Dr. Grace Mary John: The choice of career, often leaning towards engineering or medicine, is a common experience in South Asian countries, particularly in India and Kerala. For me, medicine, which aligns with biology, was initially the path I considered after completing my 10th standard, where I was an average student. I spent my 11th and 12th standards preparing for the medical entrance exams like the Kerala state exam and the All India exam (before NEET).

However, a fortunate turn of events, what one might call serendipity, changed my direction. My mother, concerned about the difficulty of securing a medical school seat, saw a newspaper clipping about emerging career opportunities in India, which highlighted the PharmD program. The article described it as a 6-year integrated postgraduate course—a Doctor of Pharmacy—stating that PharmD holders would write prescriptions while doctors would focus on diagnosis. This appealing description excited her.

She proposed this option to my father, and we decided to explore it, especially since my entry into medical school was uncertain. As the PharmD course was new in India, only a few colleges offered it. I enrolled at PSG College of Pharmacy, Coimbatore, which had one of the first batches.

The initial eligibility requirement was very straightforward and simple enough, making admission straightforward for anyone aspiring to a medical-related education. My parents also sought advice from people working abroad about the PharmD degree, and the feedback was overwhelmingly positive regarding its prestige and respect in foreign countries.

This led to the idea that PharmD might be an even better choice than an MBBS degree. The PharmD course offered a "Doctor" title in six years, all in one go, with options for specialization later and significant opportunities abroad, unlike the longer route of MBBS (5 years) followed by an MD (3 years). Ultimately, I chose pharmacy, though, looking back, I admit it was for reasons that weren't entirely aligned with a deep-seated passion for the field itself.

The decision to pursue PharmD was highly relatable for my peers and continues to resonate with many taking the course today. For me, like many others, it seemed like a more appealing option than MBBS, offering a promising path without the intense difficulties of the latter.

I'd say the choice of PharmD was the easy answer, though I initially took it for what I now consider the wrong reasons. While I used to deeply regret that decision, I no longer do.

Dr. Grace Mary John: I achieved clinical stability, job satisfaction, and, crucially, recognition from others who finally achieving board certification was a pivotal moment, allowing me to champion specialization in India, particularly in areas like infectious diseases, and demonstrate the value of a PharmD. This accomplishment solidified my confidence.
The journey through college was enjoyable, a typical experience with friends and exams. However, the true challenge and "shock" came with clinical postings. During this time, the lack of respect, recognition, and clear roles from mentors, doctors, and even ourselves was deeply unsettling. This phase led to serious doubts about the career path chosen. The regrets only subsided once understood and appreciated my contributions.

Initially when I joined Believers, my director initially saw my potential and frequently encouraged me to pursue an MBBS, feeling I was "underutilized and ordinarily recognized" with a PharmD. He even seriously discussed the possibility of me going to medical school, a thought that persisted even after my marriage. Now, however, he expresses happiness that I did not switch. He noted that as a doctor, I would be "one of the millions," but by sticking with PharmD, I've become a pioneer, "showing a path to others."

This validation, along with opportunities for international collaboration and representing Indian clinical pharmacy globally, has affirmed my decision. I no longer have regrets and feel I am in a good place. The board certification, in particular, was instrumental in gaining recognition and a standing in India, truly making me feel proud to be an Indian clinical pharmacist.

Dr. Grace Mary John: The healthcare sector is fundamentally a service industry. As a clinical pharmacist, your primary role is serving people—your patients. Significant job satisfaction stems from this direct interaction and contribution to patient well-being.

Core Responsibilities and Impact:

A clinical pharmacist's work involves deep patient engagement, which includes:

• Interacting with Patients: Engaging in conversations and taking detailed patient histories.

• Medication Reconciliation: Reviewing and reconciling the medications patients are currently taking.

• Complex Analysis: Understanding the patient's diseases and complex health situations.

• Optimizing Treatment: Analyzing the situation to determine the best possible pharmacotherapeutic regimen.
  

Dr. Grace Mary John: My choice of clinical pharmacy over a career in a pharmaceutical company was largely influenced by my internship experiences, which allowed for significant interaction with doctors. The primary goal of a PharmD is to become a clinical pharmacist, leveraging expertise to improve patient outcomes in collaboration with physicians.

During my postings across various specialties like medicine and surgery, I started receiving recognition for my work from doctors, which motivated me to excel further in clinical practice. I am grateful for the encouragement from physicians, including a cardiothoracic surgeon and others in general medicine.

A defining moment was during my surgical posting when the surgeon unexpectedly offered me an LOR (Letter of Recommendation). Receiving this letter, which acknowledged my exceptional performance and recommended me for a clinical role, was an immense honor and solidified my passion for clinical pharmacy. It was the first thing I presented to the director during my interview, rather than my CV or certificates.

