A Note About the First Rotation and What is Pharmacy School Like?

Posted by Matthew Lewis at Friday, July 29, 2011

Since this is my first post, let me introduce myself. I'm Matt, I've lived in Michigan my whole life, and got my undergraduate degree here at U of M. Right now, I have a strong interest in infectious disease (ID) pharmacy, as well as transplant pharmacy (mostly because of the ID aspect). I am excited and more than a little nervous about starting my first rotation. I'll be in the pediatric (peds) critical care ward of Mott in the University of Michigan Health System. It's a world renowned system and has all sorts of awards and highest level trauma centers. Basically, if a kid is really sick, they are coming to Mott. Being part of this system and the U of M pharmacy program coupled with the complexity of these patients means I have to bring my A-game. Another part of the difficulty associated with peds is they are not adults. Okay, that is obvious, but practically all of my classwork, all the studies I've read, and all the patients I have seen so far have been adults. Drugs work differently in kids than adults, so I have to make sure I've got pediatric dosing and efficacy in mind when working here and not stuck in "adult mode". It's sort of like being a mechanic for cars, but then switching to planes; everything you learned on one does not just translate to the other. I'm sure you've seen posts from my P4 colleague Jenna, who's crazy for peds, so if you want to learn more about pediatric pharmacy right this instant, (and who doesn't?) go check out her posts.

On another topic, some people have asked me what pharmacy school is like. I think a good analogy, at least for the academic part, is trench warfare. There are periods of digging in, where you just have to keep your head down. You find a close buddy or two who always has your back. There are times where you hear the whistle to go "over the top" and charge for the next trench, which can be the next set of exams or the next year. Oh, and in times of calm we celebrate, lots of celebration. Of course nobody is shooting at us though, so that is a plus.

Outside of the classroom, pharmacy school is incredibly rich and rewarding, and sometimes as educational as our academic portion, since you have the opportunity to meet, shadow, and have personal relationships with some of the superstars of pharmacy. I am not kidding, some of our staff are known around the world, other staff members have created whole new ways to deliver medications in the body, and others still have written chapters for pharmacy textbooks used around America. You also have so many opportunities to get to know your classmates while helping out the community. We have several student organizations such as APhA-ASP, HSP, and the pharmacy fraternity PDC among many others where pharmacy students go out into the area for health fairs and presentations, as well as the occasional purely social get together like the PDC ski trip(members only) or the PharmBash Ball organized by APhA. However, whenever anybody interested in going to pharmacy school asks me, I always end with, "Pharmacy school is what you make of it.", and leading up to the P4 year, I think I've put a lot into this program and it has given me a lot, and will continue to do so this year and beyond.

Preparing for P4 Rotations

Posted by Melanie at Thursday, July 28, 2011

Summer has definitely flown by! There are some things I am doing now to help prepare myself better for rotations. First of all, I have been in contact with my preceptor for Rotation 1 so that I know what is expected of me on the first day. My first rotation is the Generalist Rotation at the University of Michigan. My preceptor gave me some pre-rotation materials to review for the first day. Some of the materials include pharmacokinetics, especially for aminoglycosides and vanco, so it is important to review those PK therapeutic notes and practice the examples. Another key point is anticoagulation. I am currently reviewing CHEST publications and UMHS guidelines to help prepare. Other tasks include re-familiarizing myself with TheraDoc and CareWeb.

My third rotation is my Admin rotation with Dr. Jim Stevenson, Director of Pharmacy at the University of Michigan. To help prepare myself for this rotation, I shadowed the Director of Pharmacy at Hayes Green Beach Memorial Hospital. I was able to attend several meetings, including a Quality and Risk Management meeting, learn about policy writing, and discover how the pharmacy department is linked with other departments in the hospital. This shadow experience gave me insight and helped to make me feel a little more comfortable about entering an Admin rotation.

The P4 orientation program has been very helpful in alleviating some of the fears and unknowns about rotations. The PGY2 residents from UM gave a lecture on what to expect and how to prepare for rotations. For example, they suggested that we carry a calculator, PDA/Smartphone, Blue Book, notepad/pen, patient monitoring forms, and a snack in our pockets. We also received a review on kinetics and were able to go through some practice problems with Dr. Kraft. Just seeing the problems again helped to jog my memory.

