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Practicing (Episode 3): Linda Tyler and Erin Fox
Real teams are the antidote to the chaos of modern medicine. “Real teams know each other, feel loyalty to one another, trust one another, and would not want to disappoint one another” (Tom Lee, NEJM Catalyst 2016). Practicing are conversations between real team members about why the work matters. Our goal is to preserve and share the stories of the teams at University of Utah Healthcare.

inda Tyler, PharmD and Erin Fox, PharmD first met as professor and student. Little did they know that together they would build Utah’s Drug Information Service into the nation’s premier source of expertise in projecting, understanding and mitigating drug shortages. This work not only keeps our patients safe, but it also improves care for patients across the country. Accelerate’s Chrissy Daniels and Mari Ransco learn about their critical work.

(Abridged transcript below)

Start with "Why": Pharmacy and Helping Patients

1. How did you get into your line of work? How did you know you were going to become a pharmacist?

[Linda:] I knew in high school that I liked the sciences. I loved math, I loved biology. Physics was my favorite science, chemistry was awesome. I thought, "So, I'm a woman who likes sciences." There were only two women in my physics class, so there weren't very many of us that liked the sciences. One day, I was stopping by the pharmacy to pick up cigars. My father was a smoker, and every time we moved, he had to find a place to buy cigars. So, he would connect with the local pharmacy... and once I got my driver's license in high school, it was my job to pick up the cigars. I walked in the pharmacy and I would start talking to the pharmacist and the other staff in there, and I realized, "Gosh, I wonder what it takes to be a pharmacist?" I looked into it and I realized you have to take physics, chemistry, and biology. You have to take a fair amount of math—and wow—you get to work with patients. That sounded so much better than being in research lab or anything else that you do with sciences. I'd been a candy striper as well—I'd volunteered in the hospital—so I knew what jobs there were in the hospital, and I thought hospitals were just the coolest places.

I have to tell you, in college, every time going through mid-terms and they were just hard sometimes, I would re-think my choice and then think, "No, no, this is what I want to do." It really wasn't until I was in my second year of pharmacy school that I quit thinking that every semester.

Once I got into the clinical part of the curriculum, I knew I was absolutely in the right place. I knew I could make a difference in patient care. It was right when clinical pharmacy was coming to the forefront, and that was the best place to be, because you were working directly with patients and impacting patient care.

Erin, was your path as direct?

[Erin:] No. I loved science and I got a biology degree here at the university. At the time, there was a lot of stuff going on with the genome project, and I thought that was fascinating and I loved it. I worked at ARUP while I was getting my biology degree. The reality of what actually it takes to be in the lab, to do the cell culture, to do the protein isolation, I realized I didn't have the patience for it. I was all by myself at 3:00 AM in a cold room going, "What am I doing? How is this ever going to help anybody?" My very good friend that I had done my biology degree with convinced me, "Hey, let's take this pharmacy class. I'm thinking about pharmacy. We can take the class and see what it's like before we commit." We did that together and I just loved it. It was Dave Earl's biochemistry class. I thought, "Well, I'm going to do pharmacy." And I have loved that choice ever since.

2. Both of you talked about the importance of making a difference for people. When did you first understand as a pharmacist you were helping someone?

[Linda:] I was very attracted to pharmacy because of my interest in science, but it was my second year in college when I was still doing my pre-work, when the Doctor of Pharmacy program started at the University of Utah. I saw a news blurb about the Doctor of Pharmacy program. And that's when it connected, "Oh my gosh, if I did this, I could make a difference in patients' care." How can you prevent problems for problems? How can you keep patients healthy? When you go to pharmacy school you take many years of classes before you actually see a patient and make a difference. But I loved working with patients on the wards and reviewing their medication therapy. I recognized you're the one that's paying attention to the medications, you're the one that's going to spot problems with the medication.

