Saturday, February 16, 2019

Rotation 7: Oral Oncology (Ambulatory Care)

Posted by Laura Hayes at Saturday, February 16, 2019

Over the last 6 weeks I had the opportunity to experience a new (to me) kind of Ambulatory Care clinic. I worked with the Oral Oncology team to follow-up with people who were on oral medications for their cancer.

This was a phone-based clinic where we did initial, 10 day follow-up, and 6 month follow-up calls. Initial calls included medication counseling on how to take the medication, possible side effects and how to manage the side effects. We followed up with these patients after they had been taking the medication for about 10 days (and then 6 months) to see how they were doing.

This rotation required critical thinking and problem solving as each patient case was different and needed to be examined in order to know the appropriate time to contact the patient. Follow-up calls also needed to be handled differently in terms of setting up additional follow-up by the team or by clinic.

I also had the opportunity to be in the Genitourinary cancer clinic one half-day a week. This was the first time I experienced an ambulatory care clinic where the pharmacist did not have a set schedule of patients to see during the day. The pharmacist would use a custom scoring tool in order to decide which of the physician's patients she was going to see that day. When she went and saw patients she did a lot of symptom management and medication counseling. She was also available for questions from the nurses and physicians. Being in the GU clinic helped break up my Monday's, but it also allowed me to see a different format of ambulatory care clinics; and for that I am very thankful.

One of the best things about this rotation was the people! I got to work with multiple pharmacists, residents and pharmacy students who were extremely passionate about the work we were doing as well as extremely knowledgeable about the subject.

As I finish this rotation and move on to the next I am taking with me a greater confidence and ability to counsel patients, communicate empathy and adapt to different situations quickly.

As a follow-up to my last post I also wanted to talk briefly about this last rotation in terms of residency interviews. This rotation was 6 weeks long (1 week longer than the others) to allow for students to miss up to 5 days for interviews. I am very thankful that I was able to finish all of my residency interviews during the 5 days this rotation. Now all I have to do is rank the programs and wait until March 15th!

Tuesday, February 5, 2019

Rotation 4, 5, 6: Drug Information, Critical Care, General Medicine

Posted by Andrea at Tuesday, February 05, 2019

Rotation 4: Drug Information

This rotation was with a drug information company and I was able to work remotely, as my preceptor also works remotely. We met two to three times a week for about one hour and communicated often during the week via email. My responsibilities were to write monographs for drug-drug interactions and drug-gene interactions (e.g. CYP2D6, CYP4A4, etc.). This consisted of reading lots of articles, learning how to scour PubMed for literature, and writing concise summaries.

Time management was incredibly important in this rotation. I had the freedom to create my own schedule each day, but this also allows for time to slack off. I had to hold myself accountable and ensure I completed my work. I learned a lot about what goes into writing the monographs when we search our drug information resource for quick answers about drugs and interactions. I always thought I would enjoy working by myself, so I was surprised that I missed interacting with co-workers and patients daily. Looking forward, I hope to find a position that balances independent work with teamwork or direct patient care.

Rotation 5: Critical Care

This rotation was in the surgical intensive care unit (SICU) at a local community teaching hospital. Going into this, I was nervous and intimidated by the complexity of critical care patients. My typical day started with working up patients (6AM-9AM), round with the team (9AM-11AM), eat lunch and finish working up patients (11AM-12PM), then meet with my preceptor (12PM-1PM). After this, I would work on assigned drug information questions or projects for the rest of the day. Working up patients in the ICU is based on the head to toe systems approach, rather than problem based like how we learned in class. This means problems were categorized by systems, which could include neurological, pulmonary, cardiovascular, GI/FEN (fluids, electrolytes, nutrition), I/O (ins and outs), ID, and heme. Patients were very sick and often had multiple problems within each system listed above.

I am very grateful to have had this rotation. I have a much better understanding of anatomy and how surgical changes can affect drug action/metabolism in the body. I also learned about weaning patients off pressors, opioid conversions, and nutrition. I had the opportunity to work with a large team, which consisted of an attending, fellow, residents, medical students, and dietitian. I also enjoyed working with my preceptor who was a great teacher and with another pharmacy student from a nearby school! Overall, this was a great learning experience and I am glad I was able to try it out.

