Distressed into De-stressed

Posted by Matthew Lewis at Friday, December 30, 2011

After a much needed break, I've finally found the time to post again. A lot has happened since I last posted, so lets start at Midyear. The first thing to know about Midyear is that you do not and should not stress about it. Yes, you are there to make a good impression. Yes, you are there to scout out things for your future. However, you have to keep in mind that Midyear is full of opportunity and fun times, and if you're flipping out and rigid in everything you do, I think it's just as bad as being unprepared. Just be confident in yourself. Look at your CV (curriculum vitae) if you feel overmatched; you aren't in pharmacy or about to go into pharmacy at the University of Michigan because you're a slouch.

The second day is much easier than the first day, and there are two sessions instead of one. You know what people want to hear and you'll have your questions refined. I honestly think I made a mistake in going to the program I was the most interested in first, so I wasn't as fluid as I would have liked. I suggest that you talk to some other programs before you get to the ones you are really interested in, and there is plenty of time to talk to everybody you want. I also looked at the website listing of everybody there offering a PGY2 in solid organ transplant and talked to most of them, considering a position as a solid organ transplant pharmacist is my goal. As it turns out, most of the programs I was interested in before going to Midyear fell by the wayside and some I didn't even know existed, both large and small programs, rose to the top of my list. After talking to about 15 programs, I am applying to six. Hopefully, I'll get four to six interviews and eventually match with one of them.

In rotational news, I completed my community rotation, and learned quite a bit. I was lucky enough to work with Mr. Frank Pawlicki at the University Hospital. He was a great preceptor and treated me as a student instead of just another pair of hands or a volunteer tech. When you get to rank sites for rotations, and Mr. Pawlicki is available as a choice, I strongly urge you to rank him high. I also got to spend time in the sister sites of the Oncology Center and East Ann Arbor (the transplant medication hub), so I was exposed to many facets of community pharmacy. This particular site does a lot of compounding, so I got to prepare myself for a future rotation by compounding things like rifampin solutions and seeing how eye drops were prepared. My new drug review was on Tracleer, which is a newer drug for pulmonary hypertension. It looks pretty good and I think we will see more use in both pediatric and adults patients as a different option to sildenafil (Revatio).

My next rotation is infectious disease at the University Hospital. It is going to be a challenging rotation because expectations will be high and I now have half a year of clinical rotations under my belt. So, in between writing applications and relaxing during my break, I will be looking over my old therapeutics notes and getting the recommended drug reference books.

That's all for now, so until next time have a safe and happy New Year.

Drug Info at DMC

Posted by Elizabeth Kelly at Saturday, December 24, 2011

Christmas Eve... a wonderful time to avoid the tradition of watching boring tv with the family and instead blogging on this past months rotation. So, I was at the DMC with Dr. Margo Farber getting information about drugs this whole past month. And even though the rotation was technically very boring, I actually learned a lot and utilized my time very well.

Typical day:

Get there 8:30-9. Spend forever getting settled in, check my email, finally settle in and get working on a drug monograph or whatever miscellaneous drug information question that was given to me by Dr. Farber or one of the other drug information specialists.

Sometime during the day go to a meeting or lecture... note they have a lot of free food on this rotation. You probably only need to buy/bring a lunch only half the days if you play your cards right. And they have a subway right on the floor above...healthy eating!!!

Leave after 8 hours of course......................................

How I made this rotation fabulous:

1) I knew I was applying to the DMC residencies so I introduced myself to as many "big-wigs" as possible and Dr. Farber really facilitated that.

2) Asked to shadow different pharmacists... got a great experience for the other student and I in the anticoagulation clinic.

3) Made a point to learn about the material that I had to research. Might as well... I have boards to pass in a few months.

4) Dr. Farber is a great preceptor and really made an effort to teach us pertinent information and guide me in my residency search (she is even writing me a letter of rec!).

There are a few pains with this rotation:

1) Distance from Ann Arbor (although that didn't matter to me since I live at home in St. Clair Shores)

2) You have to park way away from the hospital and either take a shuttle or walk (note... if you have this rotation it is WAY faster to walk from the hospital back to the Bethel church parking lot then it is to wait for the bus... even if it is sitting right there waiting for you).

Now, if anyone has any questions about this rotation feel free to email me!

Multidisciplinary Oncology

Posted by Eric Zhao at Thursday, December 22, 2011

St. Joseph Mercy Hospital has been my home for the past month, where I rotated with Dr. Carol Yarrington in Ambulatory Care Oncology.

New Oncology Infusion Centers in Canton, MI and Brighton, MI
Patient bays increase privacy and comfort

After brushing up my knowledge on the oncology drugs, therapeutic areas, and side-effect management strategies, I was charged with setting the groundwork for a pilot pharmacy intervention at the Multidisciplinary Oncology Clinic.

The Multidisciplinary Clinic (MDC)
The clinics are held on Monday (head/neck cancer), Tuesday (lung cancer and gastrointestinal cancer), and Friday (breast cancer). In one sitting, a patient can see a nurse navigator (explained below), nurse practitioner, palliative care nurse, physician assistant, medical oncologist, radiation oncologist, and surgeon. What's nice about this initiative is that the patients receive the full spectrum of care in a single trip. Each of the healthcare professionals will individually visit with the patients, rotating between patient rooms. Afterwards, they all convene to discuss their plan for each patient.

The Multidisciplinary Team in the Cancer Care Specialty Center
[Link to Brochure]

Nurse Navigator

The nurse navigator, a rising new concept, serves as the main contact and face of the multidisciplinary clinic. They make sure the patient is acquainted to the clinic by setting up appointments with the healthcare professionals and providing follow-up when needed. Because days can get hectic, these navigators help orient the patient during their treatment visits.

