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Pharmacy Leaders Podcast: Inspiring Pharmacy Leadership Interviews

May 2, 2018

Pam Tarlow, PharmD, is a nationally known expert in the field of integrative pharmacy.  Dr. Tarlow’s clinical practice began in 1981 and now involves recommending pharmaceuticals, botanical, homeopathic and nutritional agents to clinicians and counseling patients on their safe and effective use. She is an experiential educator for many pharmacy schools and teaches part of the Self-Care course at USC. She is on the faculty of the Healthy Aging Program at Yo San University of Traditional Chinese Medicine. She works as a clinical pharmacist at Santa Monica Homeopathic Pharmacy and Cedars-Sinai Medical Network Integrative Health program.

Full Transcript:

welcome to the pharmacy leaders podcast
with your host Tony Guerra the pharmacy
leaders podcast is a member of the
pharmacy podcast network with interviews
and advice on building your professional
network brand and a purposeful second
income from students residents and
innovative professionals welcome to
pharmacy leaders podcast I am Tony
Guerra Han I was just in a carrier chat
about an hour and a half ago so this is
really cool that I'm going to be talking
to another pharmacist who is in a
physician's office at least one day a
week but pam carlo pharmd is a
nationally known expert in the field of
integrative pharmacy she's her clinical
practice began in 81 and now revolves
involved recommending pharmaceuticals
botanical homeopathic and nutritional
agents to clinicians and counseling
patients on their safe and effective use
she's an experiential educator for many
pharmacy schools and teaches part of the
self-care course at Southern Cal she's
on faculty of the healthy aging program
at US and university of traditional
Chinese medicine
and she works as a clinical pharmacist
mostly non dispensing at Santa Monica
homeopathic pharmacy and cedars-sinai
medical network integrative health
program welcome to the pharmacy leaders
podcast thank you being here well I
I think the one thing that I keep
hearing over and over again from the
audience is that they want to know about
opportunities that are outside the
traditional and this is about as outside
as it goes without actually switching
professions so let's first hear about
the traditional part of your role which
isn't really that traditional the four
days a week you spend in quotation
fingers retail pharmacy yes well it
actually is a retail and I'm the
pharmacist in charge and do all the
things that any other pharmacists in
charge would do at a retail pharmacy
independent though my prescription
volume is extremely low and one of the
reasons my prescription volume is low is
we don't take any insurance plans and
we've also decided not to do compounding
here we investigated it for a while
because I have a lot of experience
compounding pharmacy but we just allow
our customers our patients to go to
other pharmacies that specialize in
dispensing so I guess tell me a little
bit about someone this is kind of the
dream that you know it's cash only
it's kind of like being a veterinarian
where you know there's no insurance it's
just here you go this is the cash and we
just took our dog in for something and
she needed something for her ears and
this is the lab test that we did and
that's how much that cost and this is
the medicine and that's how much that
costs and it's you know it's under a
hundred bucks or whatever it was so tell
me a little bit about how you go into a
model where you don't worry about
insurance I wish I could tell you
because maybe it would be helpful for
you and for the listeners to know that
this is a very unique situation this is
a one-of-a-kind family business that's
been in Santa Monica for 74 years and it
was started by a pharmacist and his wife
and the family still owns it and good
fortune for me is that none of the kids
or the grandkids became pharmacist so
they they hired me and so it's a model
that grew really from this when Santa
Monica was a small community and the
reputation really speaks for itself and
so customers patients from all over the
country even all over the world and
practitioners have come to rely on us
and so we don't do a lot of marketing
because a lot of people come to us so I
don't know how you build a pharmacy like
this except that it's very very based on
principles and the desire to know the
most about both pharmaceuticals and
natural medicine and to serve the public
including serving clinicians well I
don't want to call Santa Monica a small
town but it's it's it still probably got
less than a hundred thousand so it's
smaller than the Des Moines metro
although you're bordered by Los Angeles
but tell me a little bit more about how
pharmacy is practiced in California or
some of the things that you can do or
some of the relationships that you have
in terms of natural medicine versus
maybe the allopathic medicine I don't
know that it's any different than
anywhere else
there's no as far as I know there's no
state laws in California that differ now
the subject that we'd have to talk about
it another time would be hemp oil and
that's a that's a whole different story
but we have started it to investigate
that but there's of course a clear
relationship between what a prescription
drug is what an OTC drug and what a
dietary supplement they're regulated by
the FDA in different ways and that's
also my job here is to make sure that we
don't cross any lines and that we follow
the laws on that so with dietary
supplements possibly this is what you're
asking too is that there's no medical
claims they're not approved for any
disease or condition and they all have
to have the disclaimer that they can't
cure or treat any condition right I
guess my my concern with pharmacy
