Through the Lens: Photovoice Reveals the Role of Pharmacists in Primary Care

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Grant, PhD, MBA, MS, Ashley W Ellis, PharmD, MBA, CDECS, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7696085/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Nov, 2025 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted 9 You are reading this latest preprint version Abstract Introduction : Meeting patients’ needs requires team-based approaches that address disease management, medication safety, and patient-centered care. Pharmacists are uniquely positioned to close care gaps, optimize medication use, and provide valuable education to patients, clinicians, and staff. This study explores the lived experiences of pharmacists integrated into primary care clinics.​ Aim : To explore the real-world role of clinic-embedded pharmacists in primary care clinics.​ Method : The study employed photovoice, a visual research technique using participant-generated photographs. Pharmacists providing direct patient care were asked to take 3–5 photographs related to their experiences with collaboration, interactions with physicians and patients, successes, and system-level barriers and facilitators to integrating clinical pharmacy into primary care clinics. A focus group was conducted to share photographs and reflections, followed by thematic analysis.​ Results : Six pharmacists from the University of Tennessee Health Science Center’s Tennessee Heart Health Network, representing four healthcare systems participated in the study.​ Five themes emerged: 1) From skepticism to advocacy (role clarity and trust), 2) Integration through visibility and accessibility, 3) Role expansion from medication access tasks to clinical leadership allows physicians more time, 4) Safety and quality gains via innovation and standardization, and 5) Patient education and co-visits enhance the care experience. Pharmacists reported outcomes, including improved medication safety processes and better chronic disease management.​ Conclusion : Collaboration between pharmacists and care teams was perceived to improve patient experience and care processes. Integrating pharmacists may help alleviate physician workload and burnout. qualitative research pharmacists primary health care burnout professional quality indicators Figures Figure 1 Figure 2 Figure 3 Impact Statement This study highlights pharmacists’ perspectives on their integration into primary care clinics. Participants perceived that providing patient-centered education allows them to support patient experiences and chronic disease management. They also reported that their involvement may help strengthen care coordination and contribute to population health efforts. Additionally, pharmacists described their role as potentially reducing workflow burdens for physicians and other staff, allowing greater focus on complex care tasks. While these findings reflect perceptions rather than measured outcomes, they suggest that pharmacist integration may hold promise for improving care processes and warrant further study in future evaluations. INTRODUCTION Physician burnout is pervasive, marked by exhaustion, depersonalization, and reduced accomplishment [ 1 ] and threatens care quality and workforce stability [2]. In recent years, attention has been given to the role of pharmacists in primary care [ 3 ], and their potential to improve health outcomes and reduce costs while improving patient experience [ 4 , 5 ] and physician well-being [ 6 ]. Embedding pharmacists into primary care clinics can foster a supportive and collaborative work environment, strengthen the sense of community among healthcare professionals, and improve quality of care [ 7 ]. While not routine in the US, some clinical pharmacists are embedded within some primary care teams to enhance medication adherence. These pharmacists can play a crucial role by helping to achieve a more balanced distribution of workload across a team of healthcare providers while increasing the team’s expertise in chronic disease care and comprehensive medication management [ 8 – 11 ]. Despite these benefits, less is known about how pharmacists themselves perceive their role in addressing burnout and what implementation conditions enable impact in real-world primary care settings. This study explores pharmacists’ perceptions of integration within primary care teams. Understanding these perspectives can guide practical strategies for integrating pharmacists to support clinician well-being and high-quality, value-oriented primary care. AIM This study sought to explore pharmacists’ perceptions and experiences of working within primary care teams, with attention to their perceived roles, day-to-day activities, and the barriers and facilitators that shape integration. METHODS Photovoice was used to enable pharmacists to document and reflect on their lived experiences through images. It allows participants to express experiences through images, often symbolic, to share insights that might not emerge through interviews. Photovoice is a qualitative method well suited to small samples and to eliciting nuanced, practice-based insights [ 12 , 13 ]. Pharmacists were purposively recruited from primary care clinics participating in the Tennessee Heart Health Network (TN-HHN) Pharmacist–Physician Collaborative. [ 14 ] All eight participating pharmacists were invited and six (representing four organizations) enrolled and submitted photographs; four participated in the focus group. A TN-HHN team member described the study, answered questions, and instructed participants to avoid pictures of individuals. IRB-approved verbal consent was obtained at enrollment. Over four weeks, participants captured digital images and brief captions representing their experiences with the integration into primary care including: 1) team interactions, 2) implementation challenges 3) successes or positive outcomes for physicians, clinicians, and staff, 4) specific moments that represent the impact of the intervention, 5) changes in patient outcomes, 6) ability to provide patient-centered care. Data collection culminated in a 2.5-hour, virtual, semi-structured focus group moderated by an experienced qualitative researcher. Each participant introduced 3–5 photos by answering, “What were your thoughts when you took this photograph, and what does it represent to you?” followed by group discussion. All submitted photos were reviewed during analysis. De-identified transcripts and photos were stored on a secure site at the University of Tennessee. Consistent with photovoice practice [ 12 , 15 ], analysis began during the session: a note-taker documented emergent themes, which the moderator confirmed in real time. The discussion was audio-/video-recorded and transcribed (31 pages). Two qualitative researchers independently coded the transcript, reconciled a codebook, and selected representative quotes and images. Respondent validation with three pharmacists confirmed themes and exemplars [ 16 , 17 ]. This study was deemed exempt from full review by the University of Tennessee Institutional Review Board (Approval Number: 24-10066-XP) in accordance with federal guidelines for research