Terra Sigillata

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This month, DrugMonkey is hosting the Diversity in Science Blog Carnival, started by DN Lee of Urban Science Adventures! to celebrate the scientific contributions of individuals from underrepresented groups. To celebrate US Hispanic Heritage Month, DM asked for us “to write and submit your posts in honor of scientists whose ancestors came from Spain, Mexico, the Caribbean and Central or South America.”

One of the greatest rewards of being an academic scientist is watching remarkable people pass through your laboratory and classroom who then go on to do amazing things. Upon reading Drug’s call, my mind turned immediately to a perfect subject for this carnival.

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Sandra Leal was a rising pre-pharmacy sophomore from the University of Arizona in Tucson who came to the University of Colorado School of Pharmacy for a summer cancer research internship sponsored by the American Cancer Society. She took on a difficult project involving transient transfection of human leukemia cells to ascertain the role of the oncoprotein transcription factor c-Myb in activating production of DNA topoisomerase IIα, an enzyme whose action in DNA decatenation and chromosomal segregation is absolutely required for cellular proliferation. Among her many laboratory talents, Sandra became a champion at CsCl double-banding of supercoiled plasmid DNA because even Qiagen-prepped plasmids were too impure for leukemia cell transfection. Her intellectual and technical contributions then and later led ultimately to co-authorship on a publication in the Journal of Biological Chemistry.

Despite her initial intentions to go the University of Arizona College of Pharmacy, Colorado was successful in recruiting Sandra to their BS and Doctor of Pharmacy programs due to the generosity of L Samuel Skaggs and his family’s ALSAM Foundation. A philanthropist whose family is deeply entrenched in the history of pharmacy in the western US, Skaggs endowed over a dozen full-tuition scholarships at Colorado for students from underrepresented groups in inner cities or rural towns to become pharmacy professionals and, ultimately, return as role models for young people like them.

Sandra graduated as valedictorian of her class of over 100 doctor of pharmacy students.

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With her basic science foundation and training in pharmacy practice, she returned to Arizona for residency training with a focus in diabetes education and clinical service. Among her many accomplishments since, Sandra became the first pharmacist in the state of Arizona to earn limited prescribing rights and she is immediate past-president of the Association of Clinicians for the Underserved.

For this Diversity in Science Blog Carnival entry, Sandra agreed to answer a few questions for Terra Sigillata readers. Sandra is not only a role model for Hispanic students in science and pharmacy but her story tells us what can and should be done in the field of pharmacy practice.

Welcome to Terra Sigillata, Sandra. Would you tell us a little about yourself and your current job?


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Sandra Leal: Currently I am the Director of Clinical Pharmacy for El Rio Community Health Center in Tucson, Arizona. It is a wonderful place to practice because of the populations that we serve. I started here approximately 8 years ago developing a program where the pharmacist was integrated into the health care team managing complicated patients with diabetes, hypertension and dyslipidemia.

At about the same time, Arizona started working on allowing pharmacists to prescribe under collaborative practice so I was fortunate to be the first person to be able to do this as I was developing the program. Now we have a total of three clinical pharmacists, on our way to hiring a fourth. We have had success with our program primarily because of the support of the center, the providers, and most importantly the patients. As part of my current work, I am allowed a lot of flexibility to collaborate with others such as the University of Arizona where I have an adjunct faculty position precepting and teaching. I was also appointed as an adjunct instructor for AT Still University College of Osteopathic Medicine.

Aside from teaching, I have gotten very involved in policy work as faculty for HRSA’s Clinical Pharmacy & Patient Safety Collaborative [of the US Dept of Health and Human Services] which is trying to spread practices such as mine to other areas of the country. Finally, I was selected as the first pharmacist to sit on the National Center for Farmworker Health and the Association of Clinicians for the Underserved (which I was president for) to again, integrate pharmacy into the treatment team.

Tell us where you grew up and a little about your family. Were your parents or any other family members in health care or the sciences?

Sandra Leal: My mom and dad came from Saric, Sonora, Mexico to the United States before I was born. My dad use to work in the fields in California picking lettuce and in various other jobs as a factory worker along with my mom. My mom never had the opportunity to go beyond elementary school in Mexico and my father finished high school and had some training in accounting in Mexico. Nobody in my family had attended college before me and my parents were actually surprised that I wanted to go to college. So much so that my mom did not want me to go because she wanted me to stay close to the family.