At the time, the industry was still evolving its understanding of the capabilities of PharmD graduates, which made clinical pharmacy a more open path. I am glad I chose this direction.

Starting my journey as a pioneer in the early batches of PharmD in India presented challenges. My director, a hepatologist and gastroenterologist, initially offered me a three-month trial. He was supportive and open-minded about integrating me into the team.

However, many doctors, including the HOD of the pharmacy (also a surgeon), were unfamiliar with the PharmD role and asked me to define my work. As a fresh graduate, I was initially unsure but used my internship experience to start implementing basic clinical tasks, such as renal dosing adjustments for antibiotics and other drugs, identifying drug interactions, and correcting dosage errors. This practical work slowly demonstrated the value of a clinical pharmacist.

In 2016, a surgeon suggested I get involved in antibiotic stewardship, a concept I had never encountered. I began self-learning through online courses, but a significant gap remained between my theoretical knowledge and the confidence needed to make drug recommendations.

In 2017, I approached my director about the need for growth. Recognizing the limited opportunities in India to observe advanced clinical pharmacy practice, I requested to shadow a clinical pharmacist in the U.S. This request coincided with a CME on infectious diseases featuring a reputed U.S. ID physician, Dr. George Abraham (President of the American College of Physicians) who was a friend of my director.

My director's connection led to a shadowing opportunity at Tufts Medical Center in Boston, Massachusetts, where I worked with a board-certified infectious diseases clinical pharmacist. This experience was truly transformative. Observing the clinical pharmacist's confidence, the value they provided, and the advanced nature of their consultations—much of which was beyond my current understanding of topics like pharmacokinetics—made me realize the extensive work needed to become a proficient clinical pharmacist.

Returning from the U.S., I attended the SITSCON National Infectious Diseases Conference in Nagpur in 2017. The high-level discussions among the ID physicians further underscored the gap in my knowledge.

This realization drove me to pursue formal training. I completed a 7-month certification program at Christian Medical College (CMC) Vellore, followed by taking the board certification exam. Since achieving board certification, my journey has been much smoother. The initial phase, however, was a long, slow process of building the necessary knowledge and confidence to effectively practice clinical pharmacy and stewardship.

Dr. Grace Mary John: My journey to choosing specialized courses, especially in clinical pharmacy, was really all about finding the right fit, and for me, that always came down to faculty expertise and program rigor.

When I first wanted to expand my knowledge, specialized courses for clinical pharmacists were practically non-existent. My big opportunity came when I took the initiative and met with Dr. Priscilla Rupali, the head of Infectious Diseases at CMC. She was planning a fellowship, but I insisted on doing a pilot certification course first. That was strategic—I knew having the certification would better prepare me for the fellowship application and give me a real competitive advantage.

CMC is, of course, a prestigious place, one of the first in India to have an Infectious Diseases department. But the absolute key factor in my choice was the quality of the teaching faculty. Because there were so few clinical pharmacists at the time, being taught by experienced ID physicians, who were treating patients every single day, was invaluable.

I really stress this for anyone selecting a course: you must know who is teaching you. Are they experienced practitioners, or is the program just a formality? You're making personal sacrifices—being away from your family for months, for instance—so the program has to be highly regarded; it must be worth the commitment.

My connection to CMC was helped by the former Director, Dr. George Chandy Matteethre. While I needed assistance to get in back then, I'm happy to say the fellowship course is now openly accessible for applications.

I’ve had a few experiences that really highlight the importance of high standards, especially after I achieved board certification. Once, a university in North India asked me to help start a fellowship program and take a faculty role. I declined. I realized the program was suboptimal; I couldn't be there full-time to mentor students, and the local clinical pharmacist support wasn't sufficient. The training would have been poor, and I just didn’t want my name attached to a program that could waste a fellow's year of training.

On the other hand, the Indian Pharmaceutical Association (IPA) approached me to structure a fellowship. This was unique because it was funded by a pharma company, meaning the fellows would be paid. My main condition was clear: the teachers must be ID physicians, not even ID clinical pharmacists. We successfully established 10 training centers across India, with every fellow mentored directly by an ID physician. My role was to focus on the curriculum to guarantee comprehensive learning.

So, when people ask for my recommendations, I confidently endorse both the CMC and IPA programs. I know their structure and rigor firsthand. My advice to prospective students is always this: Before you enroll in any course, ask the critical questions: Who is going to teach me? What exactly will be taught? And how much clinical time will I actually spend with patients?

