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!

Finished with internal med

Posted by Amanda at Sunday, October 30, 2011

For the last two weeks of my general med/internal med rotation I got to experience what it would be like to not go on rounds with a medical team. For the week I followed the patients for 5 attending physicians, my case load was about 40 patients. I would arrive at the hospital in the morning, and I would spend all morning working reviewing patient charts. In the afternoon I would meet with physicians to discuss medication issues/problems. I felt like a valued member of the health care team when I spoke with physicians because they actually listened to my suggestions.

One of the attendings had pulmonary patients so I got to learn about how to dose antibiotics for cystic fibrosis patients. I learned a lot about cystic fibrosis patients and the importance a lung transplant can have on the quality of their lives.

I returned to rounds my final week of rotation. I rounded with two medical teams by myself -- that is, without the company of a pharmacy preceptor. I carried a laptop and used it a few times to help answer questions from the medical team. In short, I got to experience what it would be like to be a hospital-based general pharmacist, which is what most pharmacists do in a hospital if they choose not to specialize.

Motivational Interviewing in Action

Posted by Nina Cimino at Thursday, October 27, 2011

This week, I started a new rotation in ambulatory care at the Veteran's Administration. I have been really excited in anticipation of this rotation, because ambulatory care has been a practice area of interest for me. This rotation is a great opportunity to experience ambulatory care first hand, and to see if it might be right for me!

For those of you who may not know what ambulatory care pharmacy is, I'll give a brief overview. Clinical pharmacists work within outpatient clinics, and there they help to manage a patient's chronic diseases and related medications. There are endocrinology clinics where pharmacists focus on caring for diabetes patients, primary care clinics, pain management clinics, anticoagulation clinics ... you get the idea.

Within ambulatory care, pharmacists have "subspeciality" areas, and they work in a clinic to care for those patients who fall under that subspecialty. I have been attracted to ambulatory care because it seems to provide a great mix of patient interaction and clinical pharmacy. I don't think it's for everyone as there's a lot of motivational interviewing and patient education involved. But if you like that -- as I do -- ambulatory care pharmacy could be for you.

One experience I really enjoyed this week was attending a smoking cessation clinic that is run by the pharmacy residents. Not only was this a great chance to interact with residents, it was really exciting to see them running a clinic! Veterans who are interested in smoking cessation can drop by the clinic (it's an hour long and held twice per week). Once there, they discuss smoking cessation therapies and behavior change strategies. If needed, the residents can place medication orders for the smoking cessation therapies, but they also provide a lot of help by facilitating group discussion and nudging the veterans toward self-directed behavior change.

So far, ambulatory care pharmacy practice has been even better than I hoped! I'm so excited to see more of this practice environment in the weeks ahead!

On to the next one...

Posted by Christine Rabah at Thursday, October 27, 2011

Rotation #3 in ambulatory care (AmCare) wrapped up nicely for me. I counseled my very last patient on how to use Lantus. He had never used any type of insulin before, so this was very new to him. I started my consultation by asking him our typical AmCare questions: diet, exercise, blood sugar readings/low sugar reactions, caffeine intake, pain scale, and reviewed all of his medications. When he started telling me about his diet, I knew we were in for a very long visit. Let's just say he and his wife own a particular convenience store, and the food sold there consisted of his whole diet. Uh oh. That's about the LAST thing we want to hear from a patient with diabetes.

Needless to say, he got a TON of diabetic diet counseling. This consisted of talking about the plate method (half of your plate should be veggies, a quarter should be protein no larger than the palm of your hand, and the other quarter should be carbs no larger than your fist size). We also talked to him about how to check food labels for carb values, and counseled him on how many carbs to aim for with meals and snacks. While gathering his dietary information, I learned that whenever he gets low sugar reactions, he would eat a doughnut or candy bar. This is the last thing you want your patients to eat in these situations! So I had to counsel him on this too: that it's best to drink either juice or milk, or take 2-3 glucose tablets.

He walked away that day with a lot of information to process, so let's hope after our counseling (*fingers crossed!*) he started making major changes to become healthier.

Currently I am on my Institutional Pharmacy rotation at St. Joe's. I have never worked in an inpatient hospital pharmacy before, so I am way out of my comfort zone. They have me doing a TON of things here. My daily activities include checking orders called "F-8's" (mainly bulkier products that can't fit in the Pyxis machines), monitoring patients on warfarin (Coumadin) and/or enoxaparin (Lovenox), adverse drug event (ADE) report screening, checking patients' own meds, and checking ALS kits and A Packs.

What does all of this mean? I'll explain a little, since I didn't know before Monday, either.