involving minimal risk. Each participant provided informed consent to participate and to use their photographs and narratives in this publication. RESULTS Collectively, participants described a trajectory from initial resistance to integrated, pharmacist-led contributions that streamlined workflows and supported safety, quality, and patient-centered care. Five themes emerged: Theme 1: From skepticism to advocacy (role clarity and trust). All participants initially encountered physician doubts about pharmacists’ role encroachment (Fig. 1 ). As contributions became visible, physicians endorsed and expanded the pharmacists’ role. In one health system, pharmacists were credentialed as mid-levels with independent billing capability. Theme 2: Integration through visibility and accessibility. Relationship-building (Fig. 2 ) was enabled by open door policies and intentional placement. Positioning the pharmacist’s office along the patient checkout path facilitated warm handoffs and quick consultations on the way to checkout, normalizing team collaboration. This further strengthened collaboration and integration into the care team. Theme 3: Role expansion from medication access tasks to clinical leadership allows physicians more time. Beyond prior authorizations and medication access, pharmacists led chronic disease management education and assisted with clinic operations related to medications. This allowed physicians to cover other important topics during patient interactions. A common example was pharmacist-led inhaler technique education paired with titration protocols. Theme 4: Safety and quality gains via innovation and standardization. All pharmacists participated in resource development to support clinical staff. For example, one pharmacist created an order set (a standardized set of medical orders in the electronic health record) to help Certified Medical Assistants reduce phone calls to clarify prescriptions. Another organization had clinical pharmacists serving as key consultants on all medication-related matters, contributing to policy development, reducing medication waste, and identifying best practices for medication handling. One pharmacist developed a safety survey to assess critical questions related to international normalized ratio (INR) management. The clinic now uses the survey to help guide comprehensive care for patients. Theme 5: Patient education and co-visits enhance the care experience. Pharmacists provided time-intensive counseling and valuable education to patients (Fig. 3 ). Clinics adopted joint physician–pharmacist visits, enabling thorough medication reconciliation and more comprehensive chronic disease support within a single appointment. Participants agreed that patients with chronic conditions often require more guidance than physicians alone have time to deliver, especially when managing complex medication regimens. All participants reported their clinics had adapted the clinical model to include joint physician-pharmacist visits, enhancing the patient experience by allowing both professionals to be seen during a single appointment. These co-visits enabled pharmacists to conduct thorough medication reconciliation and provide more comprehensive support for chronic disease management. See Table 1 for notable quotes by theme. Table 1 Participant Quotes by Theme. Theme Participant Quote From skepticism to advocacy (role clarity and trust) “When I first started…one physician sat with arms crossed in meetings and never looked up…[I found small ways to be a resource to him and] now he is one of my biggest physician champions…willing to drive 1.5 hours each way to [explain to] others why they need a pharmacist. He still comes to my office 3 or 4 times a week to ask me questions about new medications and rare diseases.” “The [pharmacist-physician] collaboration has really pushed me to explore uncharted territory. Sometimes I’m aware of what I’m getting into, sometimes I’m flying blind alongside the providers. But knowing I’ve got a trusted ally [in the physician], my willingness to ‘sniff out’ that uncharted territory is less scary because I’m not navigating it alone.” Integration through visibility and accessibility “When I…started…[I had] a big office…but no one knew I was there…I intentionally walked around the office just to remind people I’m…here to help. One day, I sat at the nurses’ station all day and worked…alongside the nurses and providers. Instantly I became a part of the team…” “As my rapport continues to build with providers, I receive more ‘drive-by’ consultations. Often, this is for drug information questions, drug interaction review, confirmation of a clinical drug application, advice on how to navigate SDoH cases, etc.…While the ‘drive bys’ are a quick in and out…they afford the providers the content desired to then effect change not just for the patient in front of them, but to similar clinical scenarios they will see again. “Alongside the ‘drive-by’ consults…are real-time consultations while the provider has the patient in the room. While it may feel I’m being pulled into a scenario I’ve not had much time to prepare for, they…lead to positive outcomes for the provider in developing the care plan…patients getting the medical and medication services desired, and more consultations for my clinical services.” Role expansion from medication access tasks to clinical leadership allows physicians more time “It started as…can you teach people how to use an inhaler? I can, and we could also bill for the visit. A conversation with a physician about…inhaler education morphed into…a service line to provide inhaler education…doing a full assessment of their asthma or their COPD to ensure…[the patient] is on the right device…and are using it correctly.” “Between annual visits, I…[review charts] to fill in the missing pieces…[for quality measures] and provide care coordination [when needed…so that the physician can be more efficient and cover more ground during the patient visit and improve the patient-physician interaction.” “[We added a] standing line item in our monthly management meeting at the clinic for pharmacy… [this has] increased collaboration and communication between staff members and physicians to…improve [our] processes.” “A…barrier for implementation…is the initial perceived provider benefit [that] the pharmacist’s value is [limited to] managing patient assistance program applications. …the administrative workload can…[limit the amount of] clinical time…if not carefully balanced.” Safety and quality gains via innovation and standardization “I made preference lists [accessible to] everyone…for [information on] GLP-1 titrations, supply ordering, etc….in Epic [with] a step-by step guide. [If a provider] has trouble seeing patients continuous glucose monitoring (CGM) data, [I set up] a picture-by-picture guide on how to get patients CGM’s connected with our clinic account to view patient data. This standardized workflow ensured accurate medication adjustments and met documentation requirements for billing the clinical visit in addition to lab services.” “[My role…slowly [expanded into] all aspects…of [the] clinic where medications are involved including [chronic care management]. I was a fresh