I have also learned that P4 year is a lot more self-guided and you have to have discipline. For example, you have to make sure that you are reviewing materials yourself because there is no exam that is making you study a particular section. In addition, it isn't about cramming to study for an exam anymore; it is about acquiring knowledge to become a better health care professional. One thing I learned today is that you should determine what you want to get out of each rotation and make sure that your preceptor is aware of your goals. This is a chance to learn with some very knowledgeable preceptors to help guide you! It is important to take advantage of these opportunities and get the most out of each rotation!

Rotation 1 - Here I Come!

Leukemias & Nausea/Vomiting

Posted by Jenna at Thursday, July 28, 2011

Leukemias stem from 2 lines: the myeloid lineage (granulocytes including platelets, monocytes, basophils, eosinophils, neutrophils, & erythrocytes) or the lymphoid lineage (B & T lymphocytes). A leukemia diagnosis is made when >20% of the cells in the bone marrow are blasts, or immature blood cells.

Typical leukemia treatments consist of an induction phase aimed at achieving remission (>5% blasts in the bone marrow & recovery of blood counts), a consolidation phase to eradicate clinically undetectable disease, and a maintenance phase to prevent relapse & prolong remission. CNS prophylaxis is routine during all stages of ALL (acute lymphoblastic leukemia) treatment since the brain & spinal cord serve as a sanctuary for blasts. A cure is considered greater than 5 years out of treatment without return of disease.

ALL accounts for approximately 1 out of every 3 pediatric oncology diagnoses. Patients are usually stratified into 1 of 2 groups: low risk for relapse vs. high risk for relapse. A variety of factors including age, cytogenetics, WBC (white blood cell) count at diagnosis, & phenotype determine which category of treatment the patient will be placed in. Patients are either enrolled in a COG (children’s oncology group) protocol or are treated with the standard of care.

Other cancers that are 'common' in kids include neuroblastoma (cancer of the sympathetic nervous system), Wilm's tumor (mass in one or both kidneys), retinoblastoma (cancer of the retina), rhabdomyosarcoma (cancer of the muscle), osteosarcoma (cancer of the bone), AML (acute myelogenous leukemia), & various brain cancers (gliomas).

Unlike adult oncology, where pharmacists may have more say in the actual selection of chemo, peds oncology is more about supportive care treatment (since most chemo regimens are protocol). The most common supportive care issue in oncology is trying to prevent and also treat a patient's nausea/vomiting related to their chemo regimen. With highly emetogenic chemotherapy agents or regimens, giving scheduled (rather than prn) antiemetics help make sure your patient is as comfortable as possible during their course of treatment. There are a handful of other supportive care measures but I'm sure some of the other bloggers will cover in time.

Drug Information

Posted by April at Thursday, July 28, 2011

My first rotation was drug information. I worked with a pharmacist from the drug interactions group at Lexicomp. I enjoyed this rotation for several reasons.

1. I was able to work from home. The majority of my time was spent researching and reading articles regarding drug interactions. When I needed to communicate with my preceptor I could email or bring something up during one of our two weekly meetings.

2. Since this is a medical writing rotation, I drafted the drug interaction monographs that appear when an interaction is put into the software. I thought this was good practice at translating what was in a journal article and bringing out the major points.

3. I also led a journal club discussion. I picked out the article and made a handout for the discussion. It was a good opportunity to present and review an article and get feedback.

4. This rotation has a broad therapeutic scope. Drug interactions are a pretty broad subject in and of itself, so this makes sense. But I appreciated this aspect because it was a good review from tyrosine kinase inhibitors to HMG-CoA reductase inhibitors.

Overall, I recommend this rotation because it was not what I pictured a drug information rotation to be. I will definitely be able to apply all my knowledge to future rotations! Next rotation…ambulatory care!

Kids and Cancer

Posted by Jenna at Saturday, July 09, 2011

I'm not sure where the summer went! Rotations will be starting in 3 weeks and I'm excited but definitely nervous. For those of you that don't know me, I'm Jenna. I'm originally from Upstate NY and did 3 years of undergrad at the University at Buffalo before coming to UofM. My passion is pediatrics and has been pretty much since I walked into the doors of CCLittle 3 years ago. Some may find pediatric pharmacy practice scary, after all, much of what's done is a 'best guess' since there aren't many pediatric clinical trials. But, I love it and I love helping adorable kiddos!