schools is that so if you were to take
you know a percentage you know one of
those pie charts and put you know how
much we learn about medicines that are
you know prescribed FDA approved how
much we learn about herbals and how much
we learn about you know pharmaceuticals
and things like so homeopathic and
nutritional agents it would be a very
tiny sliver if we went to botanical
homeopathic and nutritional so could you
tell us a little bit about how you maybe
counsel patients and talk to patients or
recommend those types of medicines sure
sure yes yes most of the schools of
pharmacy that do give some information
on this do it in their self-care class
and various number of hours are spent on
that for Ann one example would be
melatonin melatonin is a dietary
supplement and that a lot of allopathic
practitioners are comfortable with and
so what my practice
has evolved I didn't go to any formal
school to learn this so the way it even
started is in the pharmacy I was
previously working at in a very in uh in
Los Angeles area my patients would come
to me and say is this herb good for this
or I heard that taking ginseng would
give me energy will it and will it
interact with my drugs and I didn't know
I had never been trained but I like to
be the expert so started studying it and
over the years that's evolved into
getting an idea of what might be harmful
for somebody what might be helpful but
it always starts with communication in
learning how to listen to the patient
and find out what they're interested in
because in some cases at least in Los
Angeles the physician will suggest a
botanical black cohosh is often
suggested glucosamine as a nutraceutical
will be suggested melatonin coenzyme q10
it's the doctor that's suggesting it and
so I like to know that right up front
because then I can be a regular
pharmacist in that I take it I find out
what the patient's taking and I support
them in following the prescribers orders
okay well that's your your regular day
the the four days a week tell me a
little bit about what it is to work in
as a clinical pharmacist in a
physician's office that seems to be the
dream of many of the new graduates that
they'll be spending five days a week in
a physician's office working hand in
hand tell me about your one day a week
in a physician's office and that's
relatively new and that's an evolving
process so this is a quite progressive
office that has asked for a clinical
pharmacist in their practice and
currently we have one MD and one ND
naturopath naturopaths have licenses in
California I know they don't in a lot of
states and we also have a nutritionist
and hope to grow that practice and my
primary responsibilities there is to do
the initial medication reconciliation on
the electronic medical record so for
example if a patient is going to see the
or the naturopath I would have a phone
conversation with them much like an MT M
though I would get all of not only all
their medications but all their dietary
supplements their homeopathics
alternative treatments most of which I'm
somewhat familiar with which really puts
the patient at ease if I've heard of a
lot of the things they're doing even if
I don't agree with them I've at least
heard of them and then I make sure the
medical record is accurate and prepare
some recommendations for the physician
or the naturopath before they see the
patient and how does that work what what
day of the week do you go over there
does it vary I guess I just I want to
know how it works in the in the workflow
because it's just so foreign to me I'm
graduated 20 years ago and I might
practice and it would really change much
I just you know traditional retail
pharmacist until I started teaching so I
don't know much about being in a
physician's office that's completely
foreign to me and it was my first
exposure to actually after being a
pharmacist for 30-something years 35
years is the first time I learned how to
use an electronic medical record okay
and so I Tony I think we're gonna have
to do this interview again in six months
or a year and I'll have more to tell you
because this is a very new model and so
it's evolving and so they do try to
schedule those phone appointments on the
day that I'm there it's a fixed day
obviously because I have another job and
so and often I am able to do that when
I'm not able to do that in additional
medication reconciliation then the next
time I go in that we are the next week
I'll have a little conference with the
doctor and we can go over what the
patient told them and any particular
interactions I'm concerned with or in my
case working at the pharmacy I know a
lot of products so they may be aware of
two or three magnesium products and I
know about 15 that I'm very familiar
with and I might say mmm they have this
reaction to this what did you consider
this or that
okay well let's let's then talk about
what an AP PE student would do
you're actually a national there are a
few of these where it's a national setup
where you know something like Johns
Hopkins people from all over the country
will apply to to do rotations there and
same thing with other places and and
this happens with very specialized
groups or specialty pharmacies and you
certainly have a specialty in terms of
the naturopathic homeopathic nutritional
agents things like that so tell me a
little bit about what an AP PE student
would do day to day on the pharmacy side
and then maybe some of the things that
are just very different from what they
would do at a traditional ap PE okay
sure I'm happy to and they do very
little on the pharmacy side it's a
requirement a prerequisite to come to
this rotation that they've had some
dispensing experience because they don't
dispense here they also don't do very
much patient consultation in the way
