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.

Laura

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.

Thursday, October 11, 2018

Rotation 1, 2, 3: The Pharmacy Life Chose Me

Posted by Michael Tsai at Thursday, October 11, 2018

Hi Mom! Look, I’m on a blog!

Hello everyone! I hope you have been enjoying the posts by my fellow classmates. Since we aren’t spending our days together in the classroom anymore, it’s been interesting to read about their experiences in all the different settings of pharmacy. 


As fall arrives here in Michigan, here's a look back at my summer experiences:

Community Pharmacy
I had the pleasure of completing my first rotation at an independent specialty pharmacy. The store pharmacy, where I mainly worked, had an organized workflow and offered services, such as immunizations, medication synchronization, and medication therapy management, which set it apart from other pharmacies. My routine started with clarifying prescriptions with doctors if there were any discrepancies in the mornings. Throughout the day, in addition to helping with the dispensing process, I answered several questions from patients. Patient questions included anything about over-the-counter products, side effects, drug interactions, and device administration. Being able to fully assess patient characteristics and quickly refer to drug information references were essential on this rotation. I also conducted phone calls for medication therapy management and adherence checks to ensure that patients had an optimal therapy regimen in place and that they did not have issues getting their refills. 

On this rotation, I also had the opportunity to tour the corporate headquarters and shadow the process of a prescription order and follow-up for patients around the country. Much work goes into making sure the patient receives their medication on time and in optimal condition. Something as detailed as weather conditions need to be monitored as these changes may affect the stability and efficacy of medications. Patients are also kept in close contact to ensure that the medication is working for them and that any side effects they are experiencing are properly managed. Since specialty pharmacy is a hot topic these days, it was very insightful to see how one operates on a national scale, especially considering its interactions with different stakeholders, including healthcare providers, the pharmaceutical industry, and healthcare payors.

As a community pharmacy rotation, this rotation helped further develop my patient counseling skills and showed me all the behind-the-counter work that goes into dispensing a prescription and running a store. I am grateful I got to see the corporate side and the various roles pharmacist play in that setting as well.


Non-traditional Pharmacy
My second rotation was at the Food and Drug Administration (FDA) in Maryland. Though hesitant at first, I ended up enjoying the adventurous drive to Maryland and even stopped along the way at the United 93 Memorial in Pennsylvania, which was very sobering and momentous. 

I had an incredible time learning about drug development and drug regulation. I was placed in the Office of Clinical Pharmacology, which focuses on studying pharmacodynamics (what the drug does to the body) and pharmacokinetics (what the body does to the drug) with a given dose and dosage form. Clinical pharmacology reviewers determine if the proposed dose is safe and efficacious with statistical analysis that the pharmaceutical company provides. Sometimes, reviewers will conduct further analysis to confirm the findings. While this office consists mainly of Ph.D. graduates instead of Pharm.D. graduates, there still are pharmacists that pursue additional training to become well-versed in clinical pharmacology. 

My project for this rotation focused on developing a training program for new clinical pharmacology reviewers. The program centered around building a knowledge system of past reviews to help reviewers make decisions on current reviews. Through that, I learned much about using publicly available information. It’s surprising how much one can learn from reading past reviews and going through several reviews can give a bigger picture of regulatory standards from a clinical pharmacology standpoint. Besides attending several internal meetings, I also attended lectures about the different roles for pharmacists in government agencies. Along with my previous rotation, this rotation has me questioning my post-graduate career plans (which I hear is common among P4 students).

Being in another state was also an amazing experience. I spent my free time exploring the area and befriended many locals and pharmacy students.


Ambulatory Care Pharmacy
When I first began exploring pharmacy as a career path, I thought ambulatory care pharmacy meant a pharmacist working in or with ambulances. I quickly learned I was wrong. The best way I would describe the field of ambulatory care is helping patients manage illnesses through individualized clinic or phone visits. On this rotation, I primarily focused on diabetes management. Patients who were still having trouble with their glucose levels while being cared for by their primary care doctor could be referred to the pharmacist. One of the physicians personally told me that she was grateful to have a pharmacist who could focus one visit on solely addressing diabetes, since many times physicians did not have time during their visits. Patients would always want to bring up other concerns.

On this rotation, I was responsible for collecting information from patients, including their dietary and exercise habits, their blood glucose readings, and their medications. I would then discuss this information with my preceptor and come up with a plan on how to best help the patient moving forward and relay this to the patient. This plan is very individualized and could be either specific changes to improve diet and exercise or adjusting medication regimens. Additionally, it was very important for the patient to agree to this plan. Only then would the patient have the motivation to carry it out. In addition to lifestyle and medications, I also gained exposure to the medical device world. As many patients with diabetes were on insulin therapy, they needed glucometers, test strips, and lancets to optimize insulin dosing. I also learned about continuous glucose monitors, which are implanted into a patient’s arm and save patients from having to poke themselves several times a day. 

