CHPPC Module 32, Section 1.1: Reading the Room
MODULE 32: FORMULARY, NON-FORMULARY & THERAPEUTIC INTERCHANGE—WITHOUT FRICTION

Section 32.1: Reading the Room: Attending Preference vs. Policy

A masterclass in clinical diplomacy and navigating the human element of formulary management.

SECTION 32.1

Reading the Room: Attending Preference vs. Policy

The art of clinical diplomacy and navigating the human element of formulary management.

32.1.1 The “Why”: The Formulary is a Social Contract, Not a Law

This may be the most important, and initially counterintuitive, concept to master in your transition to hospital practice. In retail, the formulary is largely a rigid, external force dictated by insurance companies. It is a “law” enforced by a third party, and your role is to help the patient and prescriber navigate its unforgiving rules. In the hospital, the dynamic is profoundly different. The formulary is an internal creation, a carefully curated list of medications selected by a committee of the hospital’s own physicians, pharmacists, and nurses—the Pharmacy & Therapeutics (P&T) Committee. It is not a law handed down from on high; it is a social contract. It is a collective agreement among the medical staff that says, “Based on the best available evidence for safety, efficacy, and cost, these are the agents we agree to use as our first-line choices to provide the best possible care for our patients.”

Because it is a social contract, it relies on trust, communication, and mutual respect for its enforcement. The attending physician, as the ultimate clinical decision-maker for their patient, retains the professional autonomy to deviate from that contract when they believe it is in the patient’s best interest. This creates the central tension of your daily practice: balancing your duty to uphold the evidence-based, cost-effective principles of the formulary with your professional obligation to respect the clinical judgment of the prescriber. Your success in this role is not measured by how many times you “win” an argument and force a change. It is measured by your ability to navigate this tension without friction—to make the right thing for the institution (formulary adherence) the easiest and most attractive thing for the provider, and to handle deviations with grace and professionalism.

This is not a battle of wills. It is a nuanced negotiation. Approaching a seasoned attending physician with a rigid, policy-driven demand like, “You can’t use that, it’s non-formulary,” is a recipe for conflict and will instantly damage your credibility. Your role is to be a consultant, an educator, and a diplomat. You must learn to “read the room”—to understand the motivations, preferences, and communication style of the prescriber in front of you—and tailor your approach accordingly. This section will provide the masterclass in that art, teaching you how to move beyond being a formulary police officer and become a trusted formulary advisor.

Retail Pharmacist Analogy: The “Special Order” Negotiation

A long-time, valued customer comes into your pharmacy and wants to buy a very specific, obscure, and expensive brand of vitamin C that you don’t carry. You have your store brand on the shelf, which you know is therapeutically identical, has been quality-tested, and is half the price. This is your “formulary.”

How do you handle this? You “read the room.” You don’t start by saying, “No, we don’t have that. You should buy my store brand instead.” That’s confrontational. You start with diplomacy and investigation.

  • The Approach: “Thanks for coming in! I see you’re looking for Brand X. We don’t typically stock that one, but I’d be happy to see if I can special order it for you. Out of curiosity, what is it about that particular brand that you like?”
  • The Triage: The customer’s answer tells you everything you need to know about their motivation.
    • If they say, “My doctor told me to get this exact brand,” you know this is about trust in the prescriber. Your best tactic is to offer to call the doctor to clarify if a substitution is acceptable.
    • If they say, “It’s the only one that doesn’t upset my stomach,” you know this is about a perceived side effect. Your tactic is to compare the inactive ingredients and suggest your formulary brand if it’s formulated differently.
    • If they say, “I just read online that it’s the best,” you know this is about external information. Your tactic is to gently educate, comparing the active ingredients and showing them the value of your trusted store brand.
    • If they say, “I’ve just been using it for 20 years and I trust it,” you know this is about habit and comfort. For a valued customer, the best relationship-building move might be to simply say, “I understand completely. Let me order it for you; it should be here tomorrow.” You’ve honored their preference and strengthened their loyalty.

Each of these scenarios requires a different communication strategy, even though the underlying issue (non-formulary request) is the same. This is the exact skill you will use when navigating attending preferences. Your first step is not to state the policy; it is to understand the “why” behind their request.

32.1.2 The Art of Reconnaissance: Know Your Players and Their Preferences

Before you can effectively “read the room,” you need a map of the room’s occupants. In a hospital, prescribers are not a monolithic group. They are individuals with unique training backgrounds, levels of experience, clinical specialties, and personalities. A significant part of your job in your first few months is to become a clinical anthropologist—to observe, listen, and build a mental database of the key prescribers on your units. Understanding their archetypes will allow you to anticipate their prescribing habits and tailor your formulary recommendations before a conflict even arises.

This proactive “reconnaissance” is a force multiplier. Knowing that Dr. Adams always prefers levofloxacin for community-acquired pneumonia, even though the hospital guideline recommends ceftriaxone/azithromycin, allows you to prepare your talking points in advance. When you see her admission orders, you are not surprised; you are prepared. You can approach her with a recommendation that is already tailored to her likely perspective, dramatically increasing your chance of success.