Pharmacy Intervention
Between visits from the healthcare providers, patients may have 30-120 minutes of downtime before the next visit. What a convenient time for pharmacy to step in, interview the patient, and review their medication list! The clinic is mainly focused on the oncology aspect, so there is a lot of room to manage their chronic health concerns. Oftentimes, patients with cancer will try complementary or alternative medications to improve their situation. However, these medications may interact with chemotherapy to reduce their efficacy; for example, some chemotherapy agents rely on creating free radicals to destroy tumor cells, so ingesting a large amount of antioxidants may cause more harm than good.

Green tea, an antioxidant, may negate chemotherapy agents that depend on producing free radicals to destroy the tumor

Future Direction
The multidisciplinary clinic shows a lot of promise, and I hope the clinic continues to pilot the program with the next student. It's a great way for pharmacists to get involved in the multidisciplinary care of oncology patients through a review of not only their chemotherapy regimen, but their maintenance medications too.

Eric Zhao

Happy Holidays from the Ann Arbor VA!!

Posted by Anna Polk at Wednesday, December 21, 2011

Can you believe 2011 is almost over?!  This semester has flown by and rotations are now over halfway over!  I am finishing up my ambulatory care rotation at the Ann Arbor VA.  I always had a feeling that I would enjoy the practice environment at the VA and also the patient population and I’m finding this to be absolutely true.  Pharmacists play an integral role in ambulatory care at the VA, seeing patients in all sorts of clinics, from arthritis and anticoagulation to pain management and geriatrics.  I have had the opportunity to rotate through several of the clinics- I think I’ve had a pretty similar experience to Nina and am enjoying it just as much as she did!  

I am also happy to report that I’ve had a major breakthrough in terms of my long-term goals and aspirations while on this rotation.  After spending a lot of time in the pain and arthritis clinics, and speaking with my preceptor, I’ve discovered that I really enjoy practicing in areas where there several shades of gray.  Let me clarify- rather than trying to cure the patient or get their condition to a predetermined goal, I enjoy working with patients with less clear-cut goals.  I have always loved working with the geriatric population; I like how you are not trying to cure them or get all of their conditions to their recommended targets, but instead the focus is on quality of life and functional status.  I am finding that this interest is not limited to geriatrics, but rather areas that I like to think of as ‘empathy-driven care.’  These are areas where listening to your patient and developing a solid trusting relationship are essential.  You can’t treat numbers and there are few hard and fast rules to follow.  I think this helps explain why I enjoyed my psych rotation so much, as well!  

With residency application deadlines fast approaching this revelation could not have come at a better time.  I am feeling particularly passionate about pharmacy right now, and I was so excited to talk to all of the programs at the Midyear Meeting in New Orleans earlier this month.  I have ‘narrowed down’ my list of programs to apply to (I’ll admit it- there were ten that I just couldn’t bear ruling out) and am now putting all of my energy into my cover letters.

To any current or future pharmacy students:  get excited for your P4 year!!  I cannot believe how much fun I am having actually getting to practice these things that we spent so much time preparing for in the classroom!  What an exciting field we have chosen!  I guess I'll just end this post on that note- enjoy your time off for the holidays!!

Midyear Recap

Posted by Jenna at Wednesday, December 21, 2011

Midyear has come and gone and I would love if someone could tell me how it's already the end of December!! My time in New Orleans was purely exhausting and a little 
overwhelming. So how did I spend my time at Midyear?

Saturday
I landed in New Orleans around noon CST and spent the rest of the day exploring New Orleans: the pharmacy museum, Bourbon Street, Canal Street, the Riverwalk, Cafe du Monde, and the French Quarter.

Sunday
I had 4 PPS interviews. PPS stands for Personal Placement Service and is commonly used to find PGY-2 residencies or jobs. The advice is usually not to participate when you're looking for a PGY-1 but I ended up joining PPS last minute. My advice differs, though, because I had a great experience with PPS. If you're looking for a 'specialized' PGY-1, for example in administration, managed care, or pediatric-focused, PPS could be a great investment. Joining allows you to see the complete list of institutions participating in PPS and also allows you to post your CV and an objective statement. After I joined, I sent messages to 5 programs that I was interested in, and then sat back & let PPS work its magic!

I heard back from all 5 programs and also received messages from ~10 other institutions. One important thing about PPS is to be professional: if a program sends you a message and you're not interested, make sure you respond! Don't ignore their message, just thank them for their interest and nicely explain that you are currently pursuing other options.
Through PPS I got invited to a really great networking event, the CHCA (Child Health Corporation of America) reception, which I went to Sunday evening.
Monday
I had 3 PPS interviews prior to the 1st residency showcase. PPS interviews can vary in style. Most of mine were more informational, rather than a real interview. The interviews are booked for 30 minute slots and only people that are registered for PPS are allowed in the PPS area. If PPS is something you're considering, definitely be prepared to answer these typical questions:
1. Tell me about yourself.
2. Why do you want to do a residency?
3. Why are you interested in this specialty area?
4. What are your future goals?
And make sure that you have plenty of questions to ask! Some programs use PPS as a tool to weed out candidates, while others use it more as a personalized Q&A session. 

Tuesday
The 2nd residency showcase was from 8-11:30 and the 3rd session was from 1-4:30. I had my last PPS interview right after the last showcase. 

Wednesday
I had planned to use Wednesday to attend the residents' poster session. However, by Wednesday, I was honestly just sick of Midyear! So I ended up going to the Audobon Aquarium instead. I spent the plane ride home working on thank-you notes, as these should be sent out as quickly as possible. I sent out all 40, yes FORTY, thank you notes Friday. 

