comfortable reading, interpreting, and in most cases, extrapolating medication therapies from varying patient populations.
With the exponentially growing pool of neurology literature, I’ve learned to delve more thoroughly into complex neurology topics in a way that other training programs may not have time to. This is important because as anyone who practices in neurology can tell you, neurology is not black and white. A pharmacist needs to develop the skills to provide optimal patient care in the “gray areas.”
Training in neurology has provided me with a solid foundation of dedicated neurology skills that collectively, I may not have experienced in a single year in a different specialty program. A select list of unique experiences are included in Table 1. The combination of neurology/NCC experiences molds a different type of clinical pharmacist, bringing a distinct perspective to neurology patient care.
Table 1: Select Experiences Described by Dr. Medenwald
Beyond the ICU environment, the need for a neurology-trained pharmacist continues to expand. There are now over 24 antiepileptic medications, and the FDA has approved two additional new multiple sclerosis medications in March 2019. With increasing focus on monoclonal antibodies, similar expansion is occurring with migraine headache, and Parkinson’s and Alzheimer’s diseases. Many of these medications are parenteral with unique dosing criteria, adverse effects and access barriers. In addition, customization of therapy, such as dual antiplatelet therapy, is becoming increasingly common. Another role for neurology-trained pharmacists is in bridging the gap between NCC and ambulatory care through post-intensive care unit clinics.
In addition to inpatient responsibilities, Dr. Dergalust and her residents use a multidisciplinary, team-based approach to address outpatient needs, even those beyond the clinic visit itself. A list of some of the activities described by Dr. Dergalust are included in Table 2.
Table 2: Select Outpatient Responsibilities Described by Dr. Dergalust
Neurology pharmacy is a specialty area I anticipate will continue to develop and grow. I envision that soon neurology-trained pharmacists will be able to sit for board certification in neurology. With neurology as a recognized specialty, many colleges of pharmacy will likely expanded curriculums to introduce students to neurology diseases, such as multiple sclerosis. In addition, as more institutions incorporate NCC units, there will be a growing need for NCC pharmacists. This growth will likely lead to greater opportunities for students to take NCC rotations and increased interest in neurology pharmacy residency programs.
It is yet to be determined if clinical pharmacy will continue following the same pattern as the medical profession, but I can foresee formal subspecialties, such as neurocritical care, being recognized in years to come.