set of eyes for where we could improve safety around therapeutic agents and [even address] emergency situations [where] I help with triage and by drawing up medicines that the staff are not as familiar with. [This has] increased my presence [among all staff]in the clinic.” Patient education and co-visits enhance the care experience “[A newly diagnosed patient with diabetes said, I have six siblings], some are dead and some…are living, but every…one…[is] without a limb and this is going to happen to me.” [My clinician brain] stopped and I talked to him about acceptance. When I saw him three months [later], he was [an evangelist for diabetes management…and his blood sugar and A1C were under control.” “I go home after work satisfied. I go home after work fulfilled. I have a greater sense of personal and professional value as a result of my … collaboration [with providers and patients]. I find myself excited to go to work, because I know I’m valued, and I know the services I provide are valued. And I know the impact I get to have on patient care is positive.” DISCUSSION Despite early challenges with role acceptance, participants described the expansion of responsibilities and improvements in patient care processes across primary care clinics. These findings align with prior studies of Clinical Pharmacist Practitioners (CPPs) [ 18 ] emphasizing open communication, mutual respect, aligned priorities, and pharmacist visibility as essential to overcoming integration barriers and studies conducted in Great Britain, underscoring establishing rapport with general practitioners, interprofessional collaboration, and cultivating relationships as critical to pharmacist integration [ 16 ]. Structural barriers also persist [ 19 ], notably the inability of pharmacists to bill for clinical services under Medicare Part B, despite their qualifications. While some states allow reimbursement through Medicaid by designating pharmacists as “other licensed practitioners,” broader progress is limited by fragmented advocacy among state pharmacy associations and academic institutions. Stronger collaboration among these groups could strengthen advocacy efforts, improve reimbursement mechanisms, and enhance the sustainability of pharmacist integration. Additionally, opposition from the American Medical Association underscores the need to examine how policy debates affect the adoption and long-term impact of pharmacist-led models. Similar challenges are seen internationally, where variations in polices and norms affect the scope of clinical pharmacy practice across countries, causing differences in pharmacy education and training. In response, Paudyal, et.al., proposed the development of global guidelines, which can be tailored to various healthcare settings, helping to overcome common policy and structural challenges [ 20 ]. Broader Medicaid coverage offers promise in the U.S [ 21 ]. When pharmacists are reimbursed for clinical services, healthcare tends to become more colocated and accessible, particularly critical in rural areas. In Tennessee, where 93 of 95 counties face primary care shortages, integrated models like the Tennessee Heart Health Network represent a vital strategy for addressing geographic disparities in access. A strength of this study is its use of the photovoice method, which provided rich, real-world insights into pharmacists' integration experiences. Engaging frontline pharmacists allowed for the identification of their contributions, as well as practical barriers and facilitators, informing future interventions and policy recommendations to support scalability across diverse primary care settings. The participant group represented both rural and urban clinics, adding to the study’s relevance. A limitation of the study is that the findings are context-specific to Tennessee, where the scope of pharmacy practice is governed by state-specific regulations under the Pharmacy Practice Act [ 22 ], and a small group of pharmacists; readers should be cautious in extrapolating to other settings. Additionally, the findings are exploratory; we did not aim for theoretical saturation, but rather to uncover key insights and generate hypotheses for larger studies. With only one focus group, we cannot claim to have reached saturation; additional participants or sessions might have revealed further themes. Thus, the results highlight core insights but may not capture the full range of experiences. Interestingly, participants from four different health systems reported similar experiences, suggesting some common pathways to successful integration. However, given the small sample, we advise caution in generalizing broadly. CONCLUSION This photovoice study offers unique insights into the perceived impact of pharmacists within clinical healthcare teams. Pharmacists in this study not only strengthen clinical care delivery but also support other team members in achieving their highest level of training, which may be a sustainable source for reducing physician burden. Declarations Funding This research has been funded by the Agency for Healthcare Research and Quality (AHRQ). 1U18 HS27952-01; Tennessee Heart Health Network: Implementing Patient-Centered Practices in Primary Care to Improve Cardiovascular Health; EvidenceNow. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by CG, AE, GH, and SF Candidate. The first draft of the manuscript was written by QV, CG, SF, AE, and GH, and all authors including JB and BJ commented on previous versions of the manuscript. All authors read and approved the final manuscript. The authors have no relevant financial or non-financial interests to disclose. Acknowledgements We gratefully acknowledge the Principal Investigator of the EvidenceNow grant in Tennessee, James Bailey, MD, MPH, FACP, who provided encouragement throughout the completion of this project, without whom this achievement would not have been possible. We also gratefully acknowledge the pharmacists who gave their time, experiences, and creativity to this study. The main text contains information on ethics review: This study was deemed exempt from full review by the University of Tennessee Institutional Review Board (Approval Number: 24-10066-XP) in accordance with federal guidelines for research involving minimal risk. Participants provided consent to participate and use their photographs and narratives in publications. References Maslach C, Schaufeli WB, Leiter MP, editors. Job burnout. Annu Rev Psychol. 2001;52:397–422. 2. Institute of Medicine Committee on Quality of Health Care in A. 