Dr. Rabia Atayee got a head start. "After working in the lab as a high school student for two summers, I thought, 'I need to talk to people, and do things more interactive than with my lab colleagues,'” Atayee told ValuePenguin. After completing her pre-pharmacy requirements without getting a bachelor's degree and working as an in-patient pharmacist for an intensive care unit, Atayee became a palliative care specialist in the clinical setting. And now she does it all: splitting her time between her palliative care team and being an associate professor at the University of California-San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. We asked her about her dual careers, her students and what she sees for the future of pharmacy education.
How do you divide your time between your clinical work and teaching?
Yes, it’s definitely busy. I’m a full-time faculty member, but my clinical expertise is in pain and palliative care. So the medical center pays for 40% of my salary. So on paper I’m 40% a clinician and 60% everything else. Some weeks I work 120%, so it does shift around. When I sometimes struggle -- because both jobs would love for you to do 100% on each end -- you really have to ask yourself, "OK, do I like what I’m doing? Can I maintain this?" And obviously my family is a huge part of my life, so, "Am I still getting enough family time, quality time?" The beauty of my job, besides the fact that I have to be at the hospital two days a week, is that there is flexibility. So I can carve a couple of hours to go volunteer at my kids’ school, just to spend that extra quality time with them. And then work nights and weekends if I need to write a paper, or grade exams, or do something else. But it doesn’t have to be during school hours. So I’m able to maintain that. And obviously I have great support -- my husband, and my extended family -- so I'm able to have my cake and eat it too.
The main thing I try to do is I want to have a consistent schedule with the days I’m going to be at the hospital, so everybody knows what days I’m going to be there, and when I can provide services. And I try to make sure that it's somewhere in the middle of the week, so it kind of keeps the momentum going. But even on the days that I’m at the medical center, I can still do some teaching. I have students that do their fourth-year clerkship with me when I’m in the hospital.
My one-day schedule is never the same as the next day. My responsibilities are that I do clinical, I teach, I do research and publish, and then I do the university and national services. So I sit on committees, I write protocols, whether those are local committees, national committees. And even in education, there’s an expectation that obviously you’re going to teach your own students, you’re going to teach other students within your hospital, but you’re also going to provide national education at conferences.
What is your average workday with the palliative care team like these days compared with your previous work on the clinical side?
When I used to be in clinic -- I worked at The Moores Center until about a year ago, doing outpatient palliative care -- I was able to get prescribing authority as a pharmacist in California. So I can write a prescription for a patient. Because in palliative care a lot of the symptom you’re treating is pain, and pain management requires all sorts of meds, but meds that require you to have a prescription and prescribing authority, especially controlled substances: like opioids, like Norco, and Vicodin, other things like that. So on the clinic side I would see patients in the clinic, either by myself or with the team, and it just varied over the years based on our team composition. An integral component of that was if I couldn’t meet with the team, I would see them with a social worker, to really address the psycho-social, spiritual suffering. I as a pharmacist didn’t have all that background and training to do that, but I had the training to assess a patient for physical symptoms, recommend medication and non-medication therapy, prescribe those medications, and then schedule a follow-up to see them. It was based on how severe things were. So if it was somebody really in a lot of pain I would want to see them sooner just to make sure the medications were working; versus a patient who had been stable on their medication regimen, then I’d see them further off. And in the setting of cancer, there’s a lot of different moving parts. They’re getting chemotherapy, so I’d know that they get really nauseous after they get chemotherapy, so let me go visit them in the infusion center while they’re getting chemotherapy, and let me make sure they have all the medications, and they’re aware and know how to use those medications at home after they get their chemo. Or if they just got radiation, at first their pain is going to get worse, but then after a few weeks it’s going to get better, so let me make sure to see them frequently so that we can adjust the medication appropriately for how their symptoms are. And so that’s kind of the outpatient setting. I was able to practice in that for quite a bit. I’ve been with the service for nine years, so eight of the nine years I did clinic at least part of that time I was with the hospital.