that I do it because they don't know the
natural products they don't come in here
knowing that but they do know is the
drugs and it's really fun because the
way we start out our rotation first week
is I try to demonstrate to them that
what they know about Pharmacy gives them
about three quarters of what they need
to know about natural medicines so then
what what gaps are you filling is it
kind of a weak one this is how we start
off and then by week five where do you
expect them to be or six weeks depending
on you know the school that you're
taking it yeah it's a six-week rotation
Antoni that really varies because some
students are more self-learners and some
need their hand held a lot and
unfortunately in this rotation I can't
really hold their hand because I'm
working almost the whole time but they
can definitely shadow me and we do a lot
with Google Docs so I will listen I
they'll do write-ups for during the day
and then I'll comment in the evening but
and they what they were a lot of what
they do for me and for us at the store
is they check drug herb interactions or
drug nutrient
actions or they will sometimes write
down all the drugs that the patients are
taking and then I have them do a classic
MTM for a lot of the we call them
customers here when we don't fill their
prescriptions but for a lot of our
clients I will have them do that and
then for example if I can just give you
it for example today we have a
naturopath on staff here and she asked
whether a patient on tamoxifen can take
black cohosh and whether there's any sip
interactions with black cohosh and I
usually know that answer but things
change so I had them look that up and
report that and we're gonna have an an
ongoing conversation about that because
I supplied them with several different
studies which are controversial some say
yes some say no and okay so they do they
definitely do that they also help me
with my research projects I'm working on
now a class for Yas on the doctorate
program for acupuncturist and we're
working on a healthy aging lecture so
I'm having them look up what nutritional
what what is known about nutrition and
okay well that's segues really well tell
us a little bit about what first of all
in traditional Chinese medicine
university is and then what your role is
in that university great I'd be happy to
and there may be a little story to go
with it but traditional Chinese medicine
is a system of medicine that's been
around for thousands of years and these
schools like the one I actually involved
with two of them they are the schooling
that acupuncturist go to the most
acupuncture schools are for years
much like pharmacy school and it's
full-time and they being again usually
their degree is a masters and
acupuncture or a master's in oriental
medicine and then at least in California
they sit for boards like we do and then
they become licensed acupuncturist and
herbalist PERTs I had no idea was that
long it is that long it absolutely is
and in California their scope of
practice is as primary care so they can
diabetes and high blood pressure
according to their scope of practice and
many insurance plans will reimburse for
some of this Wow and it's a totally
different model I'm happy to come back
and talk to you about a pharmacist view
of traditional Chinese medicine both as
a pharmacist who works with those herbs
and as a pharmacist who was treated by
an acupuncturist whose whole health
trajectory improved by going to an
acupuncturist twenty-five years ago no
even though I was skeptical and said I
wouldn't buy anything yeah no I and I
think that that happens a lot were where
we're afraid to try what we don't know
and then we finally hear somebody had
success story and then maybe that
success story will help other people but
I do want to know more about how you you
mentioned that you'd listen to one of
the podcast episodes I talked to an
author that was in Bath England
Joanna Penn who really really struggled
with her back pain because she was a
cubicle worker and the traditional
approach did not work and finally was a
combination of yoga some ultramarathons
things like that but tell me a little
bit about how medicine and stress
reduction actually need to go together
and especially with mindfulness because
she alluded to it but she didn't really
fill us in could you fill me on in on
natural and medicine plus mindfulness oh
my goodness that is such a good question
I'm trying to think of how I can do this
easily and cogently just give it your
best shot
well I'll tell you what I'm doing and
it's become a habit is I've just right
now employed a mindfulness technique to
calm my body and calm my mind so that I
can access some of the wise information
let's see how it goes but that has
become a habit in my mindfulness
training and definitely use that when
I'm talking to patients and in the store
in the doctor's office especially those
irritating patients where they say
things or also Tony when they're asked
me a question I don't know the answer
sure I'm a veteran pharmacist when I was
new I had to deal with not knowing but
not knowing can be very stressful no I
agree so there are ways there's a
variety of ways to calm the mind or calm
the body and it's kind of contagious
when I have an agitated patient or a
family member the things that I do to
calm myself they can model you find it
if you take a deep breath the person
you're talking to will also take a deep
so yes yeah and it takes some training
so I guess the area I want to go is
because our emotions impact our
physiology and in a lot of drug
it goes beyond physiology it takes over
our physiology but in many cases like
for insomnia or depression or anxiety or
even hormone balance our cortisol levels
and adrenalin norepinephrine and
epinephrine make an impact they also can
affect how we think so using some