Even as a student, even in your first week on rotation, you spot a medication error and you think "Why am I the only one seeing this?" But the rest of the team doesn't always focus. They're focusing on other things that they do the very best, and I realized that there's a huge role for pharmacists and a huge role for me to work with patients. When I was in a critical care unit, I knew I made a difference every day in terms of monitoring the drugs, making sure patients got better as quickly as they possibly could. I've had several different practices, but in each practice area that I've been, I knew I made a difference. Just spotting medication errors, the clinical problem solving that you do every day, you know you make a difference.

[Erin:] Growing up, a lot of my relatives were very sick. My grandmother died of breast cancer when I was nine. My grandfather died of heart failure. As a teenager, I would help my grandmother who had emphysema go to some of her appointments, help my mom and dad out, and it was fun for me. I would see how they would change her medicines and how many questions she would have. I didn't really connect that it would be a pharmacist that could help with that until I took that very first biochemistry class and started to learn about a couple of the drugs that my grandmother was taking, and it just kind of clicked for me. "Oh, this is a way that I could really, really help and connect with patients." So, seeing my family members take medicines, but then having that recognition during that biochemistry class, it was kind of an aha moment for me.

3. How is working as a pharmacist different than you imagined?

[Erin:] I say it's the best job you can have. It's the most interesting work. It's different every day. You get to help patients, you get to work with great people, you get to work with nurses and doctors every day, and everyone is focused on making things better for the patient. I always tell them it's the best job you can have.

[Linda:] I hadn't really envisioned the specialties. We don't think about pharmacists as having specialties. But I have always been in a specialty practice. My very first job out of graduate school was in a critical care. It was in a shock and trauma unit, and I was the clinical pharmacist and clinical faculty member there. I worked with these really intense patients and occasionally worked with the families. Then my husband got a job in another city, and then I worked in a poison control center. When I came here to the University of Utah, I came to be the director of drug information services. I was cross appointed in the college of pharmacy, so there were huge opportunities for teaching.

I did something very different in drug information. It was the opportunity to really build something—build a program and work with an incredible team. I really had never envisioned when I was in school, but it was the best place to land and it offered all kinds of opportunities. I never thought I would be a director of pharmacy. When I was starting in pharmacy school, I always thought I was going to be a clinician, yet the right opportunity opened up and now I'm a director of pharmacy. Having all this clinical experience in the position that I have now makes for a really strong combination to impact care on a global level and to grow a department in incredible ways.

The Drug Information Service, Proactively Preventing Drug Shortages, and National Attention

4. That takes us to the Drug Information Service. Linda, you were hired to lead the Drug Information Service? What did you think your mission was at that time?

[Linda:] I came in 1986, and actually the Drug Information Center had been started probably in about 1975. Up until that time, it was one faculty member in the graduate program in pharmacy. Drug information are key skills that we have to teach every pharmacist. Its core to the curriculum, and from that time starting in the mid-70s, there were classes for pharmacy students in drug information, literature evaluation, and statistics. There was one faculty member in drug information, and students on rotation providing services to the hospital. When I came in 1986, I was the one faculty member in a small room taking students on rotation and teaching a required class in drug information. It was very clear to me when I started that they kept asking, "Can't you do this? Can't you do more?" I said, "Well, I can do more. There's all kinds of opportunities but we'll need more people."

Within the first year we got another staff person. Each year for the next few years we added to the Drug Information Center. We were being asked to do really incredible things around drug policy. In drug information, you get phone calls, with people asking you questions. Most of those phone calls were very patient-specific. I was also getting asked about drug policy and how we could make a difference as a whole organization. It was both about solving individual patient problems, as well as solving problems for the organization. Some of it was for accreditations standards, some of it was because we were trying to solve problems. Over time, we grew the drug information service to 11 staff.

We started a drug information residency, which was really incredible because that developed a pipeline of really talented people who stayed at Utah. Drug information is a very, very small specialty in pharmacy, so not every center has a drug information center. At this point in time, I don't know of any other academic medical center that has a center as large as ours.

Erin, you trained here. When did you think drug information was for you?