Things since Midyear have been a blur. I decided to apply to umm a few more programs than is typically recommended. Midyear wasn't as helpful as I had hoped in terms of eliminating programs that I wanted to apply to. I had really positive interactions with everyone that I spoke to during the showcase and my PPS interviews. I did a ton of research prior to Midyear but the 'tool' I found most useful during the showcase having a single sheet of paper detailing each program I was going to talk to. After doing so much research, programs start blending together and you don't want to seem unknowledgeable about a program when you go to their booth. As I was walking (okay, more like shoving my way through people) from booth to booth, I would get the sheet out for the program that I was going to next. That way during conversation, I could glance down to see the specific rotations offered, etc and write answers to questions right on that sheet. Just an idea of something that worked really well for me! You can never be too prepared and no matter how much time you spend preparing, you're still not going to feel prepared!

iNsTiTuTiOnAL RoTaTiOn

Posted by Melanie at Friday, December 16, 2011

Only a couple more days left at my institutional rotation at UMHCC. I feel like this month has flown by, but when I look back, I have done a lot of things this month.

The 1st week was spent developing a CE presentation for Pharmacy Technicians on aseptic technique. I was able to develop this with three other fourth year students on the same rotation. We made videos illustrating poor aseptic technique. We were given the opportunity to give two presentations. I think the presentation went really well. The technicians were very engaged and seemed to enjoy the humor in our video demonstrations. In fact, we may be able to present for a third time to a larger group of technicians!

The second week was spent in the satellite pharmacy where I took on the role of a staff pharmacist. Verifying orders and serving as the final check were my main duties.

The third week was spent in the Investigational Drug Services department. I was able to develop a set of dispensing guidelines for a new study. I spent one day with the technicians who prepare for monitor visits by people who come to make sure compliance with the study is being met. I spent another day with the dispensing technician who processes orders and gets the medication ready for the patient, and I spent a day with a technician who puts away medications and keeps inventory and who also prepares intravenous/sterile products for patients.

My fourth week I was able to participate in the clean room activities. I was able to see the flow at UMHHC and gown up and go into the clean room. I also participated in the final verification process by checking IVs that technicians had prepared. I also spent some time with the clinical pharmacists where I looked at kinetics and handled anticoagulation.

Next week, I will develop a CTools website for P3 IPPE students on their institutional rotation at UMHCC. I am putting together a list of articles for them to read, as well as guidelines and other resources. These are items that will be of value throughout their P3 and P4 years, as well as beyond.

See you again in 2012 and Happy Holidays!

Independent Community

Posted by Amanda at Sunday, December 11, 2011

I started my fifth rotation at Village Pharmacy II. I am half-way through and this place is awesome. It has made retail pharmacy not seem that bad. I have had many opportunities to counsel patients. The pharmacy also does compounding so I have made oral suspensions, and capsules. Making capsules were fun. I have also learned a lot about over the counter products.

I also learned about medicare part D and I helped some patients look up part D plans.

At Village all the medications are placed on the shelves alphabetically by brand name, so I have learned the brand names to a lot of drugs. Some that were brand names 30-40 years ago.

Transplant

Posted by April at Sunday, December 11, 2011

I spent my fourth rotation on the surgical transplant service of the University of Michigan Medical Center. This service did many kidney transplants as well as liver and pancreas transplants.

A typical day started early at 0545 rounds. This rotation was unique in that it encompassed a variety of patients including pediatric critical care, adult critical care and floor status patients. The service also follows their patients after the transplant. So, there was some internal medicine therapeutics involved. For example, a patient with a history of a liver transplant was admitted for possible kidney stones. They were automatically admitted to the transplant service for management.

Although it might seem like transplant pharmacist are extremely specialized, they need to know a lot in the areas of infectious disease, critical care and internal medicine. I enjoyed this aspect of the rotation the most.

Another aspect of this rotation that I would like to mention are the protocols. This service is highly protocol driven. These specify who gets what medications based several patient characteristics. It is one of the pharmacists many jobs to see that the drug protocols are being followed. You might be surprised how often something gets missed!

I feel like there was a huge learning curve on this rotation. We only skimmed the surface in therapeutics class when it comes to immunosuppression. Not only do you have to know all the immunosuppressive medications but also why a physician should use one over the other.

Overall, I enjoyed this rotation because I really learned a lot from it.

iNsTiTuTiOnAL RoTaTiOn

Posted by Melanie at Monday, December 05, 2011

I am currently on my institutional rotation at UMHHC with Ms. Kathy Kinsey.

This is a very diverse rotation spent in different areas on the hospital.

My first week was spent designing a CE program for pharmacy technicians on aseptic technique and preventing hospital acquired infections with my fellow fourth years (there are four of us). We designed a Powerpoint presentation and recorded some skits showing improper technique and then included videos illustrating proper technique.

The second week was spent on the 6th floor satellite pharmacy. Here, I got to verify orders, serve as the final check for products being dispensed, draw up oral liquids, go on cart fill runs with the technicians, and calculate drug desensitization dilutions.

This week, I am in IDS - the Investigational Drug Services department. Today I completed an IDS training module, learned about eResearch (the website where drug protocols are submitted for approval), read an article about the development and funding on an IDS service (published in AJHP in 1987 by UMMC when the IDS service was just beginning), and learned about Dispensing Guidelines. One of my assignments this week is to develop a Dispensing Guideline for one of the new studies. Over the course of the week, I will learn about IDS and its functions.

Next week I will be in the clean room.

In addition to these activities, I will give a patient case presentation and meet with various administrators throughout the course of the rotation to learn more about their roles and responsibilities.

Behind the scenes of pharmacy administration

Posted by Nina Cimino at Sunday, November 27, 2011

After a short first week of rotation 5, I'm finding that my non-traditional rotation in pharmacy administration is answering some questions I've had, and also leading me to new ones. Here are some of the answers I've come across so far:

• Q: Would I enjoy practicing in pharmacy administration?

