CHPPC Module 11, Section 2: Communicating with Physicians
MODULE 11: PROFESSIONAL PRACTICE & COMMUNICATION

Section 2: Communicating with Physicians

If communication with nurses is the bedrock of inpatient safety, then communication with physicians is the engine of clinical progress. In this section, you will learn to translate your profound drug knowledge into concise, evidence-based, and compelling clinical recommendations. This is the ultimate evolution of your role—from a respected dispenser of medications to an indispensable consultant in their selection and management. We will deconstruct the art of the clinical recommendation, providing you with the frameworks, language, and confidence to become a trusted pharmacotherapy expert on the medical team.

2.1 The Pharmacist’s Role on the Medical Team: From Dispenser to Consultant

Shifting your professional identity from the community expert to the inpatient specialist.

In your retail practice, you are the ultimate medication authority in the community. Patients and providers alike rely on your expertise. In the hospital, this expertise is not diminished; it is refocused. You are no longer on an island of expertise but are now an integrated member of a multidisciplinary team, which includes physicians (attendings, residents, interns), nurses, respiratory therapists, dietitians, and more. Your value is measured by your ability to apply your pharmacological knowledge to a specific patient’s complex, dynamic clinical picture and to communicate your findings effectively to the primary decision-maker: the physician.

Retail Pharmacist Analogy: The “Prior Authorization” Intervention

A physician prescribes a non-formulary, brand-name medication for a patient’s hypertension. You receive the rejection from the insurance company. You don’t just relay the rejection. You become a problem-solver. You review the patient’s profile, identify a therapeutically equivalent, formulary alternative (e.g., a different ACE inhibitor), and call the prescriber’s office. You state the problem (insurance rejection), provide your assessment (drug X is not covered), and offer a specific recommendation (“I suggest we switch to lisinopril, which is on formulary and clinically appropriate. Would you like me to send a request?”). In that moment, you acted as a clinical and operational consultant to solve a problem.

This is the exact model for your communication with physicians in the hospital, but the “formulary” is now the hospital’s evidence-based guidelines, and the “rejection” might be a sub-therapeutic dose, a drug-bug mismatch, or a potential adverse event. Your intervention—identifying the problem, assessing the clinical picture, and recommending a specific, actionable solution—is the core of your new consultative role. The skill set is identical; the context is simply more acute.

Understanding the Medical Team Hierarchy and Your Place In It

In academic medical centers, the team has a clear structure. Understanding who to contact and how they make decisions is key to your effectiveness.

  • Attending Physician: The senior-most physician, ultimately responsible for the patient’s care. They lead rounds and make the final decisions. Recommendations on complex or controversial issues are best directed to them.
  • Fellow / Resident: Physicians in advanced training. They manage the day-to-day care of the patient and are often your primary point of contact. They write most of the orders and are highly receptive to well-reasoned, evidence-based recommendations. Building a strong rapport with residents is a high-yield strategy.
  • Intern (First-Year Resident): The most junior physician. They are often overwhelmed and focused on task execution. While they write orders, they may not have the autonomy to make significant changes without consulting their senior. Your role with interns is often educational—helping them with dose calculations or formulary choices.
  • Medical Student: Present for learning purposes and have no prescribing authority.

Your general strategy should be to direct routine recommendations (e.g., renal dose adjustments, IV to PO switches) to the resident. For more significant interventions (e.g., questioning the entire antibiotic strategy, recommending a high-risk medication), it is often best to present your case during daily rounds when the entire team, including the attending, is present.

2.2 Mastering Clinical Recommendations with SBAR

Structuring your conversation for maximum clarity and impact.

You’ve learned the SBAR framework for communicating with nurses. When speaking with physicians, the framework remains the same, but the content within each section becomes more data-driven, evidence-based, and focused on pathophysiology. A physician’s primary need from a pharmacist is a clear problem statement backed by a well-justified solution. They are trained to think in algorithms and evidence; your recommendation must align with this mindset.

Deep Dive: Applying SBAR to Common Pharmacist-Physician Scenarios

Let’s break down how to structure your conversation for three of the most common interventions you will make.

Scenario 1: Renal Dose Adjustment

The Clinical Situation: Mr. Jones, an 82-year-old male, was admitted with pneumonia and started on piperacillin-tazobactam 3.375g IV Q6H. His admission creatinine was 1.1 mg/dL. On day 3, you notice his creatinine has risen to 2.4 mg/dL.

SBAR Your Dialogue with the Resident
Situation “Hi Dr. Smith, this is Chris, the pharmacist for the medicine team. I’m calling about Mr. Jones in room 714 regarding his antibiotic dosing.”
Background “He’s being treated for pneumonia with piperacillin-tazobactam. I see his creatinine has trended up from 1.1 on admission to 2.4 this morning. His weight is 75kg.”
Assessment “Based on his new creatinine, his estimated creatinine clearance is now about 28 mL/min. The current dose of 3.375g Q6H is supratherapeutic for his current renal function and puts him at risk for neurotoxicity and further kidney injury.”
Recommendation “I recommend we adjust the dose to the approved renal dose of 2.25g IV every 8 hours. Would you like me to put in that order for you?”