appropriate or mindfulness techniques or
one that we resonate with can really
help because we know that lowering
stress hormones can help across the
board I talked to a physician author a
couple weeks ago and he had a story
about a patient who was asked the
question why me and he wasn't asking he
was going to lose his leg as a diabetic
and the physician had no answer for that
and so ended up bringing the chaplain
but it was the chaplain and answering
those questions and bringing that
mindfulness and kind of bringing a piece
to him that then he started taking his
medicines and then he started
cooperating with the staff and then
things started getting better for him
but it sometimes has very little to do
you can't do medicine first all the time
I guess is what I'm saying it sounds
like you you have to kind of be in a
good place and that sounds like you you
have some techniques
actually getting to that good place yes
I think there's many cases that's true
and there's probably a thousand
different situations I've been in that
other times Tony and here's why I'm an
advocate for pharmacists other times it
doesn't matter how you feel you check
your your blood sugar level you take the
insulin and we have been very sometimes
we get very stern with people and also
when I work in the doctor's office
people don't want to take their medicine
Michael please do it if you've got heart
arrhythmias or you have clotting risks
or you're on chemo please take your
medication we'll support you in other
ways but medication needs to be taken
and the person at the health food store
may not be able to give that kind of
direction to their client yeah I there's
one question I did want to ask them
where we're kind of getting towards the
the 25-minute mark which is where you
know most of our commuters well this
isn't an LA commute this is a regular
commute a regular commute but um the one
thing I wanted to talk about is a PHA a
SP so the the student pharmacists have
kind of brought on this sixth initiative
on their own which is self care of
themselves and that although they're
being students although they're working
hard I feel like the student now and the
students that we were maybe 20 30 years
ago didn't have as many side jobs didn't
have as many side responsibilities or
side distractions and they really and
then in addition you know I paid I think
it was four thousand dollars a year for
college so that the cost was
tremendously different as well what
recommendations would you have in terms
of self care for the student pharmacist
oh that is such a good question the
students that we have here have enormous
loans and job market is not so good in
Southern California some of them are
married and with children also so I can
tell you what I do here every AP PE
student that comes here has a chance
where our students are now they're
actually going to it might
this meditation session a free one at
UCLA time to do that on Thursdays and on
Wednesdays they go to the world-famous
Santa Monica farmers market to actually
touch taste the foods and talk to the
farmers so all those are stress reducing
that to learn a way to calm the emotions
and also to be in touch with nature I
find are very very helpful but there are
vitamins minerals botanicals
nutriceuticals a lot of different things
that can help
I prefer that someone that a student
would talk to somebody that knows the
range and also knows their situation if
a woman is on birth control pills we
don't want her taking Saint John's work
etc and so possibly a health coach the
other thing to say I know they have it
at some of the Southern California
schools is the department of
occupational therapy will sometimes
provide free consultations to students
and that is what occupational therapists
do they help you with it whatever you
fill up your time with and if you're a
busy student they can sometimes help
with work habits and stress reduction
yeah I never thought and we talk so much
about interprofessional and when we hear
about interprofessional we think of
these mass casualty scenarios or this
emergent you know we're in the ER what's
the nurse do what's the doctor do what's
the pharmacist do but something as
simple as when you know occupational
therapists can help you you know have a
satisfying day and not you know I don't
say hurt yourself but but that's not the
right word but but just really take care
of yourself as you're going through the
day and recognize when you need to take
breaks so that's a really good
recommendation too to kind of connect
those two schools well I've asked you a
ton of questions is there anything I
haven't asked you about that you want to
talk about will definitely have you back
in a couple of months to talk about the
the progression of your practice within
a physician's office but is there
anything you'd want to talk
wanted to say that I didn't ask about I
think so I think there's just one thing
and that I want to make sure everyone
knows the nice lecture or I start a
rotation I always emphasize that for me
now it's not an either/or it's not
pharmaceutical medicine or
non-pharmaceutical it was at the
beginning but now it's all up really an
integration in for this particular
patient at this particular time with
their beliefs their drugs and now even
their genes I'm getting quite involved
in pharmacogenomics and their what they
can afford and what they're willing to
do what might be the best approach for
them and the so it's I'm never against
I'm just for whatever is best there's
risk to benefit on everything and to us
I really enjoy assessing that and
teaching people how to assess that
that's amazing all right well thanks so
much for being on the pharmacy leaders
podcast thank you bye support for this
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