Issue Date: Nov 21, 2005

By Carla Cantor

Students in their final year at Rutgers’ Ernest Mario School of Pharmacy who hope to someday work in clinical care don’t have to travel very far to apply the lessons of the classroom to the needs of patients.

They are getting training in the real world of family health at the Eric B. Chandler Health Center, an outpatient center on George Street in New Brunswick. The center, affiliated with the Robert Wood Johnson Medical School, provides health care to families in the greater New Brunswick area, regardless of their ability to pay.

The relationship between the center and pharmacy school program began just over a year ago with a grant from Johnson & Johnson to fund a full-time clinical pharmacy faculty member at the clinic. Enid Morales, a clinical associate professor at the pharmacy school, signed on in October 2004. She provides clinical services at the Chandler center and at the Robert Wood Johnson Medical School’s Thrombosis Center of New Jersey, another site where pharmacy students on clinical rotations can get real-life experience.

“What is unique about the program is that students get exposed to the barriers that affect health care and medication compliance in underserved populations. The clinic experience is an eye opener; they learn to deal with so many different situations,” says Morales, who mentors students at the Chandler center three days a week.

The center averages about 33,000 patient visits per year and the patient population is diverse – 40 percent Hispanic, 37 percent African-American and 18 percent Caucasian. About 50 percent are Medicaid recipients. A significant portion of patients have chronic illnesses, such as hypertension, diabetes, heart disease, asthma and HIV/AIDS.

Morales, who is fluent in Spanish and lectures on the topic of pharmaceutical care for underserved populations, was a natural choice to serve as the program’s coordinator. She grew up in Puerto Rico, earned her bachelor’s of science at the University of Puerto Rico School of Pharmacy and came to the United States to pursue a Pharm.D. degree at the University of Maryland. After completing a residency in internal medicine at the Medical University of South Carolina in Charleston, she joined the Rutgers faculty in 1991.

Morales attributes her career choice to the summers she worked in her uncle’s community pharmacy. “I’ve always liked science. At one time,” she says, “I thought about becoming a physician.” She decided to pursue a career in pharmacy after discovering the variety of professional options and practice settings the profession offers.

The pharmacy school’s six-year program, leading to a Pharm.D. degree, requires that students spend their last year in nine rotations of five-week clerkships, which may include work at hospitals, pharmacies, community health centers or industry. Students who wish to practice in an ambulatory care setting can apply for a clerkship at the Chandler center, where they work in internal medicine with adult patients. The center accepts two students – chosen via a school lottery – per five-week rotation; 14 students have trained since the program began.

Students participate in the day-to-day therapeutic decision process with physicians, nurses, social workers and nutritionists. They begin by logging medications and researching drug interactions; later, they monitor and adjust medications and help patients navigate the complex maze of insurance plans and patient assistance programs.

Dr. Eric Jahn, medical director for 11 of his 13 years with the clinic, says that at the same time that the rotation expands the clinical teaching abilities of the pharmacy school, it also extends the programs the clinic can offer patients. The clinic does not have a pharmacy, he says, and Professor Morales and her students are an integral part of a team.

Disease management has become complex. “More and more, the therapies we offer require chronic disease management,” Jahn says. “The amount of medicine we recommend for conditions, such as diabetes, HIV or ADD in kids keeps expanding exponentially. A clinician alone cannot handle this – it takes a pharmacist to be part of a team just as nurses, social workers and nutritionists are.” Morales’ students even put together a newsletter for nurses and house staff that announces updates and highlights issues that come up in the pharmaceutical arena. “This has led to better patient care,” Jahn says.

Students who work at the center learn important lessons about barriers to health care that result from socioeconomic or cultural differences. Many, though not all, of the patients struggle with issues of general literacy and health literacy, as well as language deficits and culturally entrenched values and health beliefs that may conflict with “good medicine.”

“I tell students that they must be respectful and sensitive, and not to stereotype. It is important that they try to understand the health beliefs of each patient,” Morales says. “Patients are very grateful to the student interns,” she adds. “The big question in pharmaceutical care is how do you keep therapy going? Relationships can be the key to compliance.”

She recounts an example of an African-American patient in his early 60s with type II diabetes who refused to go on insulin. “He was very upset and absolutely unwilling to inject himself,” Morales says. Once he calmed down and discussed his reasoning, it became clear that he equated insulin with a prescription to die.

“He had seen relatives and a good friend of his mother’s [who had had long-term complications from diabetes] prescribed insulin, and die shortly thereafter. His belief was important to understand: ‘Everyone I know who takes insulin dies.’” Eventually, he realized that it was lack of treatment that made these people die, not the insulin, and he agreed to take the drug.

Hasham Khawaja completed his rotation at the Chandler center in May and is now finishing up the last of his rotations. The three years of Spanish he had taken in high school proved helpful at the clinic.

“One of the most important things I learned is to educate patients about their disease and the need to stick to their therapies,” Khawaja says. “It was the best educational experience I’ve had so far. It is one thing to hear about cases in lectures, it is another to see – and actually help – the real person.”

John Colaizzi, dean of the pharmacy school, believes that the Chandler program presents an excellent model of team effort. “This is a fine example of a productive collaboration between Rutgers and Robert Wood Johnson Medical School faculty that benefits patients, the city of New Brunswick and our pharmacy students. It also fosters a team approach to the delivery of modern health care. We are grateful to J&J for their support,” which, Colaizzi says, catalyzed the initiative.

This article was published in the Nov 21, 2005 edition of the Rutgers Focus and is available online at http://urwebsrv.rutgers.edu/focus/article/link/1696/