Scenario 2: IV to PO Interchange

The Clinical Situation: Mrs. Davis is a 45-year-old female on hospital day 4 for cellulitis, treated with IV levofloxacin. She is afebrile, her white blood cell count has normalized, and she is now eating a regular diet.

SBAR Your Dialogue with the Resident
Situation “Hi Dr. Evans, this is Sarah, the pharmacist. I was reviewing Mrs. Davis in 205 and had a suggestion for her antibiotic therapy.”
Background “She’s on IV levofloxacin for her cellulitis and is responding well clinically. I see she’s now afebrile, her WBC is back to normal, and she’s tolerating a PO diet.”
Assessment “Given that she’s clinically stable and eating, she meets our hospital’s criteria for an IV to PO switch. Levofloxacin has excellent oral bioavailability, so there would be no loss of efficacy.”
Recommendation “I recommend we convert her to oral levofloxacin 750mg daily to complete her course. This will help reduce the risk of line-associated infection and facilitate her discharge planning. I can enter the order to switch if you agree.”

Scenario 3: Therapeutic Duplication

The Clinical Situation: Mr. Chen was admitted for a COPD exacerbation. In the ED, he received several nebulized ipratropium/albuterol treatments and was placed on a scheduled Q6H regimen. The admitting hospitalist also ordered tiotropium (Spiriva) once daily.

SBAR Your Dialogue with the Resident
Situation “Hi Dr. Lee, this is Dave from pharmacy. I have a quick question about the respiratory medications for your new admission, Mr. Chen in 318.”
Background “I see he has an active order for scheduled ipratropium/albuterol nebs Q6H, and a new order for tiotropium daily.”
Assessment “Since both ipratropium and tiotropium are long-acting anticholinergic agents, administering them together constitutes therapeutic duplication and increases the risk of side effects like urinary retention and tachycardia without providing additional benefit.”
Recommendation “To avoid duplication, I recommend we discontinue the scheduled ipratropium component and change the order to albuterol nebulizers PRN, while continuing the scheduled once-daily tiotropium for maintenance. Would that work for you?”

2.3 The Art of the “Professional Pushback”: Questioning an Unsafe Order

How to advocate for safety while maintaining a collaborative relationship.

This is one of the most challenging and important transitions from retail to hospital practice. In retail, if you have a concern about a high opioid dose, you might call to verify it, document your conversation, and use your corresponding responsibility. In the hospital, you are part of the team directly responsible for the patient’s outcome. If you believe an order is unsafe, you have a professional and ethical obligation to prevent it from being carried out. This requires a skill called “professional pushback”—the ability to challenge a prescriber’s order in a way that is respectful, non-confrontational, and grounded in patient safety.

The Psychology of Questioning: Safety as a Shared Goal

The key to successful pushback is to frame the conversation so that you and the physician are on the same side, working together against a common enemy: a potential adverse drug event. Your tone should never be, “Your order is wrong.” It should always be, “I am concerned about a potential safety issue for our patient, and I’d like to discuss an alternative plan.”

Deep Dive: High-Risk Scenarios Requiring Pharmacist Intervention

Certain orders should be considered “hard stops” that require immediate clarification and potential pushback before you will verify them. Your pharmacist’s intuition, honed in the community, is your best guide. These often include:

  • Unprecedented Opioid Doses: A massive increase in an opioid dose for an opioid-naive patient (e.g., an order for Fentanyl 100 mcg IV push for a post-operative patient who has never received opioids before).
  • Contraindicated Medications: An order for an ACE inhibitor in a patient with a documented history of angioedema, or an order for metformin in a patient with an eGFR of 20 mL/min and acute kidney injury.
  • Major Drug-Drug Interactions: An order for linezolid in a patient actively taking an SSRI (serotonin syndrome risk), or an order for amiodarone in a patient on a high dose of simvastatin (rhabdomyolysis risk).
  • “Look-Alike, Sound-Alike” Errors: An order for hydralazine in a patient who has always been on hydroxyzine, suggesting a potential click-and-pick error.

A Framework for Professional Pushback

When faced with an unsafe order, a structured approach can help you remain calm, professional, and effective.

  1. Pause and Prepare: Do not reactively page the physician. Take a deep breath. Gather all relevant data: patient allergies, recent labs, vital signs, other active medications. Have your evidence ready—what does the package insert, Lexicomp, or a clinical practice guideline say?
  2. Lead with Concern, Not Accusation: Start the conversation by expressing your concern for the patient’s well-being. This establishes a shared goal.
  3. State Your Finding Objectively: Present the data clearly and without judgment. “I’m looking at the new order for…”
  4. Explain the “Why”: Clearly articulate the specific risk or adverse outcome you are trying to prevent. “My concern is the risk of…”
  5. Offer a Specific, Safer Alternative: This is the most crucial step. Never just point out a problem without offering a solution. This shows you are a problem-solver, not an obstacle.
  6. Escalate if Necessary: If the prescriber is unreceptive and you still believe the order is unsafe, you must escalate. This is not confrontational; it is your professional duty.