Rotation 6: General Medicine (Adult Internal Medicine)

All P4 students are required to take the Gen Med rotation and I was placed on the Adult Internal Medicine service. This was a busy rotation, due to the patient load and weekly projects. My service capped at 11 patients and by the end of the rotation, I was managing the entire service. Patients had a variety of disease states, including pneumonia, UTIs, atrial fibrillation, and diabetes. The typical day started with working up patients (5AM-7:30AM), pre-round with my preceptor where I would present patients and run my recommendations by him (7:30AM-8AM), round with the team (8AM-11AM), and post-rounds with my preceptor where I would update him with any changes (11AM-11:30AM). The rest of the day was spent educating patients discharged on anticoagulation, meeting with my preceptor to go over patients or topics, and meeting with the other students also on Gen Med to present our projects. Time management and efficiency are key to this rotation and each student will develop their own schedule or system that works for them.

Pharmacists play an important role in antimicrobial stewardship and anticoagulation management on this service. I enjoyed the variety of patients and activities in this rotation. I was constantly learning and it made the long days fly by. My advice to students is to embrace this rotation and challenge yourself to learn as much as you can!

This rotation ended just before the holidays and I am currently on my off block. After this, only 2 more rotations until graduation!

Gen Med Block 6 students wearing our ugly Christmas sweaters!

Wednesday, January 16, 2019

Preparing for the next step

Posted by Laura Hayes at Wednesday, January 16, 2019

2019. This is the year I graduate from Pharmacy school. After 8 years at the University of Michigan I will finally be done! 

I've been doing a lot of reflecting recently as I am on the precipice of many major changes: the end of school, transitioning into the role of a practitioner, and possibly moving (with everything that entails). I think it is extremely important to take a step back and reflect on where you've been and where you hope to go at times like this. 

I am amazed at all I've learned and how much I've grown in the last 8 years. These years have provided me countless joys and moments of growth and I am so excited to see where the next 8 years bring me. 

I am so thankful for all the experiences and opportunities I've been blessed with because of my education, family, friends, and connections. I have been able to travel, learn from people different than me, discover what I'm passionate about and begin to make a plan for the rest of my life. 

Last rotation was my "Off rotation". At UofM we can choose to take one rotation off. I chose the last one so I could focus on residency applications, work at the hospital and have flexibility to be with family over the holidays. I had many great conversations reflecting on the past and dreaming about the future. I am so thankful I had this time to prepare for the next steps in my life. 

In just a few months things will be very different, and I am going into that change thankful and ready to take on the challenge. 

Thursday, January 10, 2019

Rotation 4, 5, 6: Keeping up with Therapeutics

Posted by Michael Tsai at Thursday, January 10, 2019

Inpatient – Cardiology
On this rotation, I got to experience the day-to-day of a clinical pharmacist specialist in a health-system. My schedule would consist of working up patients early in the morning to make sure I had the most up-to-date lab results for the patients on my service and to check if anyone was admitted overnight.  I would start rounding with the medical team at around 9 am. The team consisted of an attending physician and 3 medical residents. During rounds, the medical residents would update the attending about the patients and make suggestions. They would also see the patient and update them on their progress. My role during rounds was to collect information and make any recommendations I previously discussed with my preceptor. I was actively thinking of labs to order and optimizing medication regimens. Outside of rounds, I also was responsible for medication reconciliations to ensure the medications the patient was taking at home was the same ones ordered in the hospital. I educated patients if they were put on a new anticoagulation medication and oversaw warfarin dosing and monitoring.

Throughout my rotation, I had the opportunity to work with three different medical teams, which showed me different leadership styles and receptiveness to recommendations. Additionally, I picked up on procedures and surgeries commonly seen in the cardiology floor. While they are not taught in our pharmacy curriculum, they may determine which medications the patient should receive.

Days were long on this rotation since there were up to 16 patients to follow at times, but it was a worthwhile experience as it sharpened my clinical knowledge. It also provided an experience in interprofessional teamwork. Working with physicians showed me how little I knew about medical procedures and surgeries, but also gave me confidence in my pharmacy knowledge, as I answered many of their questions about medications.

Drug Information – Managed Care
My next rotation was with the prescription drug plan of an employer group. This was my favorite rotation so far since I am interested in pursuing a managed care pharmacy career after graduation. Assignments on this rotation were project-based. The first task I had was to prepare documents for advisory committee meeting, where formulary decisions would be made. With a new medication recently approved by the FDA, I summarized the characteristics of the medication, clinical trial results, proposed place in therapy, and economic considerations. After presenting this to the advisory committee and hearing the committee’s final decision, I drafted the prior authorization criteria and medication request form for this medication. These were to be used by the plan’s pharmacy benefit manager to determine if coverage would be provided for patients requesting the medication.