A: I really think so! Ok, so it has only been 3 days, but so far I've really enjoyed my experience. One of the things I'm most excited about is the opportunity to make a difference in the lives of many patients, even if you're not providing their care directly. While I really love interacting with patients, I'm also really inspired by the way my administrative preceptors work so hard to help the pharmacy department achieve excellence. Whether its helping pharmacists to have the best work environment possible, solving problems to improve provision of care, advocating for projects to improve patient safety, or working on research projects to improve patient care, I have already seen how my preceptors are improving the care patients receive. While the patient may never know all that the pharmacy administration is doing, it seems that a great pharmacy department makes for great patient care. When I interned at the FDA, I was also really inspired by the pharmacists there who impact patient care on a population level- so this rotation confirms for me that there are many ways to help improve patient care. I think that solving problems and working to improve care would be very challenging, and extremely rewarding.

• Q: What do pharmacy administrators do?

A: I think the answer to this question is one I'll be figuring out throughout my rotation, but so far I have a much better idea than before I started. To me, pharmacy administrators seem to be facilitators- or people who help make progress toward a vision of excellent patient care. There are so many projects going on behind the scenes of the pharmacy in order to keep things running and constantly improve the service provided by pharmacy. For instance, while we all are constantly working to provide safe care to patients within our existing systems, pharmacy administrators are working on new ways to further improve safety. These improvements may involve changes in policies, or implementation of new technology (such as smart pumps, bar-code medication administration, and electronic health record integration).

As my rotation continues, I think I'll continue to revise and refine my answers to these questions. I'm also on the lookout for answers to other questions, such as:

• How do pharmacists working in administration manage to balance all of their projects and priorities?
• Does the fact that I am enjoying pharmacy administration so much have any implications for my career path?

I'm so happy to be gaining this experience in pharmacy administration, and I'm looking forward to seeing what else lies ahead this month!

"I don't know"

Posted by Bernie Marini at Tuesday, November 22, 2011

To remind myself to post a blog this rotation, I simply put "I don't know" in the subject heading, and I bookmarked it. I didn't have a great idea or theme for a post at that point in the rotation. Nothing great came to mind. But then, I realized "I don't know" is actually a perfect theme.

"I don't know."

Those are the three very powerful words. To me, they evoke a wide range of emotions - fear, frustration, embarrassment, curiosity. As P4's, we dread having to utter these words on rotation. However, the best rotations are those in which those three words are the most frequent...

For example, I have just finished my rotation on the infectious disease (ID) service at U of M, and for once, I went into this rotation very confident. My rotation with Dr. Frame on the BMT unit gave me extensive practice in ID; I followed patients with a diverse array of infections - BK cystitis, fusariosis, invasive aspergillosis, etc.. So, armed with my white coat pockets stuffed with my trusty bug/drug list, my "blue book", and various fungal charts, I was ready to tackle ID head on...and it hit me, hard (like a Michigan linebacker!).

There was so much in ID that I didn't know, and having a challenging and extremely knowledgeable preceptor like Dr. Carver made that apparent quickly. Sure, I had a little knowledge of basic things like the adverse effects and drug interactions with azole antifungals, pharmacokinetic dosing of vanco and aminoglycosides, but I was quickly getting questions like:

• Should colistin be dosed on ideal body weight or total body weight?
• If we MUST to use bactrim in renal failure (although the package insert says not to), how should we dose it?
• Can we use tigecycline in a cystic fibrosis patient? If so, how much should we give?

Having difficult questions such as these thrown out on a consistent basis pushes you to the next level. I worked hard each day to search the literature for answers to my difficult questions, all the while following and assessing the drug therapy of a large number of patients. This is how the best rotations go. At the start, things are a bit overwhelming. You're clearly not an expert in the subject. But then you adapt. You start to think ahead. Anticipate. Think, "what questions will I get?" "If I was the attending or preceptor, what else would I need to know?" You start thinking like a pharmacist.

Unless you're a genius, we've all had "I don't know" moments on rotations. And although we dread the feeling of unknown and the embarrassment of ignorance, it's these experiences that make us better pharmacists and better people. Sure it's corny, but it's true: unless we know that we don't know, we can't know...anything. Wait, what? You get the point.

Insight into Industry

Posted by Bernadette at Tuesday, November 22, 2011

On the first day of my industry rotation at Sanofi in Bridgewater, NJ, I was asked by my preceptor, Eric Racine, "What do you know about industry?" My honest answer then was little to nothing. When I first started my rotation, the pharmaceutical industry was just a big conglomerate entity in my mind. Millions of dollars were put into some drug-making assembly line, which would then produce billions of dollars in profits. However, throughout my 4-week stay, I came to realize that like every other industry, pharma was affected by the struggling economy as well. A week into my rotation, the CEO of Sanofi announced layoffs and budget cuts in their Research and Development (R&D) department - around 3,000 jobs companywide. Not only did this annoucement leave an air of apprehension amongst the employees, it also brought to light the fact that while pharma is big, it's also not invulnerable.

I worked on the diabetes team in the advocacy department, which was actually an area I didn't even realize existed in industry. The department worked with various advocacy groups to help promote disease awareness, and in my situation, diabetes. All the projects the department worked on focused on the disease itself - though since it is a business, with the hopes that awareness of disease prevention measures would lead to increased use of the company's drugs. Because this was advocacy and not marketing, it meant that our work really was for disease awareness and not brand promotion (i.e. promoting proper use of insulin rather than proper use of Lantus), which was quite different from what I would traditionally expect from pharma.

Over the course of my rotation, I also began to understand the clockwork behind the corporation. Every project and achievement was a result of a coalition of efforts - drug safety, medical information, marketing, government affairs, legal, etc - and that's when I really began to appreciate this environment. I had the chance to meet people from various departments and learned about their roles and how it fit into the overall scheme of the company. I had a wonderful time during this rotation, learning more about industry as a whole as well as the strategy and collaboration within an individual company.

