When a patient brings you flowers…

Posted by Kendra Yum at Sunday, August 30, 2009

The patient poked his head into the doorway, hesitant to enter when he saw the clinical pharmacist in conversation about antihypertensive treatments with this Michigan PharmD student. The pharmacist was my preceptor, Gloria, employed at Detroit’s Veterans Affairs Medical Center. The patient had arrived for a follow-up visit at the VA's Hypertension and Risk Reduction Clinic (HRRC).

“Come on in," Gloria said, rising from her seat to greet the patient at the door.

He smiled. But instead of walking in, he turned the opposite way, returning a second later with a bouquet of pink and white carnations. He spoke with a gentle voice. “These are for you, Gloria," he explained. "I really do appreciate all the help you've given me.” I was struck by the sincerity of his gesture.

Gloria started each patient appointment with blood pressure and weight measurements. She also checked for ankle edema (swelling) if the patient was on a calcium channel blocker. Then, she would ask the patient if he had completed his “homework”: recording his blood pressure twice a day at home in order to review this data with his pharmacist. (HRRC provides an automatic blood pressure machine free to its VA patients.) Next, the pharmacist asked about unusual symptoms, tolerance to medication, and compliance with the prescribed medication regimen. A large portion of the session was devoted to lifestyle assessment, wherein the pharmacist extensively reviewed the patient’s dietary consumption, smoking habits, and exercise levels. She would then offer advice on how to make lifestyle changes to improve blood pressure.

Between patient appointments, Gloria explained to me how to develop a patient-specific drug therapy tailored to the patient’s biology, disease complexity, and pattern of compliance. She also identified what symptoms and lab values should be monitored.

"Although this is a hypertension and risk reduction clinic, I spend two minutes modifying the medication regimen and explaining how to take the medications,"Gloria explained. "The rest of the time, I advise on lifestyle changes that can help reduce the risk factors contributing to hypertension.”

I learned from Gloria that clinicians often minimize the importance of patient participation in their care. She has achieved success by equipping patients with practical disease management tools, and by helping patients establish reasonable lifestyle modification goals.

Evidence shows… When we increase the dose of an antihypertensive drug, or add a drug to the regimen, we aim for a decrease in blood pressure of 10-15mmHg. Regular physical activity reduces systolic blood pressure by 4-9 mmHg. A weight loss of 10kg correlates to reduction in diastolic blood pressure by 15mmHg. A similar reduction is achieved by lowering salt consumption. Thus, multiple lifestyle changes can reduce blood pressure by 30mmHg: two to three times more than what medications achieve, and without ANY harmful side effects.

The patient who brought Gloria flowers had an excellent blood pressure measurement while at the clinic. “Your blood pressure looks great today," Gloria smiled. The patient offered an explanation, “Well, maybe the clinic has something to do with that," he replied. "When I'm here, I feel comforted.”

I have a question...

Posted by Shannon Hough at Friday, August 28, 2009

This summer came and went so quickly! I can’t believe we’re already P-4s and on our clinical rotations. My first rotation is at the University of Michigan Drug Information Service (DI). DI recently moved off-site, and is now in an office building with great views and parking. I am commuting from off-campus this year, and have been enjoying the scenery of August in Michigan.

At the DI center, pharmacists answer questions from callers, as well as work on many other projects related to pharmacy operations within University of Michigan Hospitals and Health System (UMHHS). As part of my DI rotation, I spend a portion of each day answering phone calls, learning about drug information resources, and working on our other assignments/projects. It seems like no two phone calls are alike, or even similar, so I'm really learning how to use our resources. The questions can vary from a health care provider asking about an off-label use for a particular drug, to a layperson calling to ask about using an herbal product safely.

One of DI's roles is to serve as an advisory agency for UMHHS' Pharmacy and Therapeutics (P&T) committee. (The P&T committee decides what medications will be included in a hospital or health system's formulary. A formulary is the list of prescription medications that a drug plan will pay for.)

A major project I was involved in at DI was gathering information about a drug to determine whether it should be added to UMHHS' formulary. Our reports soon will be reviewed by the P&T committee. Exciting stuff, being involved in recommending a drug for one the top health systems in the country!

