New Practitioners Forum

812 Am J Health-Syst Pharm—Vol 64 Apr 15, 2007

New Practitioners Forum

The New Practitioners Forum column features articles that address the special professional needs of pharmacists early in their careers as they transition from students to practitioners. Authors include new practitioners or others with expertise in a topic of interest to new practitioners. AJHP readers are invited to submit topics or articles for this column to the New Practitioners Forum, c/o Jill Haug, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8821 or newpractitioners@ashp.org).

Specializing in pediatric hematology and oncologyCancer is the second leading cause of

death in children, surpassed only by accidents. In 2006, 9,500 children ages 0–14 years were estimated to be diagnosed with cancer; of those, approximately 1,500 were expected to succumb to their disease.1 When compared with the nearly 1.4 million new cases of cancer estimat-ed for all ages in 2006, and the roughly 565,000 expected to die of cancer, the number of children with cancer is seem-ingly small.1 Therefore, because of the relative rarity of childhood cancer, many pharmacists may never encounter a child with neuroblastoma, acute myelogenous leukemia, or os-teosarcoma. They may never know what rhabdomyosarco-ma is, much less how to treat a child with hemophagocytic lymphohistiocytosis. At pedi-atric cancer centers across the country, these rarities become the routine.

This routine, however, is not without complications and challenges. Toxicities from chemotherapy are fre-quent, and the management of adverse events may include not only traditional mea-sures but also investigational agents. Because clinical evi-dence may be lacking or ex-ists only in case reports, the pharmacy clinician must not only use standard references but also personal contacts, in-

stitutional experiences, and clinical inter-pretation as the foundations for recom-mendations and interventions.

Pediatric clinical services. The benefi ts of clinical pharmacy services are well documented in the literature. Specifi cally, the benefi ts provided and responsibilities of clinical pharmacy services by pharma-cists, pharmacy residents, and pharmacy students in the pediatric population have been described.2–4 At Texas Children’s Hospital, several teams of pharmacists are devoted to a variety of medical spe-cialties. Dedicated to the Cancer Cen-

ter is a team of pharmacists with extra training in chemotherapy, hematology, and oncology. These pharmacists are led by two clinical pharmacy specialists (CPSs); one devoted to hematology and oncology and the other responsible for the hematopoetic stem-cell transplant service. The pharmacists are an integral part of the larger medical team, con-tributing expertise in therapeutic drug monitoring, adverse event management, parenteral nutrition, and pain manage-ment. The CPS is responsible for daily rounding, formulary management, proc-ess improvement, medication-use re-views, education of the pharmacy team, and education of medical and pharmacy students and residents. The CPS may

also assist in creating indi-vidualized treatment plans for patients with refractory toxicities or relapsed disease. Frequently, the CPS inves-tigates creative methods for managing the complications of chemotherapy, including refractory nausea and vomit-ing, and mucositis.

New practitioners’ per-spective. Texas Children’s Hospital provides clinical and institutional rotations for stu-dents from several colleges of pharmacy. Students on my ro-tation often ask how I am able to work in an environment where children have cancer. Generally, this question comes up on the fi rst day of the rota-tion when the student has not yet seen the effect a pharma-cist can have on a child’s life. After all, the majority of what

is taught in school and what is seen in practice—whether it is in the hos-pital or retail setting—relates primarily to the treatment of adults. Unlike many other rotations, students on my rotation are exposed to two subjects often under-represented in pharmacy education—

New Practitioners Forum

813Am J Health-Syst Pharm—Vol 64 Apr 15, 2007

pediatrics and hematology and oncology. Recently, an opinion paper was published concerning the state of pediatric phar-macotherapeutic education, stressing the need for increased education and expo-sure of pharmacy students and residents to pediatric practice.5 As a CPS, I play a small role in meeting this educational need. However, as the article noted, pe-diatric pharmacotherapeutic education must begin much earlier than during the last year of clerkship rotations.

Training and development. It is of-ten said that the best way to learn is by doing. With that in mind, the training process for a position in pediatric hema-tology and oncology may include clerk-ship rotations, residencies, fellowships, and on-the-job training. Currently, there are approximately 20 American Society of Health-System Pharmacists (ASHP)-accredited postgraduate year 2 (PGY2) pediatric pharmacy residencies and 32 ASHP-accredited PGY2 oncology resi-dencies, many of which offer rotations in pediatric hematology and oncology or stem cell transplant.6 There are also fellowships available in pediatrics and hematology and oncology that have un-dergone peer review; information about these programs is available through the American College of Clinical Pharmacy.7 Furthermore, unaccredited residencies and fellowships may also be available.

Regardless of the route chosen, it is critical that the clinician be competent in chemotherapy, pain management, nutritional supplementation, and in-fectious diseases. Knowledge of general

pediatric diseases, developmental stages, and pediatric malignancies is important. Therefore, in addition to formal training, some institutions may prefer specialty certification, with board certification in oncology pharmacy lending itself more closely to the roles and responsibilities of the pediatric hematology and oncology pharmacist.

Motivation and inspiration. I can-not convince each student on my rota-tion to become a pediatric CPS. What I can do is encourage students to keep their options open to the myriad of pos-sibilities in the pharmacy profession and to find a niche that is personally and pro-fessionally rewarding. Certainly there are days when dealing with the death or ill-ness of an innocent child is difficult. The emotional complications of this type of position cannot be fully anticipated and must be managed on an individual basis. The practitioner must become intimately involved in the care of the child, while still recognizing that even the highest level of care may not accomplish a cure. In those times when the child does die, the practitioner and multidisciplinary team must be a support system not only for the family members but also for each other. The practitioner must possess pa-tience with clinical research, persistence with attempting new and innovative therapies, and perseverance when a child dies. So why do I do it? I do it because one small improvement in the life of a child can make a tremendous difference to the child and the family caring for that child. Seeing the pain and suffering of pedi-

atric patients is without a doubt one of the inevitable aspects of this career path; however, to see one child laugh again, or see another leave the hospital with a chance of survival, makes the difficult days worthwhile.

1. American Cancer Society. Cancer facts and figures 2006. Atlanta, GA: American Cancer Society; 2006.

2. Buck ML, Connor JJ, Snipes CJ et al. Com-prehensive pharmaceutical services for pediatric patients. Am J Hosp Pharm. 1993; 50:78-84.

3. Condren ME, Haase MR, Luedke SA et al. Clinical activities of an academic pediatric pharmacy team. Ann Pharmacother. 2004; 38:574-8.

4. Krupicka MI, Bratton SL, Sonnenthal K et al. Impact of a pediatric clinical phar-macist in the pediatric intensive care unit. Crit Care Med. 2002; 30:919-21.

5. Aucoin RG, Buck ML, Dupuis LL et al. Pediatric pharmacotherapeutic education: current status and recommendations to fill the growing need. Pharmacotherapy. 2005; 25:1277-82.

6. American Society of Health-System Phar-macists. Online residency directory. www.ashp.org/s_ashp/residency_index.asp (ac-cessed 2007 Jan 27).

7. American College of Clinical Pharmacy. Directory of residencies, fellowships, and graduate programs. www.accp.com/ resandfel/directorynon.php (accessed 2006 Sep 25).

M. Brooke Beavers, Pharm.D., Clinical Pharmacy Specialist

Texas Children’s Hospital6621 Fannin StreetHouston, TX 77030-2316mbbeaver@texaschildrenshospital.org

DOI 10.2146/ajhp060347