I spent my summer working on a variety of projects, all of which are peds related: my PharmD project with NICU (neonatal intensive care unit) pharmacist Dr. Mehta, restructuring the pediatrics elective with the Peds ID (infectious disease) and Peds Surgery pharmacists Dr. Klein & Dr. Blackmer respectively, a case report with the PICU (pediatric intensive care unit) pharmacist Dr. Beckman, and an article for the PPAG (pediatric pharmacy advocacy group) KidsMeds website. If you haven't learned already, pharmacy (and medicine, in general) is full of acronyms!

I would definitely recommend identifying faculty that have similar interests to your own (if you know what you're interested in). Get to know them and let them know you have an interest, many times they would love to have you help out with their writing projects. This is a great way to spruce up your CV and establish good relationships for letters of recommendation and future networking!

I unfortunately did not get my first choice rotation, the Peds Hem/Onc rotation with Dr. Erika Howle, so I decided to set up an experience for myself. I met Erika in March, when I attended the PPAG Conference in Memphis, TN and I felt comfortable asking to shadow her for a week. I'm thinking that this is where I'd like to end up practicing but with such an emotionally charged area, I wanted to have some experience first before identifying this as my passion in residency or job interviews. Like peds in general, peds hem/onc scares a lot of people and most people's reaction to my interest in it is 'How can you (emotionally) do that?' or 'How are you going to deal with kids dying?' or 'That's going to be so sad.'

To be perfectly honest, I'm not positive that I can emotionally deal with a baby, child, or teen dying, especially from cancer, so that's something I need to find out. But the reason I see myself practicing here is because you can learn so much from these kids. They are so resilient and have the best attitudes about life. They're getting potions of toxic medications and yet they still find the strength to run around and play like 'normal' kids. There is something to be learned from each child you encounter and often times that lesson is: you have it good, stop complaining and live your life to the fullest! For every sad, heart-wrenching story there are several joyful stories to help buffer it. I'm sure that experiencing losing my first patient, especially my first pediatric patient, will be incredibly difficult and is something that I'm not looking forward to, but it is something I'll need to learn to handle regardless of whether I end up in peds hem/onc. In the end, you're helping patients, and whether that means a cure or making them comfortable, you're doing everything within your power - and that's all you can do.

(The above was written before a week of shadowing in Peds Hem/Onc)

Monday

It was a somber day on the unit, having lost a teen AML (acute myeloid leukemia) patient late last week. Everyone on the peds hem/onc team seemed to be pretty shaken by his passing, which happened sooner than expected. He was diagnosed in February and had been admitted since then. He seemed like a complete sweetheart, who had incredible faith and optimism despite his poor prognosis.

There are currently 7 patients on the unit (the average is ~12), 4 of which unfortunately don't have a great long-term prognosis. The patients ranged in age from 20 months to 20 years old and included: ovarian cancer, pre-B cell ALL (acute lymphoblastic leukemia), osteosarcoma with lung metastases, AT/RT (atypical teratoid/rhabdoid tumor), high risk neuroblastoma, and sickle cell disease.

The majority of pediatric oncology patients are placed on a COG (children's oncology group) protocol. The treatment names consist of a combination of letters & numbers such as ANBL0532, AOST0331, and AALL0232. The second, third, and fourth letters let you know what type of cancer you're treating, so the example protocols are for NBL (neuroblastoma), OST (osteosarcoma), and ALL. The peds hem/onc group has a handful of CPG's (clinical practice guidelines) that are good resources for students, interns, & residents to use for the treatment of chemotherapy-induced adverse effects. They include guides such as the treatment of: N/V (nausea/vomiting), TLS (tumor lysis syndrome), neutropenic fever, and different chemo toxicities as well as a guide to infection prophylaxis (for PCP - Pneumocystis jiroveci (carinii) pneumonia- and bacterial, fungal, or viral infections).

I think that's enough for one post - stay tuned for an explanation & treatment of some of the acronyms used in this post!