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Cite Share Download PDF Status: Published Journal Publication published 24 Nov, 2025 Read the published version in International Journal of Clinical Pharmacy → Version 1 posted Editorial decision: Revision requested 20 Oct, 2025 Reviews received at journal 20 Oct, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviews received at journal 07 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers invited by journal 29 Sep, 2025 Editor assigned by journal 23 Sep, 2025 Submission checks completed at journal 23 Sep, 2025 First submitted to journal 23 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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02:09:01","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":42168,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/14312a73cb9104b28b038c0e.png"},{"id":93538335,"identity":"fe692cb9-61f6-45e3-9921-fd3a5d5ebca7","added_by":"auto","created_at":"2025-10-15 02:09:00","extension":"png","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":241878,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/f0f49c854c63d7dc1e7fbfed.png"},{"id":93538338,"identity":"838060f2-de28-4c5b-b05c-6a5d72703873","added_by":"auto","created_at":"2025-10-15 02:09:01","extension":"png","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":21727,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/691fbca36c3f3dad711c7f6e.png"},{"id":93538350,"identity":"347788f7-8342-4882-9c06-77cab1a0909d","added_by":"auto","created_at":"2025-10-15 02:09:02","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":59079,"visible":true,"origin":"","legend":"","description":"","filename":"2d3f0a4b59a24053b5625b6cfaa282401structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/e2b59bce5016c506abcd1a43.xml"},{"id":93538353,"identity":"c6c41202-46cb-487e-a756-2d298059271a","added_by":"auto","created_at":"2025-10-15 02:09:02","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67197,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/742c21c0663093c20db1b319.html"},{"id":93538333,"identity":"6711f733-96af-4605-8e29-3e115f101097","added_by":"auto","created_at":"2025-10-15 02:09:00","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21705,"visible":true,"origin":"","legend":"\u003cp\u003eFrom skepticism to advocacy (role clarity and trust). The participant that took this picture said they recognized a disconnect between their own intentions of coming in openly to help and how they were perceived by physicians as a potential threat. \u003cem\u003e“One barrier I faced is the impression of 'physician creep’…while I feel I’m walking in with the doors open and lights on…[I felt] a protectiveness over the practice…[akin] to preventing a home invasion or theft of the physician’s revenue.”\u003c/em\u003e Submitted by Participant 2.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/86b95ccaf0a037cca11a9b0f.jpg"},{"id":93538337,"identity":"81a74ba2-3f99-4127-ae9b-5e3f12366eed","added_by":"auto","created_at":"2025-10-15 02:09:01","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":38467,"visible":true,"origin":"","legend":"\u003cp\u003eIntegration through visibility and accessibility. The participant who took this photograph said that the tree represents the growth of team-based care and the strong roots that represent lasting relationships.\u003cstrong\u003e \u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e“\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e…bringing medication expertise into a practice [opens the door] to [lasting] relationships with providers, staff, and patients [and provides strong roots].”\u003c/em\u003e Submitted by Participant 2.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/3d80b6ec1018d4295a87e9db.jpg"},{"id":93538346,"identity":"35cfbd97-cecd-46ae-a2d7-2a9705e05355","added_by":"auto","created_at":"2025-10-15 02:09:02","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":12586,"visible":true,"origin":"","legend":"\u003cp\u003ePatient education and co-visits enhance the care experience. The participant that took this picture said “\u003cem\u003eIn a new consultation for type 2 diabetes, the patient [who was] blind in the right eye and [had] severe cataract in left eye was experiencing a significant number of hypoglycemic events. Home alone while his wife was at work, this was dangerous. I [was able to spend] 30 minutes explaining the pharmacokinetic and pharmacodynamic properties of bolus insulin and the [importance of] dosing bolus insulin prior to meals…[to reduce] his glycemic shifts. Hypoglycemic events dropped 50% by his next visit.\u003c/em\u003e” Submitted by Participant 3.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/0501a96ae81b2fddeaafb498.jpg"},{"id":97178732,"identity":"62cded96-9fc8-4995-b44e-e1134719b01a","added_by":"auto","created_at":"2025-12-01 16:13:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":629202,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7696085/v1/2c2a3036-6b66-48da-8d2f-9541b6222f66.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Through the Lens: Photovoice Reveals the Role of Pharmacists in Primary Care","fulltext":[{"header":"Impact Statement","content":"\u003cp\u003eThis study highlights pharmacists’ perspectives on their integration into primary care clinics. Participants perceived that providing patient-centered education allows them to support patient experiences and chronic disease management. They also reported that their involvement may help strengthen care coordination and contribute to population health efforts. Additionally, pharmacists described their role as potentially reducing workflow burdens for physicians and other staff, allowing greater focus on complex care tasks. While these findings reflect perceptions rather than measured outcomes, they suggest that pharmacist integration may hold promise for improving care processes and warrant further study in future evaluations.\u003c/p\u003e"},{"header":"INTRODUCTION ","content":"\u003cp\u003ePhysician burnout is pervasive, marked by exhaustion, depersonalization, and reduced accomplishment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and threatens care quality and workforce stability [2]. In recent years, attention has been given to the role of pharmacists in primary care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and their potential to improve health outcomes and reduce costs while improving patient experience [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and physician well-being [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Embedding pharmacists into primary care clinics can foster a supportive and collaborative work environment, strengthen the sense of community among healthcare professionals, and improve quality of care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile not routine in the US, some clinical pharmacists are embedded within some primary care teams to enhance medication adherence. These pharmacists can play a crucial role by helping to achieve a more balanced distribution of workload across a team of healthcare providers while increasing the team\u0026rsquo;s expertise in chronic disease care and comprehensive medication management [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite these benefits, less is known about how pharmacists themselves perceive their role in addressing burnout and what implementation conditions enable impact in real-world primary care settings. This study explores pharmacists\u0026rsquo; perceptions of integration within primary care teams. Understanding these perspectives can guide practical strategies for integrating pharmacists to support clinician well-being and high-quality, value-oriented primary care.\u003c/p\u003e\n\u003ch3\u003eAIM\u003c/h3\u003e\n\u003cp\u003eThis study sought to explore pharmacists\u0026rsquo; perceptions and experiences of working within primary care teams, with attention to their perceived roles, day-to-day activities, and the barriers and facilitators that shape integration.