Example Dialogue: Questioning a High Opioid Dose

Scenario: You receive an order for hydromorphone 4mg IV Q2H PRN pain for a 72-year-old opioid-naive female who just had a knee replacement.

Your conversation with the intern:

“Hi Dr. Adams, this is Maria, the pharmacist. I’m calling about the new pain medication order for Mrs. Wright in 802. (Lead with Concern) I wanted to discuss the dosing to make sure we keep her safe and comfortable.

“(State Finding) I see the order is for hydromorphone 4mg IV every two hours as needed. (Explain the ‘Why’) Looking at her record, she doesn’t appear to have any prior opioid exposure, and a 4mg IV dose is very high for an opioid-naive elderly patient. My primary concern is the risk of over-sedation and respiratory depression.

“(Offer Alternative) The recommended starting dose for an opioid-naive patient is typically 0.2 to 0.5 mg. I would be much more comfortable starting with an order for hydromorphone 0.5mg IV every 3 hours PRN, and we can titrate up if her pain is not controlled. Would you be open to adjusting the order to that?”

The Chain of Command: Your Safety Net

What if the intern in the example above says, “No, my attending told me to order that. Just verify it.”? You do not have to verify an order you believe is unsafe. Your next step is to use the chain of command.

Your response: “I understand. However, I am not comfortable verifying this dose due to the significant safety risk. I need to speak with the attending directly to confirm this plan. Can you please provide me with their contact number, or we can page them together?”

If the attending physician also insists on the dose and you are still not comfortable, your final step is to escalate to your pharmacy clinical manager or director. You document every step of the conversation, including who you spoke to, what was discussed, and the outcome. This process protects the patient, protects you, and upholds the safety standards of the institution.

2.4 Participating in Patient Care Rounds: Making Your Voice Heard

Transitioning from a reactive problem-solver to a proactive member of the clinical team.

Patient care rounds are the daily meeting where the entire multidisciplinary team gathers to discuss each patient’s case in detail. For many retail pharmacists, the idea of “rounding” is foreign and intimidating. However, this is your single greatest opportunity to have a profound impact on patient care. It is where you move from fixing problems after they occur to preventing them from happening in the first place. Your presence on rounds solidifies your role as the medication expert and a vital member of the team.

Demystifying Rounds: Structure and Flow

While the exact format can vary, most rounds follow a structured presentation for each patient, often using a variation of the SOAP (Subjective, Objective, Assessment, Plan) format. The intern or resident will present the patient to the attending and the rest of the team.

  • Subjective: How the patient feels, any new complaints or events overnight.
  • Objective: Presentation of hard data. This includes vital signs, physical exam findings, laboratory results (chemistry, hematology, microbiology), and imaging reports.
  • Assessment: A summary of the patient’s problems and the team’s working diagnosis. For example, “A 68-year-old male with hospital-acquired pneumonia, now with resolving leukocytosis and improving oxygen saturation.”
  • Plan: The to-do list for each problem. This is broken down by system (e.g., “Neuro,” “Cardio,” “Pulmonary,” “ID”) and is where medication changes are discussed. This is your primary window to contribute.

How to Prepare for and Contribute to Rounds

Your effectiveness on rounds is directly proportional to your preparation. This preparation is often called “pre-rounding.”

  1. Develop Your Patient List: First thing in the morning, print or electronically access the list of patients assigned to your medical team.
  2. Systematic Pre-Rounding Workup: For each patient, conduct a rapid but thorough medication review. You are looking for the same things you always do, but with a forward-thinking perspective:
    • Are all medications appropriately dosed for the patient’s renal and hepatic function?
    • Are there any opportunities for IV to PO conversion?
    • Is the antibiotic choice and duration appropriate for the suspected or confirmed infection?
    • Are pharmacokinetic drug levels (vancomycin, aminoglycosides) therapeutic?
    • Is VTE and stress ulcer prophylaxis appropriate?
    • Are there any significant drug-drug interactions or therapeutic duplications?
    • Is the patient on the most cost-effective agent available on formulary?
  3. Document Your Proposed Interventions: Keep a concise, organized list of your talking points for each patient. When that patient is presented on rounds, you’ll be ready.
  4. Speak Up Confidently: When the team gets to the “Plan” for a patient, and you have a contribution, wait for a brief pause and address the attending or resident. State your point clearly and concisely.
Rounding Pro-Tip: The “One-Liner” Intervention

Physicians on rounds are processing immense amounts of information and value brevity. You don’t need to use the full SBAR framework for every contribution. Often, a concise, confident “one-liner” is most effective. Frame your recommendations as clear, actionable statements.

Instead of a long explanation, try:

  • “I recommend we switch Mrs. Davis’s levofloxacin to PO today; she meets criteria and has great bioavailability.”
  • “We should check a trough on Mr. Smith’s vancomycin this morning before the fourth dose.”
  • “Just a reminder that the patient is on a statin, so we should avoid ordering clarithromycin for his pneumonia.”

This direct approach shows confidence, respects the team’s time, and delivers the critical information efficiently. It signals that you have already done the assessment and are presenting the conclusion.