Another highlight of the rotation was learning to use Microsoft Excel. Managed care deals with large populations, so datasets are commonly analyzed through Excel. I conducted a drug utilization review, where I identified an at-risk target population from medical and pharmacy claims data. Using this information, the plan sent out letters to prescribers identifying their patients who were at-risk.

During this rotation, I also got to sit in on several meetings, including ones with a mail-order pharmacy, specialty pharmacy, pharmacy benefit manager, and medical benefit. These meetings showed me how a health plan interacted with these other healthcare stakeholders. Additionally, my preceptor allowed me to attend the Academy of Managed Care Pharmacists (AMCP) Nexus conference. On top of learning from multiple sessions about trending topics in managed care pharmacy, I also had the opportunity to network with managed care pharmacists and speak with residency programs at the residency showcase.

I enjoyed seeing projects from beginning to end on this rotation. Since it was a smaller health plan, pharmacists were the jack-of-all-trades and worked on all aspects of managed care pharmacy. I learned much more about this career field and gained valuable experiences.

Open rotation
At the University of Michigan College of Pharmacy, there is an option to leave one rotation free. I chose to have this rotation off to work on residency applications, serve as a groomsman in a friend’s wedding, and visit friends and family in California. I was glad to have some time off to rest and recuperate (and catch nice photos like the one below).

Now that the sun has set on 2018, I’m looking forward to new experiences in 2019!

Saturday, January 5, 2019

Rotation 6: General Medicine - Internal Medicine

Posted by Terrence Pang at Saturday, January 05, 2019

The General Medicine rotation that every single P4 goes through almost feels like a rite of passage. While its reputation for being difficult precedes it and may be exaggerated at times, the overall intensity is definitely a step up from most rotations. The patient care activities are not too different from other direct patient care rotations - you round with the rest of the healthcare team comprised of mostly doctors, and you take care of the anticoagulation and pharmacokinetic needs (read: vancomycin and aminoglycoside dosing and monitoring). However, what makes this rotation more challenging are the weekly projects, ranging from topic discussions to journal clubs. Nonetheless, I found the experience rewarding and had several interesting moments along the way that were quite memorable.

Diagnoses and ordering tests to confirm those diagnoses are usually under the physician's jurisdiction. We had a patient who had new complaints of mucosal ulcers. I patiently listened to the attending and medical students discussing potential causes. I then realized that I had been in a similar situation in my Surgical ICU rotation, and that patient had herpes simplex virus that was discovered using a HSV swab. So despite having no idea whether this would yield anything, I brought up the idea of getting a HSV swab on our patient. The attending and students seemed mildly surprised by my suggestion, but obliged. Turns out the patient did indeed have HSV, for which we started valacyclovir! The team gave me props for making this recommendation, and I have to say it is probably one of my proudest moments during rotations. It helped me realize that I was indeed progressing as a clinician, being able to take what I learned previously and apply it to a new setting. How exciting!

Another aspect of this rotation that I enjoyed was a MUE (medication use evaluation) on argatroban. Normally, this anticoagulant is used for patients with a documented heparin allergy or a positive HIT (heparin-induced thrombocytopenia) diagnosis. However, my preceptor suspected that we as an institution did not do a very good job of discontinuing argatroban upon negative HIT testing results. Sure enough, after combing through a year's worth of data, I found that we were spending tens of thousands of dollars on argatroban needlessly. It was towards the end of the rotation at this point, but we talked about setting up alerts in MiChart that would notify pharmacists whenever heparin antibody assay or serotonin-releasing assay results came back, so we can respond to such results in a timely fashion and avoid wasting more money. Perhaps getting trained in informatics could be useful...

All in all, I'm glad to be catching up on sleep this break. I won't miss waking up at 5 in the morning to get to the hospital so early, but I am glad we were put through the wringer. I have no doubt that these experiences will pay off when it comes time for residency interviews. I am also looking forward to my nontraditional rotation coming up next at the Michigan Oncology Quality Consortium. I'll be sure to update you on this in the near future!

Friday, November 9, 2018

Rotation 5: Long Term Care

Posted by Laura Hayes at Friday, November 09, 2018

Hello again.

