Date of prep: December 2020
Prescribing information and
adverse events reporting
For healthcare professionals only
Where did you study?
I studied at the University of Strathclyde and graduated in 2010.
What additional qualifications have you achieved post-qualification?
I completed the Pharmacist Independent Prescribing course at Strathclyde in 2016, and of course, I have now achieved my California Pharmacist licence.
You were a locum in Scotland for some years. What were the pros and cons of this role in your experience?
Being a locum was great for getting experience in a wide range of settings, meeting lots of new people and learning how to adapt quickly to new situations. It also allowed me flexibility in choosing my own working days. On the other hand, sometimes there might not be much work available, and the resources for professional development such as training and networking might be more limited when you aren’t employed by a single company.
Could you describe the highlights of working for NHS Scotland?
I worked in three different NHS Scotland roles – as a Pharmacy Advisor for NHS 24, a Prescribing Support Pharmacist and General Practice Clinical Pharmacist for NHS Lanarkshire and as a hospital Clinical Pharmacist, also with NHS Lanarkshire. Although these positions were different from each other in many ways, they all allowed me to feel the satisfaction of using my experience and training to help patients. Being a welcomed part of a multidisciplinary team was always a highlight, and I enjoyed learning from my colleagues in other professions and demonstrating the value that I could bring as a pharmacist. At NHS 24 I had the challenge of assessing and advising patients from all over Scotland by telephone. It was always a highlight when I could help a patient to understand their medication, provide reassurance to a worried caller, or recognise a high urgency situation and get the appropriate help in time. In primary care, I was able to review patients’ medicines and make sure they were getting the most from their treatment. Getting patients engaged with their medication, making clinical decisions based on risk and benefit and coming to a mutual agreement on the treatment plan were highlights for me. In the hospital, I saw patients admitted while seriously unwell, participated in their care throughout their journey until they improved and saw them go home looking like a new person. To see the difference I can make as a pharmacist is the greatest highlight of all.
During the course of your work in Scotland did you manage to apply your independent prescribing qualification?
I did. I used it as a General Practice Clinical Pharmacist to prescribe for patients requesting acute prescriptions, then even more extensively as a Clinical Pharmacist on the surgical wards at University Hospital Wishaw.
Why did you decide to move to the USA to practise as a pharmacist?
My wife is from Los Angeles and was offered a great job opportunity back in the US. We decided to move over and so my journey began.
Could you describe the registration requirements and process for pharmacists who may wish to work in the US?
The first requirement for working here is employment authorization from US immigration. I am able to work here as the spouse of a US citizen, but it would otherwise be very unlikely that a US company would successfully sponsor a work visa for a foreign pharmacist.
The next requirement was the Foreign Pharmacy Graduate Examination Committee (FPGEC) Certification. This program evaluated my Scottish degree to certify that it is equivalent to a US pharmacy degree. The requirement for graduates after 2003 is a 5-year pharmacy program, but they consider Highers/Advanced Highers equivalent to a year of US undergraduate study, so my 4-year Scottish MPharm was accepted. Once my SQA Certificate, MPharm transcripts, GPhC letter and other supporting documents were sent in and I passed the Test of English as a Foreign Language (required even as a native speaker), I could sit the Foreign Pharmacy Graduate Equivalency Exam (FPGEE). This is held every October in test centres across the US, comprises 200 questions over 4.5 hours and tests all the knowledge from your pharmacy degree from organic chemistry to biostats to pharmacokinetics and therapeutics. After passing I received my FPGEC certificate and could move on to the next stage.
Pharmacy in the US is regulated by the individual states rather than nationally, so I then applied to the California Board of pharmacy for a license to complete the required intern hours (similar to a pre-reg). The intern hours required vary from state to state, but in California, I had to complete 1500. I was fortunate to find a paid hospital pharmacy position quickly after arriving, but it can be very challenging to get an internship as a foreign grad. Once my intern hours were complete, I then had to pass the national clinical exam sat by all pharmacy graduates – the NAPLEX – and the California exam testing further clinical knowledge, state pharmacy law and practice standards – the CPJE. Other states use a different exam for state law – the MPJE. This was the final step in a long process to gaining my California pharmacist license, and I would certainly advise anyone making the move to start gathering the required documents for FPGEC as soon as possible, as this was the longest part of the process and unexplained delays in processing are frequent.
