The Main Ingredient

Posted by Akin at Sunday, November 15, 2009

A Pharmacy Student Seminar course is a requirement of all fourth-year PharmD students. Each of us is assigned a topic related to pharmacy to present to our P-4 classmates. Alternately, we can choose to talk about our research project (the PharmD investigations project). A seminar adviser is assigned to each of us to provide guidance at every step of the way.The Seminar is an opportunity to help us build our communication skills and confidence. We learn how to thoroughly gather information from the literature and then assemble this information into a professional looking, 50-minute PowerPoint presentation. This is a skill many, if not all, of us will need in the future.

Out of my class, I’ve noticed that relatively few of us have a natural ability to speak in front of a large audience with utter fearlessness. In fact, many of us are deathly afraid of public speaking. I think I am somewhere in the middle-to-comfortable range of the spectrum. It’s just the five minutes right before, and the first five minutes into, any presentation that tend to be the most nerve-racking for me. The fact that I’ve known my fellow classmates for over three years doesn’t make it any easier.

The situation was no different at 1:05 p.m.November 6, approximately five minutes before starting my PharmD project presentation. My adviser, Dr. Barry Bleske, must have noticed my anxiety because he took this opportunity to tease me. After the course coordinator, Dr. Sally Guthrie, told me: “You know more about this topic than anyone in the crowd, so don’t be worried;" Dr. Bleske added: "Actually there are at least seven more students [my PharmD project partners] in the crowd who know just as much as you do!" (The implication: So you'd better be good.)

Dr. Bleske had been emphasizing simplicity during our practice sessions and wanted to make sure I had overcome my natural tendency to be verbose. This was in the back of my mind throughout the presentation and when I first began: “Welcome to my presentation, I will be talking about my senior project… uhhhh, [I mean] my PharmD project.” Shoot, I thought to myself, I already messed up. But I continued without too many other blunders and 50 minutes came and went before I knew it.

Overall, I think I was successful in communicating the most important points to the audience, sticking to the main topic, if you will. The presentation was also video recorded so I was able to see my mannerisms -- such as my propensity to sway back and forth as I talk. I will certainly improve on my weaknesses and strengths and I’ll have a chance to do this most immediately at the ASHP Clinical Midyear Meeting where five of us will be presenting the PharmD project in the form of a poster presentation. I think this will go smoothly as long as I have someone else talk for the first five minutes!

Lessons from my community pharmacy rotation

Posted by Kendra Yum at Friday, November 13, 2009

It’s about developing customer relationships. When customers come into the pharmacy and address the pharmacist and technician on a first-name basis, you know the pharmacist is providing service that keeps customers coming back time after time. The community pharmacy that I now work at has many long-term loyal customers. The pharmacists and technicians are well acquainted with the customers, their families, and their personal stories. No wonder pharmacists continue to rank among the most trusted and accessible health care professionals!

OTC, OTC, OTC. If you have gazed upon the mind-boggling shelves of over-the-counter (OTC) products at a pharmacy, you may have experienced the challenges (or confusion) in finding the right OTC product. Often times, customers will come up to the counter with a question starting with: “What can I take for…?” Or “My 9 month- old son has a fever. Is there anything he can take?” Or “I started getting acid reflux (heartburn) at night. What can I take to alleviate the symptoms?” Or “My wife has a burn on her arm, what can she use to help take away the pain?” This opens up the opportunity for us to ask the patients to describe the symptoms (onset, frequency, trigger, etc.) and to determine whether the condition requires a doctor’s visit, OTC remedy, or non-pharmacological treatments. This rotation has been one of the best refresher course on the appropriate use of over-the-counter products!

The most expensive medications are those that are taken incorrectly… or not at all. Taking medications incorrectly can lead to harmful reactions; and skipping prescribed medications can lead to unnecessary disease progression and complications. I have found that something as simple as going over the directions for taking a new medication (show-and-tell) and explaining a few of the notable side effects is greatly appreciated by patients.

It's about being the patient's advocate. Not long ago, a young gentleman came into the community pharmacy with a Tamiflu prescription for his pregnant wife. He wasn’t sure if he should fill the Tamiflu prescription out of concern of possible side effect on the pregnancy and asked for the pharmacist’s advice. We carefully discussed with him about the pros and cons of taking Tamiflu. We informed him that Tamiflu has a pregnancy category C, but that pregnant women can get sicker than other people who get H1N1 flu. After our talk and a long conversation on the phone with his wife, he told us that felt much better about getting the prescription.