CoMMuNiTy RoTaTiOn

Posted by Melanie at Sunday, November 20, 2011

I completed my fourth rotation, my community rotation, on Friday. Aside from my P3 IPPE, I did not have any community pharmacy experience, as I have been a technician and intern in a hospital setting. I am thankful that the University of Michigan requires such diverse APPEs because it helps to make me a more well-rounded health care professional.

My community rotation was at Village Pharmacy II, an independent pharmacy, and my preceptor was Allan Knaak. Al is such a great community pharmacist and he is a wonderful mentor to have. He provided me with many real-life challenges and pushed me to expand my knowledge.

While I was on this rotation, I did many things. For starters, I became the compounding and drug info expert. Any compounds that came through the prescription window, I made. This was a unique experience because not many community pharmacies compound. I made oral vanco, hormone replacement therapy, omeprazole solution, magic mouthwash, and many others. I also investigated any drug information questions that other health care professionals or patients had.

Because of the timing of my community rotation, I also explored Medicare Part D Plans for many patients and had the opportunity to go over their options with them. Also, the P1s were having their mock inspections and I was able to speak with four groups and help them complete their project.

I also gave an inservice for the pharmacists and presented two new drugs, Gralise and Duexis, to them, and made recommendations for whether the pharmacy should stock these products or not. I created a poster on medication adherence and got to present this to patients. I completed MTMs and made recommendations for patients. I also made a proposal for Village Pharmacy II to offer flu vaccines for patients - a proposal which was well-received and may debut next flu season. I also learned about many OTC situations and came up with my top recommendations for different scenarios such as poison ivy, cough and cold, pink eye, boils, cold sores, and others. I took the opportunity to engage with many patients looking for products and made recommendations. I made physician phone calls when a patient needed a new prescription, prior authorization, or when the prescription needed to be clarified. I was involved in the final check of prescriptions, as well as offering counseling to patients.

I also got to work with P2 students who were on their IPPE rotation at Village Pharmacy II and was able to help them learn counseling points about bisphosphonates, ear drops, and eye drops.

This rotation went by so fast and I learned so much. My next rotation is my institutional rotation, which starts tomorrow, and I am excited to see what it will have in store for me, but sad to leave Village Pharmacy II where I feel I had the opportunity to become a part of a great pharmacy team. Independent pharmacies have such a different feel from the retail/chain stores I have shadowed people at, and I encourage everyone to explore this option and get an idea of how unique independents are from other community settings.

End of Oakwood

Posted by Amanda at Saturday, November 19, 2011

I finished my last two weeks at Oakwood Annapolis. It was an interesting rotation. I spent the last two weeks going on rounds in the ICU. I saw one code and was asked to participate in it by the attending. I decided to decline the invitation. I also did a pharmacy in-service about basal bolus insulin. The hospital is planning on replacing the sliding scale insulin protocol with basal bolus because basal bolus has better outcomes for patients.

I also got to meet with a respiratory therapist and I learned about ventilators. It was pretty interesting. After spending four weeks in Oakwood, I think I will probably not be working in a small hospital.

Drug Information: Lexi-Comp

Posted by Eric Zhao at Sunday, November 13, 2011

This month, I'm excited to help write for a drug information program known for both its online and mobile platforms:

I'm looking at you, Lexi-Comp

Working with a previous University of Michigan College of Pharmacy alumnus as my preceptor, I help write and update drug-drug interactions for the program. Some examples of the interactions are those between carbamazepine/non-dihydropyridine calcium channel blockers, levodopa/iron salts, and oxcarbazepine/phenytoin, among others.

The Process
1. Initial Search: The initial search involves a very broad query in PubMed for the interacting drugs, and if there are a reasonable number of hits (around 200 or less), we begin screening abstracts for possibly pertinent articles. Sometimes the query produces over several thousand results, so we employ alternative search strategies (e.g., using limits, excluding "review" articles, etc.).

Some sort of national database

2. Screening: After combing the abstracts, I can usually narrow the article list down to about a quarter of the original number. Here's where I access and skim the articles to see if they will be useful for the write-up. This narrows the list down even further.

3. Write-up/Update: Once I determine which articles will be useful for an evidence-based write-up, I determine a strategy. Ideally, my final list involves articles that provide many different viewpoints of the drug interaction, which include primary literature and case reports. After thoroughly analyzing the articles, I begin writing the drug interaction monograph.

4. Upload: Prior to uploading, I review my drafted monograph with my preceptor for his opinion and expertise. If all goes well, my preceptor will remotely log-in to the database and upload our monograph. It's pretty neat to see the immediate changes on my phone's Lexi-Comp application after uploading.

This rotation allows me to practice my literature searching skills while providing a lot of autonomy. My preceptor gave me several projects that he wants finished before the end of rotation and it's up to me to prioritize and deliver (i.e., I set my own schedule). During our meetings, I inform him of what I have been working on, and he lets me know my progress. That said, I'm going to get back to my projects.

-Eric Zhao

A Bit Much

Posted by Matthew Lewis at Friday, November 11, 2011

As you well know, things are progressing on rotation, but outside of rotation, things are crazy. I am trying to get an abstract presentation for the International Society of Heart and Lung Transplant (ISHLT). My preceptor wants a draft by Tuesday, and the final submission is due Friday. The stats meetings are quite long, but every meeting is another factor put into the big picture. My project has generated at least 30,000 cells in Excel worth of data entry (yes, I'm counting blank cells because I did have to determine if they were supposed to be empty). I have a volunteering session at Hope Clinic on Wednesday night. Our dinner with donors to the College of Pharmacy is Friday night. I have a paper, a monograph, and an in-service all due and presenting on Friday, and I should have drafts of my monograph and in-service in by Tuesday, Wednesday at the latest. I'm not complaining mind you, I'm just telling you that sometimes it gets busy and storms of deadlines batter the USS P4.