Masterclass Table: Common Prescriber Archetypes and Formulary Strategies
Archetype Defining Characteristics & Likely Preferences The “Reading the Room” Tactic
The “Old Guard” Attending
(The Veteran)		 Decades of experience; highly respected. Tends to be skeptical of new, expensive drugs. Relies on personal experience and “what has always worked.” Prefers older, familiar medications (e.g., cimetidine over famotidine, glyburide over glipizide). Approach with Deference & Safety. Acknowledge their vast experience. Frame your recommendation around new safety data or institutional guidelines they may not have seen. Script: “Dr. Miller, I see you ordered cimetidine. I know it’s a great drug. I just wanted to give you a heads-up that our hospital protocol switched to famotidine a while back, mainly because of all the drug interactions with cimetidine we were seeing. Would it be okay if we swapped to famotidine for this patient to avoid any issues?”
The “Academic” Attending
(The Innovator)		 Often younger, recently out of fellowship. Eager to use the newest agents based on the latest clinical trials. Most likely to order non-formulary medications because they used them at their training institution. Highly evidence-driven. Engage on the Evidence. This is your chance to have a high-level clinical discussion. Acknowledge the trial data they are referencing but be prepared to discuss the P&T committee’s rationale for its formulary decision (e.g., marginal benefit for a massive cost increase, safety concerns in a broader population). Script: “Dr. Chen, that’s a great point about [New Drug]. We looked at the PIONEER-3 trial when we reviewed it for formulary. The committee felt the 0.2% additional A1c reduction didn’t justify the $500/month cost compared to our formulary [Alternative]. For this inpatient stay, would the formulary agent be an acceptable bridge?”
The “Pragmatist” Hospitalist
(The Workhorse)		 Manages a large volume of patients. Values efficiency, clear protocols, and minimizing callbacks. Is generally your biggest ally and most compliant with formulary policies because it makes their life easier. Reinforce the System. This is the easiest conversation. Frame your intervention as helping them adhere to the agreed-upon hospital policy. Make it easy for them. Script: “Hi Dr. Smith, just calling about the PPI order for the new admission. Per our automatic therapeutic interchange protocol, I’ll be swapping the ordered esomeprazole to our formulary pantoprazole IV. Just wanted to let you know. Thanks!” (Often, this doesn’t even require a call, just a notification in the EHR).
The “Specialist”
(The Focused Expert)		 An expert in a narrow field (e.g., Infectious Diseases, Hematology/Oncology, Transplant). They often have very specific, evidence-based reasons for needing non-formulary agents for their complex patients. They are often the ones who write the guidelines, not just follow them. Collaborate and Clarify. Do not challenge their clinical judgment in their area of expertise. Instead, seek to understand and facilitate. Your role is often logistical. Script: “Hi Dr. Rodriguez, this is pharmacy. I see your note about wanting to use ceftazidime/avibactam for this patient. I completely agree based on the cultures. It is non-formulary, so it requires a non-formulary request form for approval. Can I help you fill that out? I just need you to document why the formulary alternatives aren’t appropriate.”

32.1.3 The Hierarchy of Evidence vs. The Hierarchy of the Hospital

As a pharmacist, you are trained to live at the top of the evidence-pyramid. Your recommendations are built upon a foundation of randomized controlled trials, meta-analyses, and evidence-based guidelines. You bring the data. However, you will quickly discover that the hospital operates on a second, unwritten hierarchy: the social and professional hierarchy. In this structure, the attending physician is at the top. This creates the most challenging dynamic of your job: a direct conflict between the hierarchy of evidence and the hierarchy of the hospital.

You can present a stack of papers from the New England Journal of Medicine showing that the formulary proton-pump inhibitor (PPI) is equivalent to the non-formulary one. The “Old Guard” attending can look at you and say, “In my 30 years of experience, esomeprazole works better for my sick GI bleed patients, and that’s what I am using.” In that moment, their Level V evidence (expert opinion) will trump your Level I evidence (RCT data). Trying to force the issue in that moment is a battle you will likely lose, and it will cost you “political capital.” The art is learning to cede the battle to win the war.

The Critical Distinction: Preference vs. Safety

This entire section on diplomacy and reading the room applies only to issues of preference, cost, or marginal efficacy differences. There is a hard red line where diplomacy ends and your duty as a patient advocate begins. If a prescriber’s preference results in a request that is actively unsafe, you must hold the line. There is no negotiation on safety.

  • Safety Issue: An order for ceftriaxone in a neonate (risk of biliary sludging).
  • Preference Issue: An order for ceftriaxone instead of the formulary cefazolin for surgical prophylaxis.
  • Safety Issue: An order for quetiapine in a patient with a known QTc of 550 msec.
  • Preference Issue: An order for quetiapine instead of the formulary olanzapine for agitation.

In a preference debate, your goal is to influence and educate. In a safety debate, your goal is to prevent harm, and this is where you must be willing to use the formal chain of command, escalating your concern to your pharmacy manager and the physician’s department chief if necessary.

The “Planting the Seed” Strategy

When faced with a preference-based disagreement you cannot win at the bedside, your goal should shift from immediate conversion to long-term education. You plant a seed of evidence that may influence future decisions.

From Confrontation to Conversation: The Socratic Method

Instead of making declarations, ask clarifying questions. This is less confrontational and forces the other person to articulate their clinical reasoning, which can sometimes reveal a knowledge gap or an outdated practice pattern.

  • Instead of saying: “You should use pantoprazole. It’s the formulary.”
  • Try asking: “I see you ordered esomeprazole. Is there a specific reason you prefer it over our formulary pantoprazole for this patient?”
  • Instead of saying: “All the data shows there’s no difference between the PPIs.”
  • Try asking: “That’s interesting that you’ve had better success with esomeprazole. I was just reading the new ACG guidelines for GI bleeds, and they actually state that no specific PPI is superior. Have you had a chance to see those yet? I can send you the link.”

This approach transforms a potential argument into an academic discussion. You are now two clinicians discussing evidence, not a pharmacist telling a doctor what to do. Even if they don’t change their mind today, you have planted the seed. You have positioned yourself as a knowledgeable, evidence-based resource. The next time they have a question, they will be more likely to seek you out proactively.