I remember my father always telling me and my brothers that he wanted to come to the United States to create opportunities he never had so that we wouldn’t have to struggle as much as he and my mom did. After I completed my pharmacy degree and pursued a residency, they didn’t quite understand why I needed so much school but they were very proud. Now I am pursuing an MPH. My mom still doesn’t understand why I am pursuing more education but I know that she is proud and often comments that she wishes she would have had the opportunity to go to school longer. My dad unfortunately died suddenly last year forcing my mom to really become more independent since they used to do everything together. She started driving, got her driver’s license, and is now starting to learn English. Since we grew up in Nogales, Arizona, a border town, most people speak Spanish so she really had never had to learn English.

Your dad was a lovely man – I am so sorry for your family’s loss. How did your experiences living in a border town inform how you’ve ended up in your career?

Sandra Leal: Growing up in Nogales, Arizona had a big impact on my career choice because we use to go to Mexico to get all of our health care. Whenever any of my family or neighbors had a problem, they would literally walk across the border and go into a pharmacy, rattle off a few symptoms and walk out “con un jarabe” (a suspension/treatment). I thought that the way pharmacists practice in Mexico was the way they practiced in the United States. The only reason we wouldn’t go to the pharmacist on the American side was because they didn’t speak Spanish! It was a great honor to become one of a few pharmacist that represented the community I grew up with culture and language. Now, all of my family from Mexico and the United States calls me to triage their medical concerns/needs before they ever go to a doctor, just like I had always envisioned.

It sounds like you were totally on track to go to the U of A College of Pharmacy – what made you go to Colorado?

Sandra Leal: When I decided to go to college from Nogales to Tucson, I thought my mom was going to die. I was the only girl and it was hard for her to let me go. I had promised her that I would go to an instate school to be closer to her. During my freshman and sophomore year of college, I applied for the American Cancer Society program which placed me in Denver for the summer. At the time, I was also considering Lima, Peru for another program. I literally had to beg my mom to let me go so Peru was out of the question. In fact, they sent my brother to accompany me to Denver to “protect me”. I think I saw him twice all summer…

The experience in Denver was amazing. I met a lot of wonderful people and I loved the program. I remember Dave Kroll recruiting me to University of Colorado, offering me a job in the lab and working closely with [Colorado SoP Director of Student Services] Shirley Lucas to secure admission and a scholarship! They only reason I was able to consider going out of state was because of the generosity of Sam Skaggs, the College and the individuals that went well out of their way to create an opportunity that I have never thought I would have.

I think that having gone to Colorado really allowed for me to blossom because I was able to become more independent. It really made me look at things differently and coming home, I believe that it gave me a better perspective on all the luck, the support of my family and the great efforts it takes to make it.

I notice on PubMed that you are co-author on a paper in the Journal of Biological Chemistry on c-Myb regulation of DNA topoisomerase IIα gene expression. Did you ever consider the laboratory sciences or had you always planned on working with patients? Do you still consider yourself a scientist?

Sandra Leal: When I was growing up I always loved science and math. I knew early on that I would pursue a field that would allow me to be in the health care field. My main interest at the time was AIDS and I envisioned myself discovering some breakthrough in treatment. As I started attending pharmacy school, I loved interacting with the patient, seeing their health improve. After having practices in a Level I trauma center I thought that I would never practice in a place like that again, but instead go into ambulatory care where you could prevent people from getting to the hospital. Now, that is why I am doing my MPH because I believe that health policy and health communities could reshape how we deliver health care to address prevention rather than sickness. I now consider myself a scientist in epidemiology, hence my interest in public health.

Living in Colorado was probably a little different than southern Arizona. While Denver does have a Hispanic and Latino community, it is otherwise a pretty white city and even whiter state. Did you ever experience any racism or bigotry in pharmacy or in the community?

Sandra Leal: Living in Denver, I didn’t really notice racism or bigotry in pharmacy or in the community. If it happened, I never paid attention to that because I was more involved in my studies. I do remember that on one occasion someone commented about the scholarship I received being for minority students and how that was not fair. I clearly remember that the scholarship was a private gift from Sam Skaggs to recruit minorities into his stores so that the pharmacists could represent the communities that they served. If that is what he wanted to do with his money, I thank him profusely for having had such a vision. Just recently, I wrote Mr. Skaggs a letter about what his generosity helped me accomplish. It was amazing to me that he wrote me back and that I had the opportunity to thank him!