All in all, I truly enjoyed engaging with patients and setting goals with them. It was inspiring to see some of them become more involved in taking care of their own health, which resulted in positive outcomes after subsequent visits. 

Friday, October 5, 2018

Rotation 4: Drug Information

Posted by Laura Hayes at Friday, October 05, 2018

During the last 5 weeks, I had the opportunity to work with a well known drug information company and had a great experience!

Before the rotation started, I talked to multiple people who had this rotation in the past and came in with some specific expectations. While my expectations pretty much held up (time requirement, workload, preceptor style), I learned it is important to continue keeping an open mind going into any rotation no matter what you were told by others.

First, I'll let you know that this is one of the only rotations where you get to work from home!! It was amazing and I really enjoyed setting my own schedule and working at my pace! That being said, you have to manage your time well and hold yourself accountable to getting all the work done. I met with my preceptor (and fellow classmate on rotation with me) three times a week. These meetings were between 20 minutes and 1 hour and were helpful in keeping me on track with the rotation work. My preceptor was a great resource and was very receptive to questions and suggestions. She also gave great feedback and really helped refine my skills.

My preceptor worked in the drug interaction section of the company, so we worked on updating and creating drug interaction monographs. After this rotation, I feel a lot more comfortable doing PubMed searches because of all the searching I did for this rotation! I know I will take the skills I learned in this rotation and bring them with me wherever I go! I also learned how to write concise, one sentence summaries of clinical studies for the monographs. This is a very specific kind of writing and I think it will be helpful in the future when I am writing papers and in residency. I also got to explore topics I didn't know much about during three longitudinal projects (drugs that prolong QTc, possible UGT1A1 inducers/inhibitors and interactions with smoking).

I feel really proud of the work I did this rotation. There are people all over the world who will use the monographs I created to help patients! I can go and lookup the drug interaction (e.g., omeprazole and ginkgo biloba) and see one of the monographs I created! I feel so excited thinking that I contributed something so practical and widely used to the field of pharmacy and medicine!

Two things to remember:
-Keep an open mind going into any experience and put your best foot forward!
-Make sure you take time and enjoy this beautiful life, no matter how busy it gets!

Exploring Maine: Acadia National Park (top) and Baxter State Park (bottom)

Monday, September 17, 2018

Rotation 3: Infectious Diseases

Posted by Andrea at Monday, September 17, 2018

This rotation was a bit more busy for me, because I had my P4 seminar presentation. P4s are required to put together a 30-40 minute presentation for our class about our PharmD Investigations (longitudinal research project) or a pharmacy topic. The topic I presented about was the controversy of using steroids in septic shock. While this rotation did not require much outside work, most of my days after rotation were spent working on my slide deck or practicing my presentation. I was so glad to have finished this!

Rotation 3: Infectious Diseases
My third rotation was Infectious Diseases. This was my first clinical rotation and ID was a difficult topic for me in P3 Therapeutics, so I was nervous before starting this rotation. I had a variety of experiences on this rotation, including rounding with the ID team and antimicrobial stewardship. A typical day of rounding would start with working up patients (8AM-10:30AM), meeting with my preceptor to discuss patients (10:30AM-12PM), and end with rounding with the ID team which consisted of an attending, a fellow, a resident, and two med students (1PM-4 or 5PM). Rounds take a long time, because ID is a consult service so their patients are scattered all over the hospital. Days on antimicrobial stewardship were much different. The ID pharmacists share these responsibilities. There is disease-based stewardship, where antimicrobial therapy is reviewed and optimized for patients based on targeted disease states (e.g. HIV). There is also drug-based stewardship, where restricted drugs are reviewed for appropriateness (e.g. linezolid, daptomycin). These days were spent reviewing patient charts on the computer, followed by discussions with my preceptor. I also attended antimicrobial stewardship committee meetings (pharmacists and physicians discussed initiatives to optimize antimicrobial therapy), presented a topic discussion, and journal clubs. My preceptor would often send studies to read and discuss the next day.

Something I learned from this rotation was how to “work up” patients. We focused primarily on the ID problem. For each patient, we had to assess if the antimicrobial therapy was appropriate including drug, dose, frequency. To follow up, we assessed vanco and aminoglycoside drug levels and monitoring parameters.

Some questions I encountered on rounds were: Does this drug require renal/hepatic adjustment? Anyone know the patient’s creatinine clearance today? How do I dose this if the patient is getting dialysis? I also liked seeing how there was opportunity for pharmacists to develop wide-reaching initiatives through policy and guideline development. For example, they were trialing a pilot program for penicillin skin testing, creating guidelines for community acquired pneumonia treatment, and pediatric animal bite treatment guidelines. I really enjoyed this rotation!