[Erin:] During pharmacy school, many of my classmates were just going to graduate and get a job, but some of us were thinking about residencies. I was thinking about residency too. But I remember thinking, "You know, I really like such a broad array of different things in pharmacy. I can't envision specializing in just critical care or oncology." I talked to Linda about drug information. I was her TA for that class and I remember she was delighted that I was interested. It was such a great opportunity to train in drug information and have the opportunity to get a set of specialized skills but keep a really broad base.

5. Together, you've built a program with both institutional significance and national significance. What drove you to make such a significant difference in the field of pharmacy?

[Linda:] It has always been very important that we maintained our focus on what was really important. First and foremost the Drug Information Center serves our patients. We would solve problems for our patients and our organization. But we also realized that the work we were doing internally had application to every other organization. That's really how we got into drug shortages. During the 1990s, there weren't very many drug shortages. But we realized that when we had a drug shortage, the sooner that we got the physicians involved in the shortage and worked together to find a solution, the more capable we were to take care of patients in these critical situations. Over the years, we developed a fairly structured process, and always developed written communication for people for what they needed to do when a shortage occurred.

Around 2000, there were becoming more and more shortages. There were some people who knew of our internal work that we had done around shortages, specifically how we have a consistent process and engage our medical staff. They said, "You know, others are really struggling with this. You should really partner with some of our national organizations." I said, "That's a really great idea." I started a conversation with them and they said, "Well, shortage is a big issue but we don't know what to do about it." And we said, "Well, we do." But it took a lot of convincing to get them to be interested. We eventually forged a partnership with the American Society of Health-System Pharmacists to create a website around the shortages. We would provide the clinical information for the website. The very year we forged the partnership and what started out as just a few shortages expanded mightily to over a hundred shortages.

The focus is the real work for our patients that is needed for our organization? If it has applicability to help other patients and other organizations, then let's explore that. We stay very focused that our work is patient-focused. As an academic medical center, we always have trainees with us. Our trainees participate in this work, contribute to this work, and understand how important this work is to help our patients and patients in other organizations. We never would have guessed that it grew as big and bold and that we would contribute to the huge national dialogue on both drug shortages and the rising cost of pharmaceuticals.

Erin, how do you stay focused on patients when the drug information service has grown so dramatically?

[Erin:] I think one of the best parts of working in drug information is the opportunity to make things better for not just one patient, but make things better for all of the patients in our health system. Drug information allows us to help patients at our hospital and help patients across the country. It is very, very gratifying to know that work is helpful and it's useful. I hear from colleagues across the country about how much they value the information we provide and that every shortage affects patients. Our practice is always for the patients first. That's the important work we do every day.

6. When was a drug shortage really scary for you? How did you prepare the organization?

[Erin:] In 2011, I got a call from a colleague at the FDA, and he told me that a factory had closed, and most of the drugs made in that factory were chemotherapy drugs. What was going to happen was a shortage of 30 to 40 of the most basic chemotherapy drugs that we need every day to treat our patients. We knew that things were going be really grim for a while, and so we worked closely with our colleagues at Huntsman Cancer Hospital. We developed a strategy where we would track how much drug we had, and before we would start a new patient on that medicine, we would make sure that we would have enough medicine to cover their whole course of therapy. With chemotherapy, there are often choices in regimens, but once you start a regimen, you want to finish that regimen.

By thinking ahead and being proactive, all patients finished their regimen. Not everyone across the country did that. Many centers chose to manage those shortages by providing the drugs they were able to get on that day, and some patients going to chemotherapy centers were turned away and not able to receive their treatment. That actually exploded the topic in the news media because we had patients telling the media, "Hey, I can't get my chemotherapy. What is going on?" But I was really happy with the plan that we made. It took a tremendous amount of work with the physicians, but our organization was able to get through that horrible, critical time.