So, as I noted in the introduction to this post, you were valedictorian – an amazing accomplishment among a class of very smart people – congratulations. You could’ve gone anywhere: Johns Hopkins, Stanford – why go back to the Sonoran Desert?

Sandra Leal: My mom! Plus I had a regents waiver which meant that if you graduated in the top 10% of your class you had your tuition paid for instate for 4 years if you maintained a 3.5 GPA. Were it not for that, I wouldn’t have been able to afford college and at the time, I didn’t even consider loans because I didn’t know about them.

I just read your paper in Journal of Health Care for the Poor and Underserved 2005;16.2: 220-224. What would you like to tell us about the care model at El Rio and, more broadly, how did you come to acquire prescribing rights?

Sandra Leal: At El Rio we developed a concept where the clinical pharmacist’s responsibilities include coordination of care of patients with diabetes and common co-morbid disease states such as hypertension and dyslipidemia. In addition, the pharmacist is responsible for modification of drug therapy, measurement of blood glucose, hemoglobin A1c levels (A1C), education of patients, and identification/resolution of adherence and therapy related concerns. The largest portion of the pharmacist’s work requires a comprehensive understanding of drug therapy, including formulary guidelines and drug protocols, continuous lab monitoring for improvement of patient outcomes as well as monitoring for actual or potential adverse drug reactions.

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All interventions, pertinent lab data, patient demographics, and record of routine preventative therapy (i.e., monofilament exam, vaccinations, eye referrals, and podiatry referrals) are tracked via an Access database. The database clearly and easily tracks each patient’s progress in a consistent manner, reports clinic statistics in a timely fashion, and produces a progress note that is included in the patent’s permanent medical record.

This involvement, on the part of pharmacists, helps to improve patient’s quality of life, improve medication adherence, and avoid medication-related complications. The changes in the pharmacist’s role will also facilitate the new Medicare reform that will promote the involvement of clinical pharmacist in chronic disease state management.

My experience developing this model came from my training in Colorado where a lot of the faculty was practicing in this capacity already, (aside from the prescribing). During my residency at the VA in Tucson, again I experience some incredible role models for the way pharmacist should be practicing based on the training we receive. When I applied to the state, I remember taking the best of what I had seen to create what we did at El Rio. I can simply say that in practicing before I came to El Rio, I always hated asking for permission to do the right thing.

Have you experienced any criticism or hostility from physicians about your prescribing authority?

Sandra Leal: Most of the physicians and prescribers I have worked with have been truly supportive of our collaboration. I have run into the occasional physician who doesn’t understand what I do or why I can do what I do but I think it is primarily because they have not been exposed to it. The never graduates from medical and nursing school are finally getting a lot more exposure to the role of the clinical pharmacist so I hope that as we move forward, clinical pharmacy will become the norm not the exception.

How do you feel your basic sciences training has helped you as a clinician (or not!)? Does a mechanistic understanding of diabetes pathophysiology and pharmacology inform your daily practice?

Sandra Leal: Basic sciences training has given me a good foundation for patient care because I treat patients as individuals but then try to study the social conditions and cultural aspects that influence their ability to have successful outcomes. The pathophysiology of their diabetes also plays a major role in treatment because of the trends that we see from population to population from the extreme insulin resistance in our American Indian populations to the early symptoms of sensory neuropathy reported more frequently by our Hispanic patients.

It’s clear that clinical pharmacists provide great value in health care, reducing health care costs by improving disease management and preempting drug misadventuring. However, those of us outside pharmacy don’t hear much in health care reform about maximizing the expertise of the Pharm.D. – why do you think that is?

Sandra Leal: I still believe that there is a great lack of understanding about the role of the clinical pharmacist. Too often I see the pharmacist associated with the product rather than the service. Medications cost money and a lot of the lobbying effort around pharmacy is around reimbursement rates for the product. It is always unbelievable to me that a treatment team always includes a doctor and a nurse but a pharmacist can be easily forgotten when it takes an average of 3.2 medications to treat hypertension, 27 million people are now taking antidepressants, 12% of the population has diabetes which again, requires multiple medications to treat, and by the way, our population is living longer…it is only when we start addressing poly-pharmacy issues and safety associated with medication use before or at the time of prescribing that we will begin to really deliver comprehensive care.

How did you come to be involved as a leader of the Association of Clinicians for the Underserved?