Oh yeah, stack on Midyear planning. I have a great idea of where I want to go for residencies in and out of state, but I have to figure out who I'll be talking to and what questions to ask. I also have to prep my CV and get that squared away. I very recently came to the realization that not only do I want to do residency so I can be a clinical pharmacist, but I also would like to serve the US somehow in the US uniformed services. I say uniformed service because there is the army, navy, and air force under the department of defense, but there is also the public health service, which has a uniform, ranked members, and can be deployed to disaster areas (and overseas I think). The public health service, for those of you who don't know, are responsible for the FDA, Indian Health Service, CDER, and the CDC to name a few. So, on top of all the deadlines, I've got to figure out what the next five years of my life are going to look like. They all offer great opportunity and require, at the very least, immediate sacrifices in different areas.

On the matter of residencies, I was told that I should think of stories concerning patient care that will be important on interviews. This brought up my lung transplant patients, so I asked about two gentlemen in particular when I saw my preceptor for that rotation. They are both doing well, but each had a bout in the hospital, which was quickly resolved. I then asked about another patient, Mrs. B. She was waiting for new lungs and was deteriorating. Her problem was that she was a small patient and a more rare blood type. Nothing came up. She passed away. I had talked to her a few times just one on one during rotation and got to know her a little bit. When I showed her my laptop and that you could write on it. She wrote "Please get me new lungs." half in good spirits, half pleading at that time, knowing there was nothing we could do to speed the process. It hit me hard to learn she passed. That's the risk you run when you get to know people and they want desperately to stay alive with a poor prognosis. Our system and modern medicine can't help everybody yet. I just wish that I see cases like Mrs. B as few and far between as fate, God, and human effort will allow.

Residency Search ~ part 1

Posted by Jenna at Friday, November 11, 2011

Midyear is just 3 weeks away .. well CRAP, where did time go?! Despite all of the research I did this summer, I've been stressing over what to do. I wanted to attempt to put into words the internal struggle that I've been experiencing (which will come in the second post) as well as offer some advice on starting the search for a residency. 

Those that know me know that there are 2 ways to instantly put a smile on my face and distract me from whatever I was doing: golden retrievers & babies. 

Adorable! Now where was I?!

So, peds has been my thing since day 1 of pharmacy school. My first two years of pharmacy school, I shadowed a lot of pharmacists, both on the adult & peds side. I highly recommend this - almost all of the pharmacists are open to it and it's really great exposure. Starting last year, I began to look into different residency options. As my classmates who are looking into residencies can attest to, it's an overwhelming process. There are so many programs and so many things to compare, it's hard to know where to even start. Well, the best place to start is somewhere! Real profound, I know. 

So where did I start? I decided that I'm not going to geographically limit myself because I felt like this would be cheating myself out of possibly great programs and great people. I also decided that I'm not going to base my decision on anyone else, meaning I'm not going to stay in Michigan just because my boyfriend is here. In my opinion, this is a decision that I have to be selfish about. Not everyone would agree with this and there are certainly situations and circumstances where this isn't feasible. But this is the decision that works best for me and my life circumstances. 

After making this decision, I just started from the beginning (i.e. Alabama). I could've started from the end (i.e. Wyoming) but I decided that it's much easier to scroll down a page than up it. I went to ASHP's residency directory and just started to browse around. As I scrolled down through the states, there were certainly states I skipped right over because I couldn't imagine living there. I think you have to be honest with yourself .. some people will say 'It's just a year, you can do anything for a year.' I think that's partially true but a year is also a long time to be miserable so I ignored a few states where I just couldn't imagine living for a year.

Ordinarily I would've said to decide what you want prior to starting to search through programs. However, there are so many programs with so many things to compare. For me anyway, I didn't have any 'specifics' of what I actually wanted in a program, other than a hospital that had some pediatric opportunities. So I decided to just start looking. Some programs have more informative sites than others, so by finding programs with a lot of information, I started to get exposed to what looked interesting and what didn't. In my head, I started to formulate a list of 'things' that either were important to me or things that I would need to compare amongst places. One word of advice - write these down! For some reason I didn't and I could kick myself for it. I can't tell you how many times I've been to the same program's website .. because other than a huge word document, I didn't have a way to compare things. Literally, about two weeks ago, I started a spreadsheet so that I could have 'criteria' to compare amongst places. It looks something like this and still needs a lot of work, both with filling in the information and adding criteria to compare.

I still don't have all of my 'criteria' listed because I didn't have a running list of what I wanted to compare so I end up thinking of new things then having to go back through to update that information for each program! 

Utilize your resources. Ask your professors/mentors for their opinions on specific programs. This will naturally lend itself to them letting you know if they know anyone there because let's face it, connections get you places. It's important to consider their opinions but you also have to keep in mind that things may have changed since they last knew about the program. Another important thing to remember is that pharmacy is more advanced in some areas compared to others. The midwest and pockets throughout the rest of the country are 'known' for their pharmacy practice. Just because an institution is well known for their medicine doesn't mean their pharmacy practice is 'up to par.' 


I think that's enough for 1 post. Hopefully some of my suggestions help, to recap: 
#1. Where are you looking? Are you geographically limiting yourself?
#2a. Start from the beginning and just explore a variety of programs.
#2b. Start to identify what you're looking for and ways that programs differ (staffing, flexibility, etc) so that you have a method to compare them. Identify 'must have' criteria and 'nice to have' criteria.
#3. Utilize your professors for their opinion on certain programs.
#4. Keep in mind that just because an institution has great medicine doesn't always mean they have great pharmacy. 