I can't believe I'm done with rotation 5 of 9! This year has been speeding by!
I am so thankful for all the opportunities I've had in the last 6 months of rotations. I have been able to apply the information learned in the first 3 didactic years and have experienced some lesser known areas pharmacists are involved.

One of areas I had the opportunity to explore was long term care. A long term care pharmacy is a pharmacy that prepares and dispenses medications (and sometimes medical supplies) to patients residing in various long term care facilities (skilled nursing facilities, assisted living homes, etc.). Not only do they supply the medications, but pharmacists work as consultants for the long term care facilities to meet CMS requirements. CMS (Center for Medicare and Medicaid Services) requires all patients in skilled nursing facilities to receive a monthly drug-regimen review by a pharmacist. These pharmacists travel to the facilities and often look through both paper and electronic medical charts to assess drug regimens for safety and efficacy. These pharmacists then make recommendations to the providers about necessary monitoring, discontinuing medications, decreasing doses and other clinical suggestions to best care for these patients.

For the last 5 weeks, I worked at a local Long Term Care pharmacy that services long term care facilities across Central and Southeast Michigan. There were a wide variety of responsibilities and tasks to complete both in the pharmacy and on the road. When I was in the pharmacy, I participated in electronic order verification, antibiotic dosing, clozapine REMS monitoring and warfarin dosing. I also completed medication reviews for new admits and residents that had fallen and served as the final check for prescriptions before they left the pharmacy. When I was on the road with one of the consultant pharmacists, I helped review the paper and electronic medical records and helped make recommendations for the providers.

I really enjoyed my time on this rotation. The people were amazing to work with and I liked the variety of responsibilities. It was eye opening to learn about another area that pharmacists can make a difference in (other than the well known community/retail and hospital jobs).

Now that this rotation is done, I am transitioning into my "off rotation". I will be working, preparing for the ASHP Midyear Meeting and getting everything ready for residency applications. I'll make sure to post again soon to let you know how everything is going!

Thanks for reading.


Friday, October 12, 2018

Rotation 4: Kiddos

Posted by Melanie Green at Friday, October 12, 2018

My fourth rotation and my second out-of-area rotation was on a general pediatrics unit in an inpatient practice.  I originally elected to do a pediatric rotation because I had zero interest in pediatrics (and I still have zero interest; this isn’t going to be a sappy blog about a transformative, life-changing revelation, so don’t worry).  However, I always try to stand by the policy that you don’t know what you don’t know, so I wanted to make sure that I wasn’t intentionally overlooking an experience just because I suspected that I wouldn’t be interested in it. 

This being my first clinical rotation, I was definitely nervous.  In a way, I knew that I should feel prepared to do patient work-ups, presentations, and care plans because we had done so much of that in school.  On the other hand, regardless of the amount of class time spent practicing a skill, going into a hospital and doing it FOR REAL is a whole different thing.  Fortunately, my preceptor was patient and encouraging, and always made a point to give me feedback so I could continuously improve my patient work-up efficiency and presentation skills.  I had the added benefit of working closely with a PGY2 resident who is a UM COP alumnus..  This was a major advantage for me because even though the resident did not have the years of experience that my preceptor had, we were able to relate more about life, school, and career topics because we are closer together in age and stage of life.  Additionally, everyone else at this site was always SO nice and willing to answer my questions.  It was like having a ton of mini preceptors who all wanted to help me succeed :) 

The pediatric population is generally under-emphasized in class, so I had to change my whole way of approaching patient care.  Everything from normal lab values, to weight-based dosing, to worrying about decimals, to treatment options was different than in the adult setting, so it was almost like re-learning everything I thought I knew.  The learning opportunities were endless, as there are so many pediatric-specific disease states that I had to teach myself every day.

Overall, it was a tremendous learning experience.  Regardless of the fact that I didn't have a specific interest in becoming a pediatric pharmacist going in, I wasn't going to let myself miss out on the value of working in a unique, specialized field with many talented and knowledgeable cohorts.  I had to make a conscious decision to go into each day with an enthusiasm for learning and the confidence to contribute to real decisions regarding patient care.  I can definitely say that I have a new appreciation for this field of work!  For me, my pediatrics rotation was humbling.  Every day I was reminded that no learning opportunity should be disregarded or taken for granted, regardless of my personal interest in it.