Could you describe your current role and perhaps what a typical day working in the US as a pharmacist is like?
I work as a Clinical Pharmacist in a community hospital, which is similar in many ways to hospital pharmacy in Scotland. Some duties include medication reconciliation, therapeutic drug monitoring, TPN formulation, advising medical and nursing colleagues, and ensuring safe medicines use. One significant difference when compared to Scotland is that non-emergency inpatient medicines must be screened and approved by a pharmacist before the first dose can be given, so this is a significant part of our role. Dispensing discharge prescriptions is not done by our pharmacy department; patients going home instead receive a prescription to be filled by a community pharmacy. We do however check medicines filled for inpatients, which are supplied in single unit-dose packages and labelled for a specific patient. Even the liquids come packaged as single doses in little cups (which look more like dipping sauce than medicine). Unit doses are often stocked in automated dispensing cabinets on the ward, so we also check the medicines for the cabinet refill. Almost all IV infusions are made in the aseptic room by pharmacy rather than by the nurses, so pharmacists must also check these before they are sent to the ward. These are all tasks that might all be done in any one shift, but at the core of it the purpose is the same in both countries, to make sure medicines are being used in the best way to benefit patients.
What do you now recognise to be the key differences in pharmacy practice in Scotland versus the US?
The biggest difference here is the insurance system. In Scotland, we have universal healthcare which is free at the point of use. Prescriptions are free, hospital treatment is free, GP visits are free. In the United States, healthcare is expensive and the cost can be a barrier to care. Patients are covered by a wide range of insurance plans with different costs and coverages and can easily be surprised with bills for thousands of dollars if part of their care wasn’t fully covered. As a hospital pharmacist, my interaction with insurance is minimal, but a lot of community pharmacists’ time is taken up by trying to navigate the system.
A difference in hospital is that all but the smallest hospital pharmacies tend to be 24 hours a day, 7 days a week, so there is always a pharmacist on site. Another difference is that the IT systems here are a lot more integrated; all of the prescribing, clinical notes, lab tests, outside medical history, pharmacy dispensing records and previous admissions are contained in a single system at my hospital. This means that more tasks can be carried out without being physically located in the ward. Pharmacist independent prescribing does not exist in California, but prescribing responsibility is often delegated to hospital pharmacists for certain drugs. For example, when a hospital doctor orders a drug like vancomycin or warfarin, they will often prescribe “per pharmacy”. The pharmacist then assumes responsibility for monitoring and adjusting the dose without requiring the prescriber to sign off each dose. This is in contrast to Scotland where a practitioner with prescribing authority is required to sign every time. There are differences in pharmacy education too here. Pharmacy is a 4-year doctorate program which generally requires an undergraduate degree for admission, so it takes 8 years at university (and a few hundred thousand dollars) to become a pharmacist. Clinical rotations are a lot more established as part of the pharmacy degree and students spend a significant proportion of their time on placements. I’m sure I could keep thinking of differences but this answer would soon turn into an essay!
Would you recommend the move to the US to others considering it and if so why?
It’s a long, difficult and expensive process, and opportunities here are often contingent on knowing the right people. However, I have learned so much through this process. I had to go back to basics and revise everything from university, but now with the practice experience to put it into context. I have seen new ways of working, been forced out of my comfort zone and confronted with different perspectives. I have met some amazing people and learned from them. If there was any experience in my career so far to make me a better and stronger pharmacist, this was it.
As I previously mentioned, getting a work visa through sponsorship here is basically impossible and there are other countries where it is much easier to do so. But if you are authorized to work in the United States, have the means to do it and the motivating reason I did, then it is possible.
What does the future hold for you now?
If there’s one thing this year has taught us, it’s that we can never predict the future! COVID-19 has reduced staffing and hiring at many hospitals due to elective procedures being cancelled and patient numbers decreasing. I’m currently working on a part-time as-needed basis but I’m hoping for the chance to increase my hours either at my current job or by taking on a second position once hiring picks up. I’m also looking at becoming a Board Certified Pharmacotherapy Specialist, which is a clinical pharmacy certification often sought by employers.
Pharmacy in Practice is a UK pharmacy publication with its roots in Scotland.