Posted by Nina Cimino at Wednesday, November 09, 2011

After two and half weeks of ambulatory care, I'm learning what a broad field it is! This rotation is different from some of my other rotations because rather than being very involved with one specific activity, I have had the opportunity to see a wide range of ambulatory care practices in action.

One area I've been exposed to is pain management. I was able to shadow a clinical ambulatory care pharmacist who practices in a pain management clinic. Patients with chronic pain issues can be referred to this clinic by their primary care provider if their pain is not well controlled. The pharmacist then schedules visits with these patients and works to optimize to their medication regimen and control pain. This area is one in which I have been particularly interested, so it was a great experience to be able to shadow a pharmacist practicing in this area!

Today, I shadowed a clinical ambulatory care pharmacist in a geriatrics clinic. This clinic focuses on elderly patients, many of whom are frail and have multiple medical issues. In this clinic, the pharmacist works with a team of physicians, fellows, medical students, and social workers to optimize the care of elderly patients. The goals for a geriatric population are not always the same as the general patient population. For example, while optimal management of a medical condition may require 3 or 4 medications, that regimen may be completely unmanageable for an elderly patient suffering from alzheimer's among other medical conditions. The goal of the clinic then, is to provide the best care for the patient possible while minimizing the burden of medications and adverse reactions.

I'm really enjoying experiencing the broad range of ambulatory care practice areas available at the VA! Tomorrow I head back to the pain clinic, and next week I get to participate in a cardiac risk reduction patient care group! More details to come...

Oakwood Annapolis

Posted by Amanda at Wednesday, November 09, 2011

I have finished half of my rotation in Oakwood Annapolis. Let's just say it is a very different environment compared to the hospitals that I have seen (U of M and St Joe's). Oakwood Annapolis is located in Wayne Michigan. It has about 259 beds and has 5 floors. So it is pretty small compared to U of M. I am on rotation with two other girls who are P4's are Wayne State University. I am learning a lot about other pharmacy schools from them.

For my first week I learned all about what a technician does and how useful they are at running a pharmacy. I went with them on runs. I got to fill the pyxis machines on all the floors. I learned how to fill in the pharmacy. For one day I was in the IV room, I made a lot of zosyn IV's. I did not poke myself with a needle so that day was an accomplishment for me.

Starting the second week, we started going on rounds in the ICU with the clinical pharmacist. The physicians in the ICU are very receptive to our suggestions.

Chugging Along

Posted by Matthew Lewis at Monday, November 07, 2011

First, I want to clarify something that I may have confused some people about. The Ann Arbor VA does have residency spots open for next year (2012-2013), and many of my classmates are quite serious about doing residency at some VA, either in Michigan or across the country. It's just that this current year there are no U of M grads as residents and all the current residents expected to have a Wolverine present due to our proximity. This coming year I'm sure we'll have at least one because of all the interest in the program and the Ann Arbor VA being a good fit.

Moving along, it's beyond the halfway point and I'm still feeling pretty good. I'm working on my projects and answering drug questions along the way. I feel pretty confident that most questions you will see on drug info has to do with "off label" indications or non-formulary drugs. As my preceptor explained, the doctors and nurses have more access to drug information from things like their iPhone or Blackberry than they ever had before.

Another thing I learned is that every pharmacist has their own way of practicing with their own habits and favorite drugs. It came to my attention for non-formulary drug requests, where doctors make their case for pharmacy to supply something that may cost more or be last line therapy for a patient. My preceptor does not like to approve particular tube feeding formulations without exacting data which shows a clear benefit which must be a better clinical outcome like going home earlier. On the other hand, he is more lenient with appetite stimulators for cancer patients. He's not a hypocrite since he does get data for both things, but in any evaluation, there is some subjective clinical decision making process that must go on. It'll be interesting to see when I practice what issues will be things I go on crusades for or against and what type of drugs I favor and try to avoid while keeping in mind the care the patient needs.

The Administrative Mix

Posted by Matt at Monday, November 07, 2011

Once again my last rotation ended right as I was getting comfortable. My last few weeks rounding with the Infectious Diseases team at U of M were action packed. We had cases ranging from infective endocarditis caused by a dental procedure to rash and fever that turned out to be Still’s disease, a non-infective autoimmune condition. The rotation was highly specialized and we spent most of our time focusing on infections and the associated antibiotic regimens. This was a big difference from my internal medicine rotation where we looked at all of the medications and problems. The rotation gave me a good idea of what life would be like as a specialist.

I am currently on an administrative rotation at St. John Providence in Southfield, MI. After graduation I plan on pursuing an administrative residency so this rotation was highly anticipated. I have been learning a great deal about the responsibilities associated with administration, including operations management, human resources, and the metrics associated with tracking workflow. I have sat in on several meetings disc using the implementation of new technologies and policies in the hospital. I have also participated in interviewing several technicians. We are not exposed to these situations during school so I find this training highly valuable. If you plan on pursuing an administrative position after graduation seek out leadership activities during school. These experiences will help form a foundation from which you can build your career.

The goal of my rotation is to finish a project to help maximize efficiency in the pharmacy order verification workflow. Some of the stat medication orders that come into the pharmacy have already been verified and are requested a second time for invalid reasons. I have been tracking these requests and we are planning on visiting stations around the hospital and educating staff about appropriate use of the stat order process. This should cut down on the number of stat medication requests, freeing up technicians to fill regular orders.

Toto, we're not in Kansas anymore!!

Posted by Jenna at Sunday, November 06, 2011

My fourth rotation is my institutional rotation at Henry Ford Wyandotte. Institutional rotation is classically the rotation that people wish would be eliminated because a lot of them unfortunately turn out to be a huge waste of time. After coming off such a high from my last rotation, this rotation honestly seemed horrible at first. I wanted my babies back, I wanted my preceptor back, I wanted Mott back. In case you haven't realized, I love Mott! As a side (& dorky) note, whenever I used to walk into UMHS or Mott, I would get goosebumps. Why? Because I knew that great, revolutionary things were happening within their walls. It would be my dream to work at Mott, if I don't end up moving to warmer weather! Anyway, I digress.