One of the overarching lessons I have learned at my community rotation is that pharmacists are uniquely positioned to provide patients with information on medication use. Our patients look to us to serve as their advocates. It is both a privilege and a responsibility. We are reminded each year during the Oath of a Pharmacist recitation in pharmacy school,
"I promise to devote myself to a lifetime of service to others through the profession of pharmacy… with the full realization of the responsibility with which I am entrusted by the public.”

From Inpatient to Outpatient

Posted by Shannon Hough at Monday, November 02, 2009

I've made the jump from inpatient care at Botsford General Hospital to working in an outpatient clinic area at the Ann Arbor VA. I spent my final weeks at Botsford working on a number of projects that are very representative of what a clinical pharmacist might do, outside of patient care.

One project I tackled was a drug utilization evaluation (DUE) for erythropoiesis-stimulating agents (ESAs). A DUE is a "system of ongoing, systematic, criteria-based drug evaluation that ensures the appropriate use of drugs"1. At Botsford, this entailed printing a daily report of all patients who had been prescribed an ESA, checking the paper medication administration record (MAR) to see if/when it had been administered, and checking a few laboratory parameters (hemoglobin, etc.). Health care institutions frequently conduct a DUE to investigate how a drug is being used to properly make decisions related to formulary considerations, outcomes and economics research, or to ensure that the institution is meeting current standards of care. While searching for numerous paper charts, MARs, and even patients can be tedious, the results are valuable to the institution.

My final project was to give a lecture to patients who had prior cardiac surgery. In the lecture, I gave a brief overview of each of the medication classes that the patients were likely to be using. The overview contained important safety information, expected side effects and specific instructions related to certain agents such as nitrates and warfarin. AND I SURVIVED! As a student and pharmacist intern, I felt very prepared to talk to other healthcare professionals regarding medication topics. However, I was pretty nervous to face a class of patients taking notes and asking questions. And would you believe I actually knew the answers to their questions too? A great way to end rotation 3.

I started my fourth rotation at the Ann Arbor VA last Monday

in ambulatory care. My preceptor and main clinic area is anti-coagulation, however I also attend geriatrics, primary care, and arthritis clinics. Most of the patients I have seen served in World War II. I had the opportunity to see a patient in clinic for a medication reconciliation appointment after he had confused his medication instructions.

Mr. G is 86 and on a fairly complex medication regimen with at least 9 drugs and 3 different medication administration times throughout the day. While reviewing his medications with him (and having to remove and rearrange many medications in his pillbox, and confiscate a number of expired medications), it became clear to me that he was very overwhelmed with his medication list, and was not able to understand the chart that the clinic provided to him. He jokingly told me that I could go ahead, but he wasn't going to understand how to read the chart

to fill his pillbox. At that moment, I was determined to help Mr. G, aside handing him a

chart he couldn't read and filling his pillbox correctly for a single week.

My first step was to put the medication list into his hands. I then asked him to read it to me. When he was having difficulty, I offered him a blank piece of paper, to cover up most of the chart and just read one drug at a time. This was helpful. Then, through a number of open-ended questions, I was able to understand that Mr. G knows when to take his medications by what they look like and what they are for. So it was important to list the indication for each drug on his chart. He also was not able to remember to take his medications at 3 different times, so I was able to change when he took certain medications so that he only had to take his medicines twice a day and not miss any doses. He also told me that it would be easier to read his medication list if the drugs were organized chronologically, with the morning doses listed first. By the end of the appointment, Mr. G was able to tell me when he took each of his drugs by name, reading off of the chart, and match them with the appropriate prescription bottle.

This whole encounter lasted about an hour, and Mr. G was a walk-in patient. Luckily, we had a low patient load that day and were able to spend the time with him. I have no doubt that pharmacists do not always have enough time to spend with their patients. I think that working in an ambulatory care clinic is a place where this can be especially trying. If a patient needs more time than they were scheduled for, what do I do? Spend the extra time with him and fall behind schedule, making later patients wait? Quickly update his medication sheet, throw away the expired medications and give him an encouraging pep-talk to get it together and stay on schedule? Hopefully there is a medium somewhere!

1. http://www.iuphar.org/pdf/hum_76.pdf