Dr. Grace Mary John: The maturity of clinical pharmacy in the US is roughly 50 years, while in India, we're only at about 10. We have a very long way to go to catch up. One critical strength of the US system—one we must adopt—is the fusion of academic instruction and practical experience. Students and interns are taught by practicing clinical pharmacists, often specialists in their field.

The major flaw here in India is our reliance on college faculty. Frankly, they can only teach theory effectively. They simply lack the necessary practical, clinical skills because they aren't directly treating patients. For any real improvement, we absolutely must make practicing clinicians the primary educators for our interns.

Yes, there are reforms, and yes, there are discussions, but the pace of change is painfully slow. I see extremes in the educational landscape right now. On the one hand, my department, which is a major clinical pharmacy unit, is flooded with interns, which suggests a hunger to learn and shows the potential for superior training. But then, I also see far too many interns coming from colleges where the training is severely deficient—in some cases, it's worse than what I experienced years ago.

In essence, some colleges are genuinely trying to involve students and develop their clinical abilities, but too many others remain completely stagnant. I can't give you a national assessment, but I am certainly aware of both the positive potential and the significant deficiencies we face.

Dr. Grace Mary John: There are two main misconceptions in the field of pharmacy.

1. Confusion between D.Pharm and Pharm.D, and a lack of awareness about specialization:

Many people still confuse D.Pharm and Pharm.D. Furthermore, it's not widely known that specialization within pharmacy is possible in India. We have demonstrated this is achievable; for instance, Believers Hospital in Kerala currently employs two board-certified pharmacists, one of whom is a board-certified pharmacotherapy specialist (Dr. Vineet). More board certifications in areas like critical care and ambulatory care are anticipated, which will further highlight the possibility of specialization in pharmacy.

2. Misconceptions about opportunities and roles abroad:

There is a common, often negative, misunderstanding among Pharm.D graduates regarding opportunities abroad. While the salary is undeniably a major draw, the role itself is often different from expectations in India.

• Equality with B.Pharm: Despite Pharm.D being a 6-year course compared to B.Pharm's 4 years, most foreign universities treat them as essentially equal, meaning a Pharm.D degree offers no inherent job preference.

• Initial Role: Most Indian graduates going abroad initially work as basic registered pharmacists, not immediately as clinical pharmacists. The role involves counseling, clinics, and more than just over-the-counter dispensing, but it is not automatically the clinical role many expect.

• Pursuing Clinical Pharmacy: While pursuing clinical pharmacy is possible, it requires further effort, and very few individuals (fewer than 5 known to the speaker) successfully transition into this specialized role after their initial pharmacy degree abroad.

• Registration Exam Focus: This misconception is partly perpetuated because the standardized registration exams abroad are set for general "pharmacy registration" and not specifically for advanced degrees like Pharm.D, leading to the expectation that all graduates will start at the same foundational level.

Dr. Grace Mary John: The foundation of any pharmacy curriculum is pharmacotherapy, which students typically study for three years. While the clinical postings usually begin in the fifth and sixth years, exposure to patient files starts much earlier—in the second and third years, where students are accustomed to extracting data from these documents.

A significant issue for the Pharm.D. program, in the speaker's view, is this early reliance on files. This practice creates a habit that continues into the fourth and fifth years and even the internship, hindering the development of essential clinical skills. The speaker advocates for a change, suggesting that this file-based system needs to be replaced with an alternative method.

Pharmacotherapy, as the core subject, teaches the algorithms for treating specific diseases (e.g., hypertension, diabetes), including first- and second-line treatments and adjustments for comorbidities. The crucial task for an intern is to transition from theory to practice by applying these algorithms to real patients.

Therefore, the first and most vital step for any clinical pharmacist intern is to master the clinical guidelines (e.g., ADA for diabetes, JNC/ICMR for infectious diseases). Knowing the guidelines is more critical than merely checking for dose adjustments or drug interactions, as those are simpler tasks. The primary role is to ensure the pharmacotherapeutic regimen is optimized for the patient.

For example, when a patient presents with an acute exacerbation of asthma, the pharmacist must know what combination of treatments—antibiotics, bronchodilators, specific cough syrups—is appropriate. Optimization cannot happen without a thorough knowledge of the guidelines.

Applying guidelines to every patient is crucial for developing specialized skills. For instance, according to ACC/AHA guidelines for myocardial infarction (MI), a patient being discharged after the acute event must be placed on five mandatory secondary prevention drugs: aspirin, clopidogrel, a high-dose statin, an ARB or ACE inhibitor, and a beta-blocker.

Unless the pharmacist knows these five drugs are mandatory, they cannot effectively intervene—such as pointing out a missed drug or advising against an ARB due to high potassium or against a certain drug due to high creatinine.

