A New Service, a Public Challenge, and a Resident Arriving in Eight Weeks
You are 8 months into a newly created ambulatory clinical pharmacist role at a 12-provider primary care practice. Your diabetes service receives about 6 referrals a month, visits are documented incident-to physician billing, and there is no dedicated pharmacist billing code in place. In three weeks you must present a business case for the role to medical group leadership. Separately, at a multidisciplinary huddle, a senior physician dismissed your recommendation to deintensify therapy for a frail 84-year-old with an A1c of 6.2% on glipizide and basal insulin, saying "the number is good, leave it alone," and the patient's daughter has since called the clinic questioning your competence. The residency program has also asked you to precept a PGY1 resident beginning in two months.
1. How do you handle the conflict with the senior physician and the family's concerns?
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Separate the three audiences: the physician, the family, and the record.
With the physician - privately, not in the huddle. Open on shared ground: the A1c is at goal, and the question is whether the regimen is safe for this patient, not whether the number is good. Bring the specifics: an 84-year-old with frailty on a sulfonylurea plus insulin is at high hypoglycemia risk, and guidelines call for less stringent targets (roughly A1c <8%) in limited life expectancy or high treatment burden. Offer a shared plan rather than a verdict - reduce glipizide first rather than stopping insulin, with a monitoring plan. Ask directly what his concern is; it may be fear of losing control or a past bad experience with deintensification.
With the family - respond promptly, and involve the physician. A call about competence is a trust problem, not a knowledge problem. Call back the same day, listen, explain the reasoning in plain language, and - critically - present a unified plan with the physician rather than appearing to be overruled or to be overriding.
In the record - document the clinical reasoning and the discussion. If genuine disagreement persists and the patient remains at risk, use the practice's usual peer channels rather than escalating publicly. Reserve formal escalation for an actual safety threat.
2. What belongs in the business case presented to leadership?
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Leadership is deciding whether to keep funding a role, so lead with the decision, not with the model of care.
Structure:
- The ask, stated in one sentence - e.g., continuation of the FTE plus a defined expansion, with a specific resource request.
- Baseline data - 6 referrals/month, panel size, mean A1c change among referred patients, completed visit volume, no-show rate, and the dollar value of the current billing (incident-to) versus a fully billed model. Six referrals a month is close to the threshold where the role is hard to defend; state that plainly.
- Where the growth comes from - protocolized referral triggers, expansion into anticoagulation or heart failure, and internal referrals replacing waiting for physicians to remember. Quantify the assumption and label it an assumption.
- Financial model - revenue per visit under incident-to and under chronic care management or transitional care management, cost avoidance per avoided hypoglycemia ED visit or heart-failure admission (cite the local cost, not a national average), and a three-year view with break-even stated honestly.
- Quality alignment - which payer contract measures this role moves; tie it to the same metrics leadership already reports.
- Risks and mitigations - physician adoption, documentation and billing compliance, staffing coverage.
Bring one page of data and one page of the ask. Expect "what happens if we don't fund it" - have that answer ready.
3. How do you structure the PGY1 rotation given your service is still being built?
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Do not hide the instability - use it. A service under construction is a better learning environment than a polished one, provided the boundaries are explicit.
Before day one:
- Write rotation goals in the language of entrustable activities: independently run a diabetes visit, perform a complete medication history and reconciliation, identify and resolve a drug-related problem, present a patient in 3 minutes.
- Agree with the residency program on what the resident may do unsupervised versus with direct observation, mapped to your collaborative practice agreement - the resident cannot titrate under your CPA unless the agreement and state law permit it.
- Align the resident's longitudinal project with a real practice need (for example, building the referral-trigger report), so the work is useful even if the resident leaves.
During:
- Protect scheduled teaching time; a resident who only watches refill work learns refill work. Give graded responsibility - observe, then co-visit, then independently see patients with you available.
- Give feedback weekly and in writing; huddle for 5 minutes at the end of each clinic day.
- Be explicit that the business case and the conflict with the physician are not the resident's problems to solve; shielding them from politics is part of the preceptor role.
Evaluate honestly against the stated goals and be willing to say a resident is not yet ready for independent visits.