Then it just seemed there was this void in the hospital, and there was a lot of medication management that wasn’t optimized or ideal. So I transitioned to being with the inpatient team for two days a week. So what I do now is completely different. I could go see a patient if I needed to, but there’s a lot more people on the inpatient side. So we have medical residents and various other residents and trainees that go and see the patient. As a team, we all look up the patients, maybe go visit them, and then at 9 a.m., we sit down in a room and we go through a multi-disciplinary round: There’s a pharmacist, a physician, a social worker, a nurse practitioner, and these trainees will come in and present the patients they’ve seen. And we’re able to have a discussion about what the best kind of care is. My goal is to make sure that these trainees know how to use the medication, and the pharmacotherapy, and it’s evidence-based medicine, and they’re really using these medications better.
And I really take it upon my role to teach people who are going to be physicians, to take the time to teach them. And I’ve done this for nine years, so I don’t feel shy about telling them how to ask patients questions, how to communicate with patients. One would view that as only a doctor, a physician, a traditional doctor, could teach another doctor, but I don’t feel that. The attending physician on our team might not have time, might not remember to do that. So I’ll stop them and say, “How did that interaction go?” when the trainee asked the question in a way that made the patient feel defensive, or made the patient feel not supported. So my role is really making sure that we’re using medications well, but also training the future physicians and nurses how to use medications properly. And then the bigger issue on the inpatient side is I’ve really been involved with setting protocols, things like medication management and order sets that are going to happen effortlessly when I’m not there.
On campus, what courses do you teach?
Pharmacy school is four years and I teach all four years. And I give lectures, or teach on clerkship sites all four years. But I’m mainly responsible as the main teacher, or the main professor, for two courses. One is in the first year, during the fall quarter, so it’s the first quarter in pharmacy school. And the course is called "Pharmacy Practice." And as the title of the course says, it really introduces them to the practice of pharmacy. Because they’re just so new to everything, we start them out with over-the-counter medication, ones that anybody can just go purchase. We talk about the safety and the efficacy of these medications, and how pharmacists can be involved. And then we also talk about communication skills, and lots of hands-on training. So then it’s really like your pharmacist in the health setting, but also pharmacist in the clinic. So we teach them physical assessment, we teach them how to teach a patient how to do insulin injections, and take the patient’s blood pressure, heart rate, different vital signs. We teach them how to help patients quit smoking. So it’s things that they can do right away. And when we teach them how to do a flu shot, they turn around and give flu shots to all the people at the hospital. So a few months after they learn how to give a flu shot, they’ll be giving a flu shot to me, and the other nurses and physicians at the hospital. So it’s nice for them to be able to apply what they know right away. And then we have them all volunteer at our screen medical clinics. So these are where people who don’t have medical insurance, they can come in and be seen, and the student physicians are going to be helping them manage some conditions without health insurance. And it’s a really big issue, living close to the border, and providing care for people who don’t have insurance or means to get insurance.
The other course that I’m in charge of is in the third year. I really don’t offer this course until the third year, because it’s really high-level, and it’s really focused in palliative care. So I give a core didactic curriculum about pain management, and then I offer an elective course to the pharmacy students to take. And we really focus on a team approach in palliative care: what the pharmacist’s role is, versus the other members, and really a high-level -- a sophisticated level -- of medication therapy. This year, I decided to offer it to our school of medicine, to medical students and pharmacy students together. And really offer the same level of teaching to both of them, but d
o it in a way where I’ll have physicians teaching with me. So really highlighting what each role brings, and how each role can work with other roles. So teaching what you do in the real world, but bringing it into the classroom. It’s a ten-week course, and I have ten different lab lecturers co-lecturing with me, because I wanted to bring in a social worker, and I wanted to bring in a nurse practitioner, and bring another pharmacist, and bring various physicians, to teach the students about care, but also model what a healthcare team looks like.
For your first-year students, is there any sort of sticker shock, or anything about the class that surprises these aspiring pharmacists?