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cp\u003ePhotovoice was used to enable pharmacists to document and reflect on their lived experiences through images. It allows participants to express experiences through images, often symbolic, to share insights that might not emerge through interviews. Photovoice is a qualitative method well suited to small samples and to eliciting nuanced, practice-based insights [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Pharmacists were purposively recruited from primary care clinics participating in the Tennessee Heart Health Network (TN-HHN) Pharmacist\u0026ndash;Physician Collaborative. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e] All eight participating pharmacists were invited and six (representing four organizations) enrolled and submitted photographs; four participated in the focus group. A TN-HHN team member described the study, answered questions, and instructed participants to avoid pictures of individuals. IRB-approved verbal consent was obtained at enrollment.\u003c/p\u003e\u003cp\u003eOver four weeks, participants captured digital images and brief captions representing their experiences with the integration into primary care including: 1) team interactions, 2) implementation challenges 3) successes or positive outcomes for physicians, clinicians, and staff, 4) specific moments that represent the impact of the intervention, 5) changes in patient outcomes, 6) ability to provide patient-centered care. Data collection culminated in a 2.5-hour, virtual, semi-structured focus group moderated by an experienced qualitative researcher. Each participant introduced 3\u0026ndash;5 photos by answering, \u0026ldquo;What were your thoughts when you took this photograph, and what does it represent to you?\u0026rdquo; followed by group discussion. All submitted photos were reviewed during analysis. De-identified transcripts and photos were stored on a secure site at the University of Tennessee.\u003c/p\u003e\u003cp\u003eConsistent with photovoice practice [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e], analysis began during the session: a note-taker documented emergent themes, which the moderator confirmed in real time. The discussion was audio-/video-recorded and transcribed (31 pages). Two qualitative researchers independently coded the transcript, reconciled a codebook, and selected representative quotes and images. Respondent validation with three pharmacists confirmed themes and exemplars [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This study was deemed exempt from full review by the University of Tennessee Institutional Review Board (Approval Number: 24-10066-XP) in accordance with federal guidelines for research involving minimal risk. Each participant provided informed consent to participate and to use their photographs and narratives in this publication.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eCollectively, participants described a trajectory from initial resistance to integrated, pharmacist-led contributions that streamlined workflows and supported safety, quality, and patient-centered care.\u003c/p\u003e\u003cp\u003eFive themes emerged:\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 1: From skepticism to advocacy (role clarity and trust).\u003c/b\u003e All participants initially encountered physician doubts about pharmacists\u0026rsquo; role encroachment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). As contributions became visible, physicians endorsed and expanded the pharmacists\u0026rsquo; role. In one health system, pharmacists were credentialed as mid-levels with independent billing capability.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 2: Integration through visibility and accessibility.\u003c/b\u003e Relationship-building (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) was enabled by open door policies and intentional placement. Positioning the pharmacist\u0026rsquo;s office along the patient checkout path facilitated warm handoffs and quick consultations on the way to checkout, normalizing team collaboration. This further strengthened collaboration and integration into the care team.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 3: Role expansion from medication access tasks to clinical leadership allows physicians more time.\u003c/b\u003e Beyond prior authorizations and medication access, pharmacists led chronic disease management education and assisted with clinic operations related to medications. This allowed physicians to cover other important topics during patient interactions. A common example was pharmacist-led inhaler technique education paired with titration protocols.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 4: Safety and quality gains via innovation and standardization.\u003c/b\u003e All pharmacists participated in resource development to support clinical staff. For example, one pharmacist created an order set (a standardized set of medical orders in the electronic health record) to help Certified Medical Assistants reduce phone calls to clarify prescriptions. Another organization had clinical pharmacists serving as key consultants on all medication-related matters, contributing to policy development, reducing medication waste, and identifying best practices for medication handling. One pharmacist developed a safety survey to assess critical questions related to international normalized ratio (INR) management. The clinic now uses the survey to help guide comprehensive care for patients.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTheme 5: Patient education and co-visits enhance the care experience.\u003c/b\u003e Pharmacists provided time-intensive counseling and valuable education to patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Clinics adopted joint physician\u0026ndash;pharmacist visits, enabling thorough medication reconciliation and more comprehensive chronic disease support within a single appointment. Participants agreed that patients with chronic conditions often require more guidance than physicians alone have time to deliver, especially when managing complex medication regimens. All participants reported their clinics had adapted the clinical model to include joint physician-pharmacist visits, enhancing the patient experience by allowing both professionals to be seen during a single appointment. These co-visits enabled pharmacists to conduct thorough medication reconciliation and provide more comprehensive support for chronic disease management.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSee Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for notable quotes by theme.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Quotes by Theme.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipant Quote\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFrom skepticism to advocacy (role clarity and trust)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I first started\u0026hellip;one physician sat with arms crossed in meetings and never looked up\u0026hellip;[I found small ways to be a resource to him and] now he is one of my biggest physician champions\u0026hellip;willing to drive 1.5 hours each way to [explain to] others why they need a pharmacist. He still comes to my office 3 or 4 times a week to ask me questions about new medications and rare diseases.