When monitoring patients on warfarin, I check their INR, daily, to see if they are within therapeutic range for their specific indication. (INR stands for International Normalized Ratio, which measures the time it takes for blood to clot and compares it to an average). For patients with atrial fibrillation (a.k.a. most of my patients) their INR goal is between 2-3. I check what dose of warfarin they are taking, and make recommendations on what to do with their dose if their INR is not within goal. Later in the day, I meet with the pharmacist who is designated that day to monitor these patients and talk to him/her about my recommendations. If anything needs to be done, we will contact the physician. With enoxaparin, I check their renal function and indication for use and make sure their dose is appropriate.

Adverse Drug Experience (ADE) reports print out daily, and usually are a flag for patients with renal dysfunction and I check if the doses of their medications are appropriate. With these, I have to calculate their creatinine clearance and decide if any changes need to be made. There usually aren't too many reports I need to act on, but I have had a couple where patients with high serum creatinine levels were on Metformin, or were on antibiotic doses too high for their renal function. In these cases, I notify one of the staff pharmacists.

Checking patient's own meds (POM) consists of me printing a report of patients who refuse to take certain medications provided by the hospital and prefer to take their own from home. Here's where patient interaction comes in. I review their profiles to see what meds they brought, then visit them in their rooms to talk about their medication, check what they have compared to what was entered in their medication administration record (MAR), and put a "POM" sticker on it so nurses know that pharmacy has checked and okay-ed the patient's home medication.

Lastly, I check the ALS kits and A Packs. These are the medication bags/boxes that are on ambulances, so making sure everything is where it should be is imperative. I'm not gonna lie and say I didn't feel a little pressure here :) The most important thing to watch with this is that none of the medications are expired, everything is in its designated area, and there are the correct amounts of each med.

This rotation has definitely been very interesting so far, mainly because it's all very new to me. I think I'm getting the hang of it, though :)

It's Not Boring, I Swear.

Posted by Matthew Lewis at Tuesday, October 25, 2011

Hello Readers.

I'm already in the groove for my newest rotation, which is drug info. This is my second rotation in the Veteran's Affair group of hospitals, but there is a huge difference between the hospitals, and I think that is because of financial support. For example, the Detroit VA does not have a residency program but Ann Arbor (and Battle Creek) do.

[As a side note on residencies, several students from my class hope to be placed in the VA system, but I've been told that there aren't any residencies available at the Ann Arbor VA site this year. This situation isn't unique to VA as the demand for pharmacy residencies continues to outpace the supply nationwide. That means increasingly intense competition for limited slots. Michigan has one of the highest pharmacy residency placement rates in the country, but being a Michigan PharmD does not automatically make you the preferred candidate for a residency. Landing a residency still comes down to polished interviewing skills and an ability to package your talents in ways that make you stand out from the crowd.]

Back to the story at hand. As I mentioned, my current rotation is drug info. My preceptor, Dr. Ed Lehaie is a great guy and was recognized as preceptor of the year for 1999. The first day was all about getting paperwork in and computer access. I even answered some questions. Today, I answered a few more questions, particularly on replacements for the pain medication fentanyl because there is a drug shortage looming on the horizon. First, I did not even realize there were other drugs in the fentanyl family, so learning about those was interesting. I compared onsets and found appropriate doses through literature searches for sufentanil, remifentanil, and alfentanil. Finally, I did a little cost analysis.

You may have heard about drug shortages in the news, since they have gotten so bad people are dying from not getting proper medications on time. Part of drug information's job is to figure out how to work around these shortages. The other major part of drug information's job is to ... well, dispense drug information. This is usually in the form of approving medication requests that are off-label or extremely costly, such as cancer medications. We will also present new drugs and new research to our pharmacy and therapeutics (P&T) committee, where they can discuss what additional restrictions they want to place on drugs. VA P&T committees are quite different from normal P&Ts, in that each hospital has to follow the nationally mandated formulary decided upon by the national P&T. The local hospitals can only further restrict use.

That's the nuts and bolts of this rotation. I'm definitely going to be getting some weird questions, so I'll keep in touch to share them all.

Rotation 3 Wrap-Up

Posted by Jenna at Tuesday, October 25, 2011

I was dreading this past week. Why? Because it was the last week of the most amazing rotation with the best preceptor ever. I absolutely loved this rotation - most of my patients were in the NICU (ranging in age from premature newborns to my 9 month old sweetheart of a boyfriend!) and a few were in the PICU. I loved the team - they were so easy to get along with and it was truly a fun group of people working together. It was really nice to hear how the team relies on Allison - one of the head pediatric surgeons who worked last weekend kept saying "Let's wait until Monday so Allison can tell us what to do." If that isn't full confidence in the pharmacist, I don't know what is! For the head doctors of the department, with 20+ years of experience to have such complete confidence & reliance on Allison is so admirable. I can only hope I experience something similar one day!