Sandra Leal: I became involved with the Association of Clinicians for the Underserved when the Kathie Westpheling, the executive director called me to see if I could represent pharmacy on their board. She wanted a pharmacist on the board at the time because Medicare Part D was just starting so she wanted to make sure that they could speak to that with someone in the profession. She actually received my name from the Pharmacy Services Support Center at the American Pharmacist Association because I had been doing a lot of work with them presenting the model that we had developed at El Rio.

We talk on this blog a lot about women in science and medicine, an area I care about deeply since 80% of my lab members have been women. You are an incredibly successful clinician but also have other roles as a partner and a mom of an incredibly cute and charming daughter. How do you balance your professional and home lives?

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Sandra Leal: I am blessed and fortunate to have a truly supportive partner that has been my inspiration and my advocate. She inspires me because she has type 1 diabetes that made me even more passionate about treating diabetes, becoming a certified diabetes educator, and an insulin pump trainer. She also taught me about the emotions involved with having diabetes that I never really understood until I lived with her. She is an amazing role model, a great mother to our little girl and a truly talented teacher that worries daily about her children truly being successful.

As an aside, but relevant point, her teaching at a Title I school, working with disadvantaged children, reinforces what I do in my work as well because a lot of those children and their parents end up coming to El Rio for their care. It is amazing to me how difficult it is to be a teacher, have the class sizes they do, and the extreme budget problems they face on a regular basis. You have to be a saint to be a teacher.

What is the most satisfying part of your job?

Sandra Leal: The most satisfying part of my job is that it does not feel like work. I can honestly say that I blessed to be in the position I am in and practicing the way that I always envisioned. The patients that come to El Rio are family and I know that because I get hugs and warm handshakes everyday.

What advice would you have for young people today who are interested in either pharmacology or pharmacy? Do you have any particular advice for Hispanic or Latino/Latinas?

Sandra Leal: The advice that I have for young people entering pharmacology or pharmacy is that it is an amazing field with all the opportunities in the world! Ultimately, you have to envision what you want to create and go for it. I think that with pharmacy especially, people see a pharmacist in a retail setting and might think it is limiting. Honestly, it is only as limiting as you make it. Some of my fondest memories practicing in a retail setting was being that pharmacist that people would approach to ask for advice and a recommendation, how you decide to practice is up to you.

My advice to Hispanics is pursue higher education. I see such a huge high school dropout rate for minorities and very little representation of minorities in the health care fields. I hope that one day I can establish a scholarship program like Mr. Skaggs did because his efforts have obviously made an impact.

That’s awesome. I hope you are indeed in a position to do so.

Thank you for sharing your story with our readers for the Diversity in Science Blog Carnival. You’re an incredible role model and a magnificent person. The people of southern Arizona are most fortunate to have you in their community.

To learn more about the Pharmacist-Based Diabetes Clinics at El Rio Community Health Center in Tucson, Arizona (and to see Dr Leal in action!) see this video.

If you, Dear Reader, have any other questions for Sandra, please leave them in the comments and we’ll see if we can’t get her to offer more of her wisdom.

Comments

  1. #1 atarnow
    October 10, 2009

    Thank you so much for featuring Sandra. Many aspects of Sandra’s experiences stuck out for me as a current pre-pharmacy student, who has experience in laboratory research (with topoisomerase IIa, also!), and as a woman with a latina parter. Your post was very inspiring as I try to look ahead and see what I can to aspire to in my career.

    I would be interested in hearing more about Sandra’s experiences in the profession, being gay and supporting an alternative family. In my experience, I have noticed a seemingly higher percentage of openly religious persons practicing pharmacy – as opposed to those who are in the biology research area. I wonder if this has any effect on the atmosphere of acceptance in the profession.

  2. #2 milkshake
    October 25, 2009

    I don’t know if the organizers of “Diversity in Science Carnival” have realized – but their logo looks like a giant Goatse…

  3. #3 Abel Pharmboy
    October 25, 2009

    @milkshake – I have to admit that I had to go to the Urban Dictionary. I am way out of touch.

  4. #4 Guzzo
    December 10, 2009

    Here’s a video of the El Rio Clinic and Dr. Leal at work.

    http://www.youtube.com/watch?v=35JQXKpMsBw

  5. #5 Enrique Cuenca
    April 27, 2010

    Sandra, what a beautyful woman.

    I’m in love with her.

    She is so brilliant and intelligent.

    Love to you.

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