Wyandotte is ~350 beds and takes me 50-55 minutes to get to each day. It reminds me a lot of the hospital system that I worked at at home. Paper charts, paper orders .. no real rounds, less pharmacist interaction with other HCP's. Not a fan. Granted, I will fully admit that training at a tertiary academic medical campus like UofM completely spoils us. Pharmacy (and medicine) is not as advanced or collaborative at many hospitals but having rotations and shadowing experiences at UofM makes you (or at least me, anyway) want that level of practice. 


Wyandotte is probably THE friendliest atmosphere, though! Everybody knows everybody and if they don't know you they try to get to know you. My first trip to the coffee shop yielded a 'Welcome to Wyandotte, I've never seen you before, tell me about yourself.' That, and by the third day of me getting my morning coffee, the barista knew my order. That's one of the ways to my heart .. knowing my coffee order. It's the little things, I tell ya!


Everyone in the pharmacy is really nice as well. They're a lot of fun as well. So far, I've mostly been working on projects, including:
          * MAR Reconciliation ~ Comparing the written orders from the previous 24 hours to the patient's daily MAR (medication administration record). This was to check that pharmacy entered/deleted orders correctly to ensure the paper MAR had the correct drugs, doses, & frequency/timing. 
          * Clostridium difficile infection rate ~ Collected patient antibiotic data to determine if specific antibiotics were implicated in their increase in C. diff and to determine if their C. diff treatment/duration was appropriate. 
          * Brilinta (ticagrelor) ~ Antiplatelet drug approved by the FDA in July. I did ~15 minute inservice to the pharmacists to explain the drug and it's major trial (PLATO).
          * Neonatal Umbilical Catheters & Common Neonatal Medications ~ Wyandotte has a 'feeders & growers' NICU, meaning the babies aren't sick, they just need to gain some weight. Like many people, their pharmacists tend to be hesitant about entering orders for the babies so I'm working on an inservice that will hopefully help ease some of these fears. I will probably also make a pocket reference card for them. 


Time is flying by, plain & simple. Yes, I'm excited to graduate and move on to the next chapter of my life .. but I wish time would slow down a bit. I'm starting to get pretty frazzled .. okay really frazzled. My to-do list grows daily and things aren't really getting crossed off of it. In the next few weeks I have a few looming deadlines and still a lot of work to put in to meet them. Midyear is also fast approaching and while I did a ton of research this summer, I feel like I need to get myself more prepared & fast!

Ambulating around with the geriatrics..

Posted by Elizabeth Kelly at Thursday, November 03, 2011

This month I have the pleasure of being on rotation with Dr. Tami Remington in ambulatory care practice. I don't know if people have heard but I am loving this rotation. It is a lot of work, but the amount of knowledge I am gaining from this rotation will help me a lot in the future.

Getting down to the basics with this rotation:

Mondays: Clinic day at West Ann Arbor. We see/phone new and returning patients for management of their chronic disease states: diabetes, hyperlipidemia, and hypertension. Some patients also get asthma action plans or get help managing their weight and diets.

Tuesdays and Fridays: Medication reconciliations and polypharmacy patients at East Ann Arbor. Patients are phoned after discharge to reconcile their medications with what they were taking when admitted to the hospital even before they have an appointment at the Turner Geriatrics Clinic.

Wednesdays and Thursdays: I review patients with Dr. Remington before we see the patients. We also do topic discussions, journal club, and a formal case presentation during that time.

Pros to this rotation:

1) I know a lot more about the three big disease states than I ever thought I would. I feel as is I have a much better understanding of how to monitor hypertension, hyperlipidemia, and diabetes therapy; when to make dosage changes; what starting doses should be; and when to discontinue therapy all together.

2) I know how to take one terrific manual blood pressure... that's for sure!

3) Dr. Remington is super smart and really pushes you to work your hardest, but she is also understanding and tries not to overwhelm you. She encourages you to focus in on your interests. She knows mine is about diet and exercise so she really encourages me to look more into those areas when it comes to patients. I was looking up the new myplate instead of the old food pyramid earlier today in order to help a patient with weight issues.

4) She has absolutely fun and pleasant patients to be around on Monday clinic.

5) You aren't hustling from one spot to another, 9-5. You are given plenty of free time to work up patients' therapeutic plans during your daily routinesa.

Cons:

1) You invest a lot of time and energy on your patients, but usually only on a couple nights a week, not every night.

2) Sometimes it can be disheartening to work so hard helping patients, and then they don't show up to clinic or answer their phones. It especially sucks when you have a bunch of good recommendations to offer.

3) I really can't even think of anything else.

I am really enjoying this rotation and looking forward to the next couple of weeks. I definitely recommend having your rotation at East Ann Arbor with Dr. Remington if you can!

Highlights of the FDA

Posted by Bernadette at Monday, October 31, 2011

So just to highlight some of the places I was able to visit through the FDA rotation, the left is USP's first and oldest collection of monographs

while the right shows some of the contraband shown at the Bureau of Prisons confiscated from prisoners.

Do the paintings look familiar? Maybe along the

College's wall? The drawings both on COP's hallways and at APhA headquarters highlight the significant events on pharmacy ... and the the rooftop of FDA headquarters has an amazing view!

Overall, the FDA rotation is a great place for a student to learn about the opportunities pharmacists have in government positions, not exclusively the FDA. I was able to speak with pharmacists at USP, APhA, DoD (Department of Defense), Bureau of Prisons, and IHS (Indian Health Service). So if you have any interest in these types of positions, the FDA rotation is definitely one you want to try out!