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The [pharmacist-physician] collaboration has really pushed me to explore uncharted territory. Sometimes I\u0026rsquo;m aware of what I\u0026rsquo;m getting into, sometimes I\u0026rsquo;m flying blind alongside the providers. But knowing I\u0026rsquo;ve got a trusted ally [in the physician], my willingness to \u0026lsquo;sniff out\u0026rsquo; that uncharted territory is less scary because I\u0026rsquo;m not navigating it alone.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIntegration through visibility and accessibility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When I\u0026hellip;started\u0026hellip;[I had] a big office\u0026hellip;but no one knew I was there\u0026hellip;I intentionally walked around the office just to remind people I\u0026rsquo;m\u0026hellip;here to help. One day, I sat at the nurses\u0026rsquo; station all day and worked\u0026hellip;alongside the nurses and providers. Instantly I became a part of the team\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;As my rapport continues to build with providers, I receive more \u0026lsquo;drive-by\u0026rsquo; consultations. Often, this is for drug information questions, drug interaction review, confirmation of a clinical drug application, advice on how to navigate SDoH cases, etc.\u0026hellip;While the \u0026lsquo;drive bys\u0026rsquo; are a quick in and out\u0026hellip;they afford the providers the content desired to then effect change not just for the patient in front of them, but to similar clinical scenarios they will see again.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Alongside the \u0026lsquo;drive-by\u0026rsquo; consults\u0026hellip;are real-time consultations while the provider has the patient in the room. While it may feel I\u0026rsquo;m being pulled into a scenario I\u0026rsquo;ve not had much time to prepare for, they\u0026hellip;lead to positive outcomes for the provider in developing the care plan\u0026hellip;patients getting the medical and medication services desired, and more consultations for my clinical services.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eRole expansion from medication access tasks to clinical leadership allows physicians more time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It started as\u0026hellip;can you teach people how to use an inhaler? I can, and we could also bill for the visit. A conversation with a physician about\u0026hellip;inhaler education morphed into\u0026hellip;a service line to provide inhaler education\u0026hellip;doing a full assessment of their asthma or their COPD to ensure\u0026hellip;[the patient] is on the right device\u0026hellip;and are using it correctly.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Between annual visits, I\u0026hellip;[review charts] to fill in the missing pieces\u0026hellip;[for quality measures] and provide care coordination [when needed\u0026hellip;so that the physician can be more efficient and cover more ground during the patient visit and improve the patient-physician interaction.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[We added a] standing line item in our monthly management meeting at the clinic for pharmacy\u0026hellip; [this has] increased collaboration and communication between staff members and physicians to\u0026hellip;improve [our] processes.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;A\u0026hellip;barrier for implementation\u0026hellip;is the initial perceived provider benefit [that] the pharmacist\u0026rsquo;s value is [limited to] managing patient assistance program applications. \u0026hellip;the administrative workload can\u0026hellip;[limit the amount of] clinical time\u0026hellip;if not carefully balanced.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSafety and quality gains via innovation and standardization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I made preference lists [accessible to] everyone\u0026hellip;for [information on] GLP-1 titrations, supply ordering, etc\u0026hellip;.in Epic [with] a step-by step guide. [If a provider] has trouble seeing patients continuous glucose monitoring (CGM) data, [I set up] a picture-by-picture guide on how to get patients CGM\u0026rsquo;s connected with our clinic account to view patient data. This standardized workflow ensured accurate medication adjustments and met documentation requirements for billing the clinical visit in addition to lab services.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[My role\u0026hellip;slowly [expanded into] all aspects\u0026hellip;of [the] clinic where medications are involved including [chronic care management]. I was a fresh set of eyes for where we could improve safety around therapeutic agents and [even address] emergency situations [where] I help with triage and by drawing up medicines that the staff are not as familiar with. [This has] increased my presence [among all staff]in the clinic.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePatient education and co-visits enhance the care experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;[A newly diagnosed patient with diabetes said, I have six siblings], some are dead and some\u0026hellip;are living, but every\u0026hellip;one\u0026hellip;[is] without a limb and this is going to happen to me.\u0026rdquo; [My clinician brain] stopped and I talked to him about acceptance. When I saw him three months [later], he was [an evangelist for diabetes management\u0026hellip;and his blood sugar and A1C were under control.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I go home after work satisfied. I go home after work fulfilled. I have a greater sense of personal and professional value as a result of my \u0026hellip; collaboration [with providers and patients]. I find myself excited to go to work, because I know I\u0026rsquo;m valued, and I know the services I provide are valued. And I know the impact I get to have on patient care is positive.