One of the first lectures we do is a physical assessment, assessing blood pressure, vital signs. So we teach them what all of that means, but then we’ll have them take each others’ blood pressure. Right off the bat they’ll say, “Wow!” I had a student this year tell me, “Someone was going to buy me a stethoscope, but I told them, ‘Oh, I’m going to pharmacy school.' And then this one particular student joked, and said, “I’m going to go tell my family member, ‘Yeah, buy me a stethoscope! I will need it!’” So even the ones that choose the profession, work so hard to get into the profession, it’s eye-opening for what pharmacists can do.
The other thing we like to do is have different lecturers come in that have different background specialties. So it’s very eye-opening that there’s not just one roadmap to be a pharmacist; that there’s several different road maps, and some of them haven’t even been paved. It’s up to them, or the person who comes and says to them, “When I started, there was no such thing as..." or, "The job that I have now didn’t exist when I started, but I made it what it is today.” So it’s nice for them to see that.
How many of the first-year students end up taking your third-year elective course?
Our school is really unique. We don’t have a large student body; we really want to give attention to the smaller classes. So our class size is about 60 students on average, sometimes a little bit more and sometimes less. I’ve done this elective for about three years and had about a third of the class take the elective. It’s the last quarter that they can take an elective, and by that quarter they may not even need elective units, as they may have fulfilled their elective units. So it’s pretty impressive to have a third of the class still take it. I have some students who audit it, and they don’t even need the elective credits.
Palliative care is very new and even in the pharmacy world, I feel like a lot of my pharmacists don’t know what palliative care is. And it’s not something that has been around. A lot of pharmacists manage blood pressure in clinics, a lot of pharmacists manage diabetes, on the inpatient and outpatient side. It’s only pharmacist-run when you have to take blood thinners. A lot of pharmacists are on transplant teams, so if you get a heart transplant, a liver transplant, a kidney transplant, there’s a huge amount of medication you need to be on. So those are very well-known specialties for pharmacists. I guess I gravitate to the underdog, because palliative care isn’t really well known and a palliative care pharmacist is pretty much novel. And so it’s neat to have students take that course and find out about something that isn’t as well-known in their profession to begin with.
What attributes do you look for in students that point to their potential as pharmacists?
The traits that I hope that most of our pharmacy students have is that they really have a passion and drive and motivation. And part of our job as their professor is to help them come up with that. One of my favorite quotes says something like, “The mediocre teacher tells, the good teacher explains, the superior teacher demonstrates, but the great teacher inspires.”
So I really look for students who are, maybe not natural leaders, but with some encouragement and guidance, they want to be leaders. As they learn more, they are more passionate, they have the drive, they’re motivated. I feel really strongly that our profession has come such a long way in probably the last 50 years, and I’d like to see that momentum going. So I say to my students, “It’s not enough for you to be just as good as me; you need to be better than me.” I'm looking for people who are open and receptive to that.
In terms of pharmacy education on a broader level, are there things that excite you about the future?
This multi-disciplinary educational approach: Our school already, in the second year, the pharmacy students take all their basic science classes with the medical students. It’s with the mindset that you’re going to work together in some capacity in the future, so it’s best that you get to know each other as classmates, and learn the same things. Obviously, it can’t be every class, but there are classes that they take together. I think that’s exiting. I really think the future of medicine is a team sport, and to know who’s going to be on your team and how to be a team player is really important. It’s easier to learn how to do that in maybe a little bit less stressful environment in the classroom environment. One of the things we’ve incorporated in our campus environment is actor patients.
We have a pharmacy student, a medical student and a nursing student, and they take care of that patient all together. And it’s in a room that’s like an emergency department room or a clinic. Everybody gets to practice their role. And they get to see what each other’s roles are. And we watch them as faculty facilitators through a video monitor, and we grade them. Modeling the real world in the classroom setting is really exciting for the profession.
What’s concerning about the direction of education in your field?