I learned so much from this rotation - to name just a few things:

• Common pediatric surgical issues, including gastroschisis, omphalocele, short bowel syndrome, TEF (tracheoesophageal fistula), various atresias, etc.
• Neonate/Pediatric FEN (fluids, electrolytes, & nutrition)
• Caloric & fluid needs
• PN basics
• Enteral nutrition advancement
• Tapering pain/sedation medications as well as steroid tapers

I think my passion for pediatrics really showed and the fact that peds is my future was again reinforced. I would visit my patients several times a day to check on them (& just to smile at their cuteness). There was one patient in the NICU that kind of received preferential treatment, though! He was the most adorable, chubby 9 month old and I would come see him a couple times a day to make him smile. I began to be known as his girlfriend and I just loved making him laugh by making silly faces at him/tickling him. 

I also had some new experiences on this rotation. I was able to watch 4 abdominal washouts on one of my older patients. This was definitely a very interesting experience that then led to the opportunity to go to the OR to watch the patient get his abdomen closed. I was a little nervous about the OR but I ended up standing right next to the junior peds surgery fellow who performed the surgery. I felt completely fine throughout, which is good to know since I wasn't sure I'd be able to handle it! I'm also leaving this rotation with the opportunity to continue to develop my scientific writing skills as I work on  a case report, an alternative therapy article, and possibly more. 

I am incredibly sad that this rotation is over, I'd do anything to just stay here the rest of the year! Allison joked that she could fail me so that I'd have to repeat her rotation. :-) It's going to be incredibly hard for another rotation to live up to this one but I'll have to go into each subsequent rotation with a positive attitude and an open mind. I already miss my babies and my team but if there's one thing you can be sure of, it's that I'll be back to visit as soon as I can! :-)

ECT: Not Like the Movies

Posted by Eric Zhao at Sunday, October 23, 2011

Electroconvulsive Therapy
The media has given electroconvulsive therapy (ECT or "shock therapy") a bad rap. If you were like me and the general public, the only exposure of ECT came from the silver screen.

Clockwise from left: A Beautiful Mind, One Flew Over the Cuckoo's Nest, and Requiem for a Dream (all great movies, mind you)

ECT Reality (Content from the University of Michigan ECT Program)
What an honor to view a live ECT treatment during my psychiatry rotation. The whole procedure took only 15 minutes and looked nothing like the film scenes above.

The medical team (psychiatrist, anesthesiology, and nursing) typically reserves ECT for patients refractory to first-line interventions or for those with severe psychiatric episodes. We don't know exactly how it works but some theories suggest alterations in neurotransmitters or stress hormone regulation. The aim of ECT is to induce a seizure using a brief electrical pulse, so patients are tapered off adjunctive anticonvulsants (e.g., lamotrigine, valproic acid).

EEG showing seizure activity (top) and seizure termination (bottom)

Anesthesia
The anesthesia team administers anesthetics, neuromuscular blockers (typically succinylcholine), and oxygen for both safety and comfort. A blood pressure cuff around the arm monitors blood pressure and a second cuff around the lower leg prevents neuromuscular blockers from traveling to the foot, allowing psychiatrists to monitor for motor seizures. That's right folks, the ankle/foot area is the only part of the body that showcases "classic" symptoms of convulsing.

Patient receiving ECT. Notice the blood pressure cuff around the lower leg to prevent neuromuscular blockers from traveling to the foot.

Unilateral vs. Bilateral
A full course of ECT typically ranges from six to twelve total ECT treatments. Bilateral treatment involves electrodes at both temples, and patients undergoing bilateral treatment typically respond quicker (i.e., less total treatments) than those who receive unilateral treatment. However, bilateral treatment is associated with more memory side effects.

Bilateral Treatment


Right Unilateral Treatment

Side Effects - Possible Short-term Memory Loss
Sometimes patients experience headache and nausea after the treatment. One of the greatest concerns of ECT patients is short-term memory loss during the period of ECT treatments (e.g., forgetting lunch or previous interactions). In some cases, patients may lose memory of past events, especially those 2-6 weeks before treatment.

Patient Response
It's hard to imagine patients responding well to ECT given its stigma and unknown mechanism of action. It's one of those things where you have to see it to believe it. I remember a patient with severe depression who no longer desired to live and was not responding to any conventional therapy (e.g., SSRIs, SNRIs, TCAs, etc.). A full course of ECT later, this patient was completely reborn: smiling, joking, and poking fun at the medical team. Forget electroconvulsive therapy; this was an electroconvulsive transformation.

-