[Linda:] One that I can think of is propofol. It's a very critical drug used in anesthesia. There was going to be a shortage, so we worked closely with our anesthesiologists to plan for the shortage - when we were going to use it, when we weren't going to use it, and the alternatives. We did a really good job working with our anesthesiologists by engaging them right away. I remember being at a national meeting about six months into the shortage. One of my counterparts said, "So, is this shortage really real?" And I said, "Uh, yes." He said, "Well, I just don't want to tell my anesthesiologist about it until it's real." I said, "We told our anesthesiologists about it six months ago so that we could engage them in the problem solving." He said, "Yeah, I just can't imagine doing that. We don't tell them until the very last minute."

Sometimes we forget how different places engage their medical staff during these shortages. We have a strong process, a strong partnership, and incredible trust with the medical staff. Obviously, we worked really hard to do that on a daily basis. But it really came to light that we have the same goal – to work very closely and proactively to prevent problems, to prevent harm to our patients, and where possible, make sure a patient gets the drug they really need.

7. I remember driving to work in the 90s in the winter, listening to the radio, and you were on the radio. I said, "That's Linda." I thought maybe it was local NPR, but it was national NPR, and it was the first time that you were on the radio. Both of you have now been speaking nationally about the work in the media and before Congress. Who would have thought Utah would lead the country? What has that aspect of your practice been like?

[Linda:] It's an incredible, wild ride. First of all, pharmacists in general are typically shy introverts. We're not really good about telling our story, and if you said, "I'm going to put you in front of a camera," or "You're going to talk to NPR," we go, "Oh no." We'd figure out a hundred ways not to do that. Very early on when I was in the Drug Information Service, KSL called and said, "Hey, there's this new drug on the market. We'd like to interview you." I said, "No, no, I'm really sorry. I can't do that interview. Work's busy." I could think of a hundred reasons why on that particular day I couldn't do it. Likewise when the television media calls you, they're on a news cycle and they really want to talk to you within the hour. That night I watched the evening news and they interviewed somebody who, in my opinion, got the story wrong and really didn't understand the key points. I thought to myself, "Well, if I wasn't willing to talk to them, this is what it looks like. So I have to figure out how to make this better."

I thought, "Well, we can get some of our college faculty, for whom this is their area of expertise, to talk to the media." Then again I would watch the evening news after they'd been interviewed, and I would say that their interviews, while highly accurate, failed to understand the audience that they were talking to and did not make it accessible. I worked with our PR department at the time, and they really didn't think there was much in pharmacy that would attract attention. When we got requests, we'd funnel them with PR and we'd think about it together so that relationship continued to grow. As we started getting into our work with drug shortages, we would sit down with them, and they'd say, "We just don't understand how this is a story." We said, "No, it's a really, really big story, and we're going to get questions about it, and we'd like to figure out a strategy and a way to do this. I don't have the skills to talk to the media, I need your help in learning about this."

Over time they've worked with us a tremendous amount. I would have to say we're still not comfortable doing this. Talking to the media is not my favorite thing in many ways. But I recognize that it is important to get our story out. If we don't tell our story, nobody else will. How do we craft that story? What does it look like? We're really passionate about shortages and rising drug costs, so we're willing to talk about it.

Did you ever think you'd be testifying before Congress, Erin?

[Erin:] No. As shortages heated up, though, in the media, I did wonder if they would want me to come talk. I had built relationships over the years with different reporters and I'd given them that drug pricing story and it just started a big swirl in the media. I think they also chose me because Senator Hatch was on that committee. But it was a great opportunity to tell our story and to try to get the real story from the people on the ground. I told them “this is what it looks like when a drug company raises prices, and what our hospital has to do to manage that.” Drug price increases are an extension of drug shortages, because when drug prices increase, it creates a shortage. Shortages change how if a patient can afford that medicine or a hospital has to change how they stock the medicine.

Pride and challenges

8. What do you think is different at Utah?

[Erin:] I think it's being proactive. One day in August of 2015, we learned that all of our surgical irrigation solutions were going to be cut in half, starting immediately. So I very quickly had to go work with Kathy Adamson and Dr. Saltzman and make a plan. You can't do surgery without those irrigations and we can't just quit doing half of our surgeries.