Maybe that there’s just so much more to healthcare. There are so many more disease states, there are so many more medications, and maybe that’s overwhelming for our students. We tell them everything they need to know, but we don’t give them an opportunity to be self-learners as much.
Itt varies from person to person, but I really felt like when I went to pharmacy school that it was an opportunity for me to go look things up on my own. And not just be taught it in a classroom setting, but really go out and learn things on my own, make mistakes on my own, and learn from those mistakes. What I see is that we’re doing less and less of that.
For example, when my pharmacy students are on clerkship with me at the hospital, they don’t like to do a lot when I’m not there with them. They just stay quiet. But what I’d like them to do is make suggestions, and it’s OK if they’re not the best ones. But they can learn from those suggestions.
After I graduated pharmacy school, I’ve continued to have to be a self-learner. And so I don’t want that to be a surprise for them when they graduate, and then there’s nobody to –- and I don’t mean this to sound pejoratively –- to hold their hand. We need to give them a little bit more on their own, to learn on their own.
What are your own strategies for continuing self-education?
It feels like it just happens, but it probably doesn’t. There’s some conscious effort to it, beyond just reading. Being a palliative care pharmacist, I observed other palliative care pharmacists, I networked with other palliative care pharmacists, I went to national meetings, I did training -- but my boss never told me to do any of those. I just did them. And to be honest, at the beginning, you do it on your own time; it might not even be on work time.
One of my mentors said to me a while ago to show up an hour before my job started and leave an hour after my job ended. But I saved that time to look into the things that I wanted to look at, to read the things that I wanted to read. So I really modeled that. I would, on my own time, look into articles, look into journals; set up a time to talk on the phone with a pharmacist in Baltimore who was practicing palliative care; set up a day to go visit that pharmacist; and spend a day in their hospital or in their clinic with them. Then as you get to meet more people, maybe you do research together or present at this conference together, about something that we’re seeing on both end of the country, and we think people would benefit from this type of medication use. Sometimes, this job as faculty is so flexible, you go above and beyond to a fault. Go above what the expectation is.
Do you apply this strategy in your teaching?
Because it works for me, what I do now is tell the students at the end of the day, “I want you to look up two things that you want to look up. I want you to look them up, to do a thorough job looking it up, and then I want you to teach me what you learned.” And then it really gives me insight into what’s interesting for them on the rotation. And it’s nice to see that it’s not just medication, that it’s other things that are interesting to them, they heard about in rounds and wanted to know more about. It's neat to learn from them too. It’s really humbling to know that I don’t know everything, even after nine years in this specialty. I can’t read every single piece of literature out there.
But one of my mentors, my first director, Dr. Charles von Gunten, told me in his career things that help him be successful. What’s funny is he stopped looking for permission. He thought, well, if I do something wrong, I’ll just ask for forgiveness. And maybe with a spin on it, in my career, I really want my students to do more than take a seat at the table, so to speak. What I really would want them to know, if they’re reading this article, is to say, “I’m going to take a seat at the table, but I’m not just going to sit at the table and be quiet; I’m going to sit at the table and I’m going to earn my right at the table.” Have an opinion -– have an educated opinion -– and have a voice. I feel like one of the things that is frustrating is that pharmacists have a doctorate background, but they really don’t take a seat at the table. They don’t speak up when they should.
That advice is for your current students, but what would you say to your future students?
I’ve given a few lectures at high schools, and high school students are very honest. They’ll say, “But I thought that’s what a doctor does?” So just really explaining to them what a day would look like, what a scenario would look like. I would also say: You really need to know that most of pharmacy is going to be talking to patients. That being said, there are pharmacists who just do research, who may do lab research, who may work in the pharmaceutical industry. So there’s variety, it’s hard and it’s a long commitment for education, but there are jobs out there and there is flexibility out there in what you can do.
And I think something our profession doesn’t do well is educate the community. Most people who are not pharmacists think that the only place a pharmacist can work is in a community setting, which is an important part of being a pharmacist, but not the only part.