DI was a great first rotation. I’ve definitely refreshed my drug information knowledge, and have become reacquainted with drug information resources that I'm certain will help me in my future rotations.

Cheers!

How to master shooting in the dark

Posted by Kendra Yum at Saturday, August 22, 2009

My first rotation is an institutional rotation at a hospital pharmacy. I wanted to see the operations of a hospital pharmacy at a different setting, so I have been commuting to Detroit’s John D. Dingell Veterans Affairs Medical Center (VAMC). The VAMC is a large medical facility that services some 300,000 veterans in the Michigan area. They provide primary care, surgical and specialty care, as well as medical research programs and community-living (nursing home) centers. The VAMC has an inpatient pharmacy, an outpatient pharmacy and processes prescriptions for mail-order services. Pharmacists also run an anticoagulation clinic and a hypertension clinic at Detroit’s VAMC.

Most of my time is spent at the inpatient pharmacy, reviewing patients’ records for therapeutic duplications or checking IV doses. I also help with filling orders, stocking the patients’ medication carts and compounding IV preparation in the clean room. All the inpatient medications are bar-coded, so that prior to administration, the nurse has to scan the medication barcode to verify that the correct medication is being given.

At the outpatient pharmacy, the most commonly used drugs are filled by a ScriptPro machine, with the other orders filled manually by technicians. In both cases, the pharmacist scans the bar-code on the bottle to a computer SP Station, which displays a photo of the pill for the pharmacist to verify. I have never worked with ScriptPro before, but it seemed like an efficient and effective way to catch medication errors.

On Wednesday, I had the chance to shadow the anticoagulation clinic pharmacist, Carol. Most patients have atrial fibrillation, past cardiac valve replacement, or a history of thromboembolism (DVT, PE) that requires continual anticoagulation with warfarin. It was exciting to see patients coming in every month just to see and speak with the pharmacist.

Most of the patients completed INR testing in the morning and then receive an assessment of and counseling on diet, bleeding, and medication adherence from the pharmacist. Patients on warfarin require extensive monitoring due to the unpredictability of patient’s response to warfarin and the potential danger of bleeding episodes if too much is given. It seems like warfarin dose titration can sometimes be a “shot in the dark”, since there are so many variables that can affect a patient’s INR. Is the patient’s INR too low because (a) he is not responding to the dose, (b) he is non-compliant (despite not admitting it), (c) he ate a lot more broccoli than he remembered this week, or (d) all of the above? Should we then increase the dose, not really knowing if the answer was (a), (b), (c), or (d)? That’s the type of question that requires the experience of the pharmacist and his/her knowledge of the patient. My day at the anticoagulation clinic definitely showed me how important it is to polish your patient counseling skills to get the most information from the patient to make the best clinical decision.

Leaving no stone unturned

Posted by Akin at Saturday, August 22, 2009

So I’m three weeks into my first rotation as a P4 student and I’m still alive. I’m doing an inpatient clinical rotation in the hematology/oncology department at University of Michigan Health System (UMHS). As I walked into the hospital on day one, I didn’t know what to expect. The only thing I knew for certain was that I would be doing lots of work and getting paid in class credits.

After a day full of introduction, another classmate and I were assigned three patients each. I began to work up my patients later that night at about 7 pm, and didn’t finish until after midnight. And that was just three patients! The next day I found out my classmate had had the same experience. Three weeks later, we have five patients to follow and I can accomplish this in the time it used to take me to do one patient. So I think we are starting to get the hang of it. This past week my preceptor has also started to let us round without her. We’ve also started to build a trusting rapport with the attending physician and physician asistants. They ask for our opinion more, and when they do, we hesitate a lot less.

After three weeks of my first rotation, I can better understand why former students say rotations pass so quickly. I even asked my preceptor yesterday (Friday), “How can I make the most of this last week?” She quickly threw the question back at me, “How can you make the most out of the last week?” I didn’t really have a solid answer, but it’s something I’m going to think about this weekend. I want to make sure to leave no stone unturned before moving on to the next rotation.