We were able to use smaller bags of saline, which was very inconvenient for the technicians, but it's better than not doing surgery at all. I think what's different about our organization is the teamwork. Thinking ahead, being proactive. Whenever I talk to our physicians about a potential shortage, they're always happy to know about it. I can always circle back and say, "Hey, guess what? It turned out to not be a problem." But they're never angry that we're crying wolf. They would rather be a part of that planning process. That's just a really huge benefit we have as a culture here.

[Linda:] I agree with what Erin said. It's just really incredible to work here. Physicians won't trust us [pharmacists] if we say, "Oh yeah, we've known about this shortage for three months, but now that it's real we're having a conversation with you." We've really worked hard to change the dialogue to engage them the moment we know about a shortage so that we can work together on how we're going to take care of patients under these new circumstances. It's really gratifying to positively affect patient care in terms of preventing problems, to make sure the patients with the most critical need get the medications that they need.

9. What's been your biggest struggle in your career and your practice?

[Erin:] Learning how to say no. I'm terrible at that. I love learning new things and I love accepting new challenges. I almost always say yes, and then I usually buy myself some late nights and some rough weekends by saying yes to too many things. I wouldn't necessarily change it, but it is something that I try to work on. It's a struggle. It's hard not to say yes.

[Linda:] I'm a really poor role model for her in that regard in that I have the same difficulty. I would say the biggest thing is I'm one whole person, and I have my work life and I have my home life, and it's juggling and balancing everything. I think about all the years raising my kids, and how you juggle stuff, and at times what I gave up because something was happening at work that was really important. I shared my passion with my kids. The balance has always been challenging and tricky, and I would say that's probably the greatest challenge in many ways.

When some of our residents say, "Hey, I'm thinking about planning a family. How did you do it?" I say, I don't know, because there was just so much going on and we just kind of made it happen. It took a tremendous amount of juggling of what you were doing at home and what you were doing at work. It also meant juggling with your teammates, because each of them had needs and we all wanted to be there to support them.

When my son was in high school, I’d make him pick me up from work, and I’d make him come inside to get me. I said, "You need to know the people I work with. In case anything happened, I'd want you to know who I work with." And he would say, "Mom, don't make me do that." I said, "No, it's really important." My team members saw my kids grow up. I'm seeing Erin's kids grow up. I don't see them very often, but we work together and support each other in that way. One of the keys in how we made it work is that we work together as a team and we support each other.

10. What are you most proud of as you look back on the time that you’ve spent together?

[Erin:] I'm most proud that we built a team and a service that is considered a necessity here at our organization. Not every academic medical center has a Drug Information Service, and I know that we are recognized and highly valued by nursing staff, by physicians, and by our pharmacists.

[Linda:] I'm just so incredibly proud of the great team that we have here—not only the Drug Information Service, but the entire department and the incredible work that we do quietly every day.

11. You have built work that supported our patients and our physicians, our nursing team, our region, and our country. What, Linda, do you want Erin to know about how you feel about the work you've done together?

[Linda:] I am just so proud of the work we've done. She is so committed to excellence in everything she does every day. It's absolutely phenomenal. I would want her to know how much I enjoy and value the relationship that we have, how highly I think of her, how much I love working with her on a daily basis, how much I trust her, and how much I respect her.

Erin, you came as a TA to Dr. Tyler, and here we are all these years later. What do you want her to know?

[Erin:] Linda's been an incredible mentor to me, a huge teacher. I still learn from her every day. I love working for her, I love working with her. I think part of what drives my passion for excellence, and to make my team as good as they can be and our services as good as they can be, is to help support what Linda built and to keep making that better. So I just love working for Linda and I can't thank her enough for all of the...for everything.


Linda Tyler

Chief Pharmacy Officer, Professor of Pharmacy, University of Utah Health

Erin Fox

Sr. Director, Drug Information and Support Services, Associate Professor of Pharmacy, University of Utah Health

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