Rotations 1-3: A Triad of Non-Clinical Rotations

Posted by Melanie Green at Monday, September 17, 2018

Hello fellow COP students 😃  Thanks for visiting our P4 blog!  Before I go into my first post, here is a little bit about me (feel free to skip the rest of this paragraph if you're just interested in the riveting rotation details).  I am originally from Pittsburgh, PA, and I came to U of M for undergrad in 2012.  I joined the COP in 2015 after completing 2.5 years of undergraduate prerequisites (shout out to the non-degree-ers).  I have a long history with working in community pharmacy at CVS, a job which I truly LOVE.  In pharmacy school, I have been an active member in SMPA, PSA, and MPSO, and have enjoyed taking advantage of the opportunities that those and other student organizations have offered me throughout the past 3 years.  I am always willing to talk about my extracurricular experiences, so feel free to contact me with any questions about that stuff!  This summer I have been balancing starting rotations with buying my first house and taking care of two children (cats), so if anyone is looking for advice on home-buying or parenting, I'm pretty much an expert (ha).

Our first house.  Goodbye Ann Arbor rent prices!

Buffalo Yoda Green

Lady Macbeth Green

As for my rotations so far:  my first, second, and third blocks were all very non-clinical based, which has turned out to have both positive and negative impacts on my rotation experience...on one hand, they provided a fairly smooth start to P4 life; I wasn't inundated with intense responsibilities, pharmacokinetics, or rare disease states to learn about.  I didn't do any topic discussions or any outside projects and I worked fairly consistent hours.  Each rotation had it's challenges, of course, but overall they were straightforward and stress-free.  However, it was very, VERY easy for me to fall off the clinical skills wagon.  Because I didn't really keep up with studying or reviewing notes during the first 15 weeks (even though I told myself I was going to...), it was difficult for me to switch gears back into analyzing doses and writing SOAP notes for my 4th block (more to come in my next blog post).  Looking back, my advice to myself (and to anyone reading this preparing for rotations) would be to listen to our Deans and be a life long learner!  Remember that if you don't use it, you will lose it, and that just a few minutes a day of review and staying up to date will really pay off when you need it.

Rotation 1: Non-traditional (Managed Care)

My first rotation provided a nice easy transition from P3 to P4 life.  My primary responsibilities at my Managed Care rotation were to call members to complete comprehensive medication reviews (CMRs), then to complete a write up that included important counseling points from our conversation and an updated medication list, which I would then mail out to the patients for them to use for their records and share with their families and doctors.  On the surface, these daily tasks were simple and straightforward.  However, they involved unique opportunities to provide individualized patient care in order to empower our members to improve their health.  For example, I would often get questions and comments from members about how they did not agree with a medication prescribed by their doctor, or about what medications were for and why they had to take them.  As a future pharmacist, this is where I felt my expertise in pharmaceutical knowledge and patient counseling came into play.  I was able to provide the information that the patients needed to become educated about their medications and health, and even if the patient didn't always agree with my input, they at least gained the knowledge necessary to make more educated health decisions.  Additionally, through our conversations and the write-ups that I would send, patients would receive references and information that they could use to empower themselves to start conversations with their doctors about their health an become a more active participant in their health care.  

These patient care aspects of the rotation were rewarding to me as a student because I felt that I was able to make a true impact on the members' health, either by simply sending them an organized medication list or being able to answer their health questions that they felt were previously unexplained by other health care providers.  Another special patient-care responsibility was that of sending targeted medication reviews to prescribers; if I identified the potential for medication optimization (such as duplicate therapies, target dose optimization, and finding lower-cost medication alternatives), I would send a notice to the prescriber.  On several occasions, the prescriber accepted my recommendation or would respond back that he/she had reviewed the patient's health profile as a result of my intervention.  To me, this was an unprecedented example of interdisciplinary health care and the impact it could have on a patient.

In addition to the CMRs, I also took part in several meetings and teachings about the workings of a managed care setting.  This included aspects such as formulary management, specifics of different insurance plan options and the details of payment, and STAR criteria, among others.  Overall, it was an all-inclusive rotation with a good balance of patient care and operational work that allowed me to refine my written and verbal communication within a specialized population.

Rotation 2: Community

As I mentioned, I have a long background working in community pharmacy, so this rotation was pretty ordinary for me.  However, although I was generally familiar with the everyday flow of the pharmacy, my experience here taught me to never discount the potential for new learning opportunities, even in familiar settings.  From picking up clinical pearls from different pharmacists, to being in charge of managing the a Shingrix shortage, to learning new ways that individual pharmacies operate, there was always an opportunity to broaden my community experience and knowledge.  Most importantly, this rotation taught me to always approach my pharmacy experiences with lots of questions, an open mind, and a willingness to learn.


