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Ace apothecary

Shanthi Shankarkumar

1999 was a momentous year for clinical pharmacist Nishaminy Kasbekar.

Over the course of that year she racked up numerous awards and went from a hardworking, talented but little-known professional to a celebrity in the pharmacy world.

A program to combat antibiotic resistance, which was implemented very successfully by her at the Presbyterian Medical Center notched up as many as four awards in one year. PMC is part of the University of Pennsylvania Health System.

In its very first year, the program saved the hospital $ 500,000. Kasbekar was named as one of the top 50 pharmacists in the US by American Druggist and was on the cover of its November 1999 issue -- the first Indian to do so.

"This year I'm the youngest in the top 50 Pharmacists list," said an elated Kasbekar, who is now 29.

"It was shocking to be selected because it is something every pharmacist aspires to be in, but usually only pharmacists in their forties or so get into the list," she said.

She also won the Julius Sturmer Rho Chi Memorial Award, which will be presented to her this April.

Kasbekar has earned new respect not only for herself and the program she has implemented but also for the pharmacy community in general. The respect did not come easy. Initially, there was unconcealed hostility from some of her male colleagues and doctors. This soon gave way to grudging respect and, finally, open admiration.

Traditionally, pharmacists have always had only a dispensing role in drug stores, but pharmacists with a Pharm D are called clinical pharmacists who work along doctors.

Kasbekar fought resistance of both the microbial and human kind to reach her present position. There was one American surgeon who would not listen to anything she had to say.

"It was just horrible. But I don't believe in conflict. I am for 'kill them with kindness.' I think he would write prescriptions just to get me to call him. Then he'd say 'This is what I want to do' and hang up," said Kasbekar.

The surgeon's attitude changed after she went out of her way to get a lifesaving drug for one of his patients.

"It was a study drug, I called the drug company, picked it up from the post office and hand-delivered it to him," she said.

While the resistance to the program was universal, what was surprising was that physicians from India were the ones who fought it the most.

"A lot of them had this impression that women don't belong to this role -- 'you should be home taking care of husband and kids' was their attitude," said Kasbekar. But the very same doctors, at the end of their residency, called and asked for her feedback on many patients.

However, the solid backing of her supervisor physician, Dr Neil Fishman, who also developed the program, helped to knock down some of the resistance.

"I speak to him 4,5 times a day. He makes the medical decisions, I make the drug decisions. I don't think pharmacists can do a program like this without a physician's backing. If a resident writes a prescription and I have a question, before I call him, I first speak to my supervisor and discuss things with him," she said.

If a physician does not agree with Kasbekar's suggestion, she passes it to her supervisor who works with the attending physician to make the final decision. It means she does not have to personally battle the physicians.

"I'll be honest. Some physicians have felt that since I am a Pharm D, I should not be making these decisions. But the physician I work for specializes in infectious disease and is very respected. And he always supports me," she said.

Essentially, what Kasbekar does is to review every prescription written for an anti-microbial by each of the 100-plus physicians who see patients at PMC. She then studies the reactions patients have to the drugs, keeps an eye out for problematic drugs and doses, ones that may lead to microbial resistance and subsequent treatment failure. She then contacts the physicians and suggests changes to a different drug, dose or administration form.

Of the 50-odd antibiotic orders she reviews on an average every day, she makes some kind of intervention on half them. She puts in a punishing 12 to 15 hours a day and gets paged even in the middle of the night. The work she puts in is evident from the statistics -- she makes an average of 300 to 400 interventions per month as compared to the 200 interventions done by the whole pharmacy department of 15 people.

"They enter order prescriptions and since they are not frontline they cannot pick up what the doctors had to say, whereas I am actually with the patient and the doctor," said Kasbekar modestly.

What she need not be modest about are the program's impressive results. Against an estimated savings of $ 200,000, the program went on to save $ 500,000. While there are similar programs in big teaching hospitals, the results seen in this small community hospital with almost one-third the number of beds have been stupendous.

"The program won so many awards because we took it to a community hospital. We have just 200 beds compared to big teaching hospitals with almost 700 beds. With one-third the number of beds, we saved the same amount of money as the big hospitals," said Kasbekar.

Its success was even more impressive because it is a community hospital.

"Sixty per cent of our patients come from nursing homes where they have a higher rate of resistance. Plus a community hospital is not supposed to do what a (teaching) hospital can do, because of (limited) resources and the fact that we have to deal with private physicians," said Kasbekar.

While the program has saved money in terms of drug costs, it has also saved on what Kasbekar calls "soft costs", including reduced hospitalization and emergency room visits. She hopes to publish the results of the program in a medical journal later.

Just how indispensable she is to the program's success can be attested by an interesting incident that occurred during the first year of the program.

Kasbekar went on a two-week vacation to India and since there was nobody to cover her work, the physicians were allowed to do what they pleased. On her return, she did a comparative study of the patients she had followed up and the patients who had seen given whatever antibiotics the physicians had desired during her absence. The results were surprising.

"The cure rate of the patients in our care was higher, while failures were more during my absence. Costs had gone up by $ 20,000 in the two weeks. The doctors, in fact, said they'll never let me take a vacation," said Kasbekar.

But all the long hours and midnight calls are worth it when seriously ill patients take a turn for the better. Kasbekar particularly remembers the HIV patient who had meningitis and could not be treated because he had a very resistant organism in his brain.

"We did a lot of research and came up with a couple of cases where the injections were given directly into the head. We came up with a formula and did it," said Kasbekar. Pretty soon, the HIV patient who had been comatose, woke up and walked out of the hospital.

"I worked with the main physician and did the research and worked on the formula, so it was great when it all worked out," said Kasbekar.

Her interest in pharmaceutical studies was kindled when she worked in a drug store while in high school. She was intrigued by how a drug worked in the body and what happened to the body. She then got a bachelor's degree in pharmacy and a doctorate in pharmacy at the Philadelphia College of Pharmacy and Science.

"It is more satisfying to participate and watch what the drugs have done. In the pharmacy you give the drug and don't now what happens after that," said Kasbekar.

Kasbekar was born in Philadelphia. Her parents migrated to America 35 years ago from Bombay.

Her father is a textile engineer and her mother works in the accounting department at a major firm.

Kasbekar is set to tie the knot this May. Her fiancée is a physician from India, she met in the hospital.

"It has been very, very satisfying and I truly enjoy what I do. The only hard part is the hours, especially now that I am going to be married. But my fiancée's hours are just as bad as mine!" she says with a laugh.

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