Mastery of clinical guidelines is thus the core, albeit challenging, requirement for any individual to effectively function as a clinical pharmacist and build expertise in different specialties.

Dr. Grace Mary John: There are two distinct paths to a research career in pharmacy.

Path 1: Research as a Primary Career Choice

Some individuals choose research immediately after pharmacy school (e.g., pursuing a PhD) because they dislike the clinical setting. This approach prioritizes a research career over first establishing clinical expertise, offering a direct route to different professional avenues.

Path 2: Research as an Advanced Career Step

My preferred approach is to first develop strong expertise as a clinical pharmacist. Only then would I consider research (such as a PhD) as the next step. This sequence allows one to leverage valuable clinical data and experience to inform and enhance research, ultimately leading to better patient outcomes.

A PhD and engaging in research are now important to me, though they weren't 10 years ago. Research is crucial for gaining recognition, publishing data, and publicizing one's work. While research involvement can begin early, it is generally better for a clinical pharmacist to achieve proficiency first. People typically do not pursue a PhD and then become a clinical pharmacist; it is usually the other way around. Therefore, I advocate for establishing your position as a competent clinical pharmacist before diving into research.

Dr. Grace Mary John: To be a successful clinical pharmacist, you must genuinely enjoy direct patient interaction and engaging in multidisciplinary team discussions. If you do not find satisfaction in this kind of work, clinical pharmacy may not be the right path for you.

Alternative roles, such as pharmacovigilance or other non-clinical positions, might offer good career prospects and a satisfying salary through data-focused tasks.

For those committed to becoming a clinical pharmacist, setting clear goals is paramount. As the speaker's own journey demonstrates—moving through stages to specialize in infectious diseases—having a defined goal is the foundation for progress. Continuously reassessing and elevating your goals over time is essential for sustained growth and engagement.

Above all, it's crucial to "listen to your heart" and pursue what truly brings you happiness. If you enjoy collaborating with doctors, providing patient recommendations, and feel a sense of accomplishment when your recommendations are accepted, then clinical pharmacy aligns with your core passion.

Specifically, for a clinical pharmacist, especially by the fifth year of practice, a deep understanding of clinical guidelines is non-negotiable. Without this knowledge, you cannot effectively practice as a good clinical pharmacist.

Dr. Grace Mary John: The presence of 75 clinical pharmacists is truly a testament to the strong support and multidisciplinary collaboration we have with our doctors, who highly value the contributions of our team.

I want to emphasize that this achievement is not solely due to my efforts, but rather the wonderful result of this collaborative environment. Gaining the doctors' confidence is absolutely crucial for our clinical pharmacists to acquire the necessary responsibilities, and this trusting relationship is a significant advantage we enjoy in our institution. In fact, the doctors are directly involved in training our pharmacists, as they recognize that specialty-specific training requires their expert knowledge.

Our clinical pharmacists are deeply integrated across various departments, often taking on significant responsibilities.

• Nephrology: This is one of our busiest departments, with 10 clinical pharmacists. Their roles are diverse: two in dialysis, one in transplant, one in onco-nephrology, and one dedicated to the ambulatory hypertension clinic. Remarkably, one of our clinical pharmacists also serves as the dialysis administrator.

• Hematology: We have 6 clinical pharmacists here. Two of them entirely manage the bone marrow transplant unit, while the other four cover the ward, oncology, daycare, and chemo drugs.

• ICUs: We have 8 clinical pharmacists covering our different Intensive Care Units.

Dr. Grace Mary John: For those with aspirations, I stress the importance of perseverance. A dream is essential; without one, you surrender control of your life's direction. Therefore, you must not only dream but also possess the commitment to see that dream realized.

My own journey to becoming a board-certified pharmacist, which I achieved in 2021 after five years, was challenging and included significant interruptions during my PharmD education. Rather than viewing these gaps as insurmountable obstacles, I focused on continuous self-improvement and diligently filling those missing pieces. This persistent effort has brought me to a place of inner peace and professional fulfillment. My board certification allowed me to represent clinical pharmacists from India on a global stage.

Furthermore, my selection as an administrative assistant director was a result of demonstrating my competence and trustworthiness through my work. While administration was never an initial goal, dedicating most of my time to it now is incredibly rewarding, especially witnessing the respect it garners.

To achieve this level of recognition, consistent effort is key. You should be able to look back each year and point to a specific accomplishment. Success isn't instantaneous; it's the culmination of many small, deliberate steps. In essence, perseverance and a clear dream or goal are vital, preventing you from being pulled in multiple unproductive directions.