Rotation 3: Health Systems/Hospital

My third rotation was where I really started to feel comfortable with the P4 rotation experience.  Initially, I was apprehensive about this one;  it was my first out of area rotation, which was intimidating in itself, let alone the fact that my preceptor happened to be the senior director of pharmacy AKA knows everyone AKA could have a real influence in me getting a job/residency in the future 😉.  The rotation was set up to be very independently driven; I was given a schedule of shadows and events to attend, but my preceptor made it clear to me that I could make the rotation what I wanted.  I could follow the schedule, or I could skip all of the events and do research in the library every day for 5 weeks.  For me, this was a refreshing approach to precepting, because it meant that I could build my rotation around what I personally valued and what I knew would be the most beneficial to me.

It turned out to be somewhat of a career-defining rotation.  Throughout my time, I saw just about every aspect of how a health system runs: operational, financial, inpatient pharmacy, pediatric pharmacy, purchasing and inventory, and business management.  Additionally, because my preceptor was a director, I had a lot of exposure to the administrative side of the hospital, which is where I really felt in my element.  Prior to this, I had suspected that I might have an interest in pharmacy administration, and when I finally got to work in that setting, my interest was confirmed.  Because of my preceptor's willingness to let me forge my own rotation path, I was able to tailor my experiences to the administrative side of things, and in doing so I rubbed elbows with several higher-ups and worked on hospital-wide projects, including a shortage management project and one on reducing hospital readmissions for acute kidney injury.

While each of my experiences on this rotation were valuable to both my education and personal growth, the biggest message I took away from it all was to be fearless.  While it's definitely a cliché, it's a valid one.  Although I was a bit intimidated by the environment an the people with whom I was interacting, I tried to approach each situation with confidence and motivation to succeed, and it couldn't have been more beneficial.  I met a lot of successful people who were very encouraging and willing to share their knowledge and experiences, which was invaluable.  I can definitely see myself pursuing a career in this setting, which is such an exciting thing to be able to say!


Sunday, September 9, 2018

Rotation 3: Specialty Ambulatory Care

Posted by Terrence Pang at Sunday, September 09, 2018

This was my first experience dealing specifically with specialty drugs, which are commonly referred to as "high cost, high touch" drugs. The high cost part makes sense, but what was not immediately apparent to me was the concept of high touch. I soon learned that high touch simply meant that these drugs needed more hands-on management in the forms of baseline evaluations and follow-up calls with the patients, which is not like what a regular community pharmacy would do. I liked this aspect, since it gave me a sense of how patients progressed through a short-term treatment plan. In particular, I gained some familiarity with hepatitis C treatment, which was usually treated for a duration of 8 - 12 weeks. Having previously done the HIV community rotation and now this, I also developed an appreciation for how far we have come in terms of improving medications. Compared to the antiviral options we have today, the early drugs just seemed much more burdensome in every way possible, not to mention that their efficacy was also not as good. The problems with side effects, frequency of administration, and other administration considerations (e.g. with or without food) are mostly not an issue with today's options.

Another aspect of therapy that I understand a little more of after this rotation was the prior authorization process. While the majority of submissions from our service to insurance companies do get approved, occasionally we had to submit appeals after receiving the denial verdict. While writing appeals to insurance companies did not sound appealing at first, this exercise actually proved very insightful. I was forced to delve deeper into the primary literature and use the data to demonstrate that my patient truly would benefit from getting this drug approved. Depending on the insurance, I also may have needed to collect lab results to illustrate the severity of the patient's condition, and it was not just limited to the Child-Pugh score that we learned in class.

Aside from my main priority in doing baseline and follow up calls with patients mostly for hepatitis C medications, I also had the opportunity to contribute to some quality improvement projects. Specifically, I collected the data to show that compared to the national average, our specialty pharmacy financial coordinators did a great job in terms of PA and appeal approval rate. Furthermore, I also looked into the average turnaround time for prescriptions filled by Michigan Medicine versus those filled by outside pharmacies. These small side projects allowed me to look at the bigger picture of healthcare, and see that there is clearly much more to treatment than just the drugs themselves.

Although I prefer more in-person consultations as opposed to telephonic ones, this was still a valuable learning experience. I learned how to manage my time and juggle multiple responsibilities, but I also now understand that taking extra time to be meticulous about your work is important to. In other words, try to avoid speeding through tasks just to get them done, and really spend some time to think about what you're doing. All good things to take with me as I head into my next rotation (and first inpatient) at the neuro ICU here at Michigan Medicine!