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"DISCUSSION ","content":"\u003cp\u003eDespite early challenges with role acceptance, participants described the expansion of responsibilities and improvements in patient care processes across primary care clinics. These findings align with prior studies of Clinical Pharmacist Practitioners (CPPs) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e] emphasizing open communication, mutual respect, aligned priorities, and pharmacist visibility as essential to overcoming integration barriers and studies conducted in Great Britain, underscoring establishing rapport with general practitioners, interprofessional collaboration, and cultivating relationships as critical to pharmacist integration [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStructural barriers also persist [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e], notably the inability of pharmacists to bill for clinical services under Medicare Part B, despite their qualifications. While some states allow reimbursement through Medicaid by designating pharmacists as \u0026ldquo;other licensed practitioners,\u0026rdquo; broader progress is limited by fragmented advocacy among state pharmacy associations and academic institutions. Stronger collaboration among these groups could strengthen advocacy efforts, improve reimbursement mechanisms, and enhance the sustainability of pharmacist integration. Additionally, opposition from the American Medical Association underscores the need to examine how policy debates affect the adoption and long-term impact of pharmacist-led models. Similar challenges are seen internationally, where variations in polices and norms affect the scope of clinical pharmacy practice across countries, causing differences in pharmacy education and training. In response, Paudyal, et.al., proposed the development of global guidelines, which can be tailored to various healthcare settings, helping to overcome common policy and structural challenges [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBroader Medicaid coverage offers promise in the U.S [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. When pharmacists are reimbursed for clinical services, healthcare tends to become more colocated and accessible, particularly critical in rural areas. In Tennessee, where 93 of 95 counties face primary care shortages, integrated models like the Tennessee Heart Health Network represent a vital strategy for addressing geographic disparities in access.\u003c/p\u003e\u003cp\u003eA strength of this study is its use of the photovoice method, which provided rich, real-world insights into pharmacists' integration experiences. Engaging frontline pharmacists allowed for the identification of their contributions, as well as practical barriers and facilitators, informing future interventions and policy recommendations to support scalability across diverse primary care settings. The participant group represented both rural and urban clinics, adding to the study\u0026rsquo;s relevance.\u003c/p\u003e\u003cp\u003eA limitation of the study is that the findings are context-specific to Tennessee, where the scope of pharmacy practice is governed by state-specific regulations under the Pharmacy Practice Act [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and a small group of pharmacists; readers should be cautious in extrapolating to other settings. Additionally, the findings are exploratory; we did not aim for theoretical saturation, but rather to uncover key insights and generate hypotheses for larger studies. With only one focus group, we cannot claim to have reached saturation; additional participants or sessions might have revealed further themes. Thus, the results highlight core insights but may not capture the full range of experiences. Interestingly, participants from four different health systems reported similar experiences, suggesting some common pathways to successful integration. However, given the small sample, we advise caution in generalizing broadly.\u003c/p\u003e"},{"header":"CONCLUSION ","content":"\u003cp\u003eThis photovoice study offers unique insights into the perceived impact of pharmacists within clinical healthcare teams. Pharmacists in this study not only strengthen clinical care delivery but also support other team members in achieving their highest level of training, which may be a sustainable source for reducing physician burden.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research has been funded by the Agency for Healthcare Research and Quality (AHRQ). 1U18 HS27952-01; Tennessee Heart Health Network: Implementing Patient-Centered Practices in Primary Care to Improve Cardiovascular Health; EvidenceNow.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by CG, AE, GH, and SF Candidate. The first draft of the manuscript was written by QV, CG, SF, AE, and GH, and all authors including JB and BJ commented on previous versions of the manuscript. All authors read and approved the final manuscript. The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eWe gratefully acknowledge the Principal Investigator of the EvidenceNow grant in Tennessee, James Bailey, MD, MPH, FACP, who provided encouragement throughout the completion of this project, without whom this achievement would not have been possible. We also gratefully acknowledge the pharmacists who gave their time, experiences, and creativity to this study.\u003c/p\u003e\u003cp\u003e The main text contains information on ethics review: This study was deemed exempt from full review by the University of Tennessee Institutional Review Board (Approval Number: 24-10066-XP) in accordance with federal guidelines for research involving minimal risk. Participants provided consent to participate and use their photographs and narratives in publications.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMaslach C, Schaufeli WB, Leiter MP, editors. Job burnout. Annu Rev Psychol. 2001;52:397\u0026ndash;422. 2. Institute of Medicine Committee on Quality of Health Care in A. In: Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US) Copyright 2000 by the National Academy of Sciences. All rights reserved.; 2000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThorakkattil SA, Parakkal SA, Mohammed Salim KT, Arain S, Krishnan G, Madathil H, et al. Improving patient safety and access to healthcare: The role of pharmacist-managed clinics in optimizing therapeutic outcomes. Explor Res Clin Soc Pharm. 2024;16:100527.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSudeshika T, Deeks LS, Naunton M, Peterson GM, Kosari S. Evaluating the potential outcomes of pharmacist-led activities in the Australian general practice setting: a prospective observational study. Int J Clin Pharm. 2023;45(4):980\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHazen ACM, de Bont AA, Boelman L, Zwart DLM, de Gier JJ, de Wit NJ, et al. The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: A systematic review. Res Social Adm Pharm. 2018;14(3):228\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcFarland MS, Buck ML, Crannage E, Armistead LT, Ourth H, Finks SW, et al. Assessing the Impact of Comprehensive Medication Management on Achievement of the Quadruple Aim. Am J Med. 2021;134(4):456\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChoe HM, Standiford CJ, Brown MT. Embedding pharmacists into the practice: collaborate with pharmacists to improve patient outcomes. AMA Steps Forward; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSeston EM, Schafheutle EI, Willis SC. A little bit more looking\u0026hellip; listening and feelingA qualitative interview study exploring advanced clinical practice in primary care and community pharmacy. Int J Clin Pharm. 2022;44(2):381-8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoung AJ, Richardson F, Fitzgerald D, Heavrin BS, Tweddell B, Gettings L, et al. Let Their Voices Be Seen. Ann Emerg Med. 2020;76(3s):S73\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaag JD, Yost KJ, Kosloski Tarpenning KA, Umbreit AJ, McGill SA, Rantala AL, et al. Effect of an Integrated Clinical Pharmacist on the Drivers of Provider Burnout in the Primary Care Setting. J Am Board Fam Med. 2021;34(3):553\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith M, Bates DW, Bodenheimer T, Cleary PD. Why pharmacists belong in the medical home. Health Aff (Millwood). 2010;29(5):906\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang C, Burris MA. Photovoice: concept, methodology, and use for participatory needs assessment. Health Educ Behav. 1997;24(3):369\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHergenrather KC, Rhodes SD, Cowan CA, Bardhoshi G, Pula S. Photovoice as community-based participatory research: a qualitative review. Am J Health Behav. 2009;33(6):686\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrant CC, Mzayek F, Mamudu HM, Surbhi S, Kabir U, Bailey JE. Building Statewide Quality Improvement Capacity to Improve Cardiovascular Care and Health Equity: Lessons from the Tennessee Heart Health Network. Jt Comm J Qual Patient Saf. 2024;50(7):533\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStegenga K, Burks LM. Using photovoice to explore the unique life perspectives of youth with sickle cell disease: a pilot study. J Pediatr Oncol Nurs. 2013;30(5):269\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSeston EM, Schafheutle EI, Willis SC. A little bit more looking\u0026hellip; listening and feelingA qualitative interview study exploring advanced clinical practice in primary care and community pharmacy. Int J Clin Pharm. 2022;44(2):381-8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeung L. Validity, reliability, and generalizability in qualitative research. J Family Med Prim Care. 2015;4(3):324\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHawes EM, Page C, Galloway E, McClurg MR, Lombardi B. Pharmacists Colocated With Primary Care Physicians: Understanding Delivery of Interprofessional Primary Care. Med Care. 2024;62(2):87\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLorenz LS, Chilingerian JA. Using visual and narrative methods to achieve fair process in clinical care. J Vis Exp. 2011(48).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaudyal V, Okuyan B, Henman MC, Stewart D, Fialov\u0026aacute; D, Hazen A, et al. Scope, content and quality of clinical pharmacy practice guidelines: a systematic review. Int J Clin Pharm. 2024;46(1):56\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHawes EM, Misita C, Burkhart JI, McKnight L, Deyo ZM, Lee RA, et al. Prescribing pharmacists in the ambulatory care setting: Experience at the University of North Carolina Medical Center. Am J Health Syst Pharm. 2016;73(18):1425\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAdams AJ, Weaver KK. Pharmacists' Patient Care Process: State Scope of Practice Priorities for Action. Ann Pharmacother. 2021;55(4):549\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"qualitative research; pharmacists; primary health care, burnout, professional, quality indicators","lastPublishedDoi":"10.21203/rs.3.rs-7696085/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7696085/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e: Meeting patients\u0026rsquo; needs requires team-based approaches that address disease management, medication safety, and patient-centered care. Pharmacists are uniquely positioned to close care gaps, optimize medication use, and provide valuable education to patients, clinicians, and staff. This study explores the lived experiences of pharmacists integrated into primary care clinics.​\u003c/p\u003e\u003cp\u003e\u003cb\u003eAim\u003c/b\u003e: To explore the real-world role of clinic-embedded pharmacists in primary care clinics.​\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod\u003c/b\u003e: The study employed photovoice, a visual research technique using participant-generated photographs. Pharmacists providing direct patient care were asked to take 3\u0026ndash;5 photographs related to their experiences with collaboration, interactions with physicians and patients, successes, and system-level barriers and facilitators to integrating clinical pharmacy into primary care clinics. A focus group was conducted to share photographs and reflections, followed by thematic analysis.​\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e: Six pharmacists from the University of Tennessee Health Science Center\u0026rsquo;s Tennessee Heart Health Network, representing four healthcare systems participated in the study.​\u003c/p\u003e\u003cp\u003eFive themes emerged: 1) From skepticism to advocacy (role clarity and trust), 2) Integration through visibility and accessibility, 3) Role expansion from medication access tasks to clinical leadership allows physicians more time, 4) Safety and quality gains via innovation and standardization, and 5) Patient education and co-visits enhance the care experience. Pharmacists reported outcomes, including improved medication safety processes and better chronic disease management.​\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e: Collaboration between pharmacists and care teams was perceived to improve patient experience and care processes. Integrating pharmacists may help alleviate physician workload and burnout.\u003c/p\u003e","manuscriptTitle":"Through the Lens: Photovoice Reveals the Role of Pharmacists in Primary Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 02:08:29","doi":"10.21203/rs.3.rs-7696085/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-20T14:31:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T12:48:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25304947213898600963568230054897693190","date":"2025-10-15T10:03:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-07T14:29:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280998668340194354127988072583866948630","date":"2025-10-01T18:21:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-29T18:11:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-24T03:12:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-24T03:11:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Clinical Pharmacy","date":"2025-09-23T15:31:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-pharmacy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcp","sideBox":"Learn more about [International Journal of Clinical Pharmacy](https://www.springer.com/journal/11096)","snPcode":"11096","submissionUrl":"https://submission.nature.com/new-submission/11096/3","title":"International Journal of Clinical Pharmacy","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4d01eb8d-5572-4b01-93d6-7cf7dda79d84","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:06:11+00:00","versionOfRecord":{"articleIdentity":"rs-7696085","link":"https://doi.org/10.1007/s11096-025-02047-2","journal":{"identity":"international-journal-of-clinical-pharmacy","isVorOnly":false,"title":"International Journal of Clinical Pharmacy"},"publishedOn":"2025-11-24 15:57:06","publishedOnDateReadable":"November 24th, 2025"},"versionCreatedAt":"2025-10-15 02:08:29","video":"","vorDoi":"10.1007/s11096-025-02047-2","vorDoiUrl":"https://doi.org/10.1007/s11096-025-02047-2","workflowStages":[]},"version":"v1","identity":"rs-7696085","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7696085","identity":"rs-7696085","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}