One hundred residency directors were identified as being responsible for 158 training sites within the 17 family medicine residency programs in Canada (i.e., the 17 programs utilize many different training sites that each employ a director). Eighty-six of the 100 residency directors (86.0%) responded to the email asking which of their training sites had direct involvement of a pharmacist in resident teaching. These 86 directors reported that 25.3% (40 / 158) of the training sites had the direct involvement of a pharmacist in resident teaching. A detailed description of the 40 residency training sites that employ a pharmacist teacher is published elsewhere [11
Interviews were completed with 11 family medicine residents, six residency directors and 17 pharmacist educators who practiced within the 40 family medicine residency sites that employ a pharmacist educator. Thirty of the 40 training sites were represented by one or more interviewee. Data saturation was observed in all three groups. Although saturation was observed after 12 pharmacist interviews, five additional interviews were in progress when saturation was reached and were therefore included in the analysis. All of the residents were in the second year of their program. There was a reasonable representation in each group from the various regions of Canada (Table ).
Regional representation of interviewees
Themes from deductive analysis
The results of the deductive analysis confirmed the hypotheses that the pharmacist educator role has a positive impact on resident training and that the residency programs do not use a formal pharmacotherapy curriculum to guide pharmacist teaching.
All three interview groups independently confirmed that a formal evaluation of impact of the pharmacist educator role within their residency program had never been performed. Nevertheless, there was a consistently strong message expressed by all three groups that the role had a positive impact on resident training. The residents consistently felt that the teaching role would make them better doctors in the future. The residency directors and residents found this service to be valuable and highly appreciated. Four sub-themes emerged regarding the detailed nature of the positive impact of the pharmacist teaching role: (1) improved patient care; (2) improved drug knowledge; (3) improved confidence; (4) appreciation for the expertise of pharmacists.
1. Improved patient care
All three groups consistently reported that the pharmacist teaching role led to a direct improvement in the quality of the patient care provided by the residents within the clinic.
Resident - “It has changed or modified my approach to the medications I prescribe and to some of the parameters that I am monitoring.”
Resident – “Specific things I have asked the pharmacist about with one patient, I have remembered and that has definitely affected patients that I see later. It is improving care in almost every situation.”
Pharmacist - “…when I am at the hospital, I see the prescriptions from the residents and I can see that they apply the tools or tips that we are giving in the workshops.”
Director – “We think (the teaching) is leading to better care, (but) we never really checked that out. It is just a feeling that we have.”
Director – “Yes I think it definitely leads to better care. (The pharmacist) makes the residents think of the finer details of prescribing and of medications.”
2. Improved drug knowledge
All three interview groups consistently reported that that the residents’ overall drug knowledge improved as a result of the pharmacist educator.
Resident – “I went to a seminar that educated us on different kinds of insulin and…how to administer insulin, which I had no idea about before the seminar.”
Resident – “Our pharmacist has clarified the many over-the-counter medications available and now I can guide patients in terms of what they choose.”
Director – “I am sure it improves resident drug knowledge. A resident had a guy with gout and he remembered what was discussed in rounds the week before, so it sticks with (them).”
3. Improved confidence
All three groups consistently responded that the pharmacist educator improved resident confidence in prescribing and managing complex medication regimens. Residents consistently touched on the impact that this teaching role had on their overall confidence and many provided anecdotes about how the pharmacist directly affected their prescribing practices.
Resident – “If I choose a medication that the pharmacist suggested as their first choice…then I must be doing something right. That is always a confidence builder.”
4. Appreciation for the expertise of pharmacists
All three groups observed that, as a result of the pharmacist educator, residents developed an improved understanding of a pharmacists’ expertise and the services that a pharmacist can offer in a primary health care setting. Some residents expressed a sense of regret about losing this pharmacist resource and some had already contemplated how they would ensure they could access similar pharmacist services post-residency.
Pharmacist – “A lot of residents come with preconceived ideas of what a pharmacist does, but here they get regular exposure to me and they start to understand the pharmacists’ skill set and what we can bring to the table in terms of collaborative patient care.”
Resident - “It is always good to know what (pharmacist’s) responsibilities are and what their abilities are so we can use them when we are in practice. I learned that from our pharmacist.”
Resident – “I am going to be sad (when I don’t have access to this pharmacist) and I am not sure what I am going to do, but I have thought about it a few times. I will need to establish a relationship with a community pharmacist I suppose.”
Themes from inductive analysis
The inductive analysis identified the following themes, which were not anticipated or hypothesized by the research team prior to the study: (1) desire for expansion of pharmacist teaching; (2) impact of the teaching on collaboration; (3) impact of the teaching on faculty; (4) lack of criticism of the role.
1. Desire for expansion of pharmacist teaching
Directors and residents consistently stated that the pharmacist educator role with their residency program should be expanded. No themes emerged regarding additional teaching roles or therapeutic topics that were desired and most appeared to want ‘more of the same’. The residents noted that currently the pharmacists taught using a combination of formal, scheduled lectures and informal, unscheduled discussions while caring for patients. Residents felt that it would be beneficial if the pharmacists teaching role was more ‘formalized’ with more regularly scheduled teaching opportunities.
Director – “We have work for a full time pharmacist, but we don’t have it so we don’t do it. I don’t think there would be anything about the pharmacists’ role I would change. Might increase her load, but not change anything.”
Resident – “I wish I had more interactions with them. I wish we had more formal sessions where we could talk about more difficult patients that come to us.”
Pharmacists did not consistently agree that their teaching role should be expanded. They expressed concern regarding their ability to fit an expanded teaching role into their already busy schedule and the impact this may have on their ability to provide patient care in the clinic.
Pharmacist – “It has been a real balance (trying to teach the residents more). My own professional interest lies more with seeing patients and I think I consider myself more of a clinician than a teacher.”
2. Impact of the teaching on collaboration
All three groups felt that the pharmacist educator had a significant influence on the residents’ willingness and ability to practice in a collaborative, interprofessional setting. Interviewees hypothesized that these improved collaboration skills were a result of the residents spending two years working closely with the pharmacist. This collaborative learning also appeared to have influenced the residents’ future career plans, as many expressed a desire to find a future practice site that used a similar collaborative approach.
Director – “I think most of our residents now would like to practice in a multi-disciplinary situation. Not that there are that many jobs out there for them, but a lot of them now express the desire to have a team approach.”
In addition, residents voiced support for the importance of involving pharmacists on all family medicine teams within the primary health care system and they recognized that this opinion was influenced by their exposure to pharmacist educators in their residency.
3. Impact of the teaching on faculty
Interestingly, residency directors responded that they felt the entire faculty within the family residency program (not only the residents) received similar benefits and value from having the pharmacist educator on the team.
Director – “I also learn from the pharmacist every day. I think she does as much for us (the faculty) as she does for the residents.”
4. Lack of criticism
When the interviewees were asked to describe the positive or negative impact that the pharmacist educator had on resident training, it was notable that not a single negative response was received. Even when interviewees were specifically prompted to think about negative aspects of the teaching role, none offered an example. When asked to comment about the theoretical concern that the presence of a pharmacist educator might lead residents to become reliant on the service and not learn to independently manage complex medications, all three groups responded that this was not a concern. Interviewees felt that since the pharmacists teach in a manner that does not ‘spoon feed’ the residents, it was unlikely that residents would become reliant on this service.
Resident - “I think we would do more harm by retracting the pharmacist component to our training simply because of the theoretical concern that we might use them as a crutch.”
Pharmacist - “I think you have to bear that in mind when you are teaching and when you are interacting with them…to prepare them as much as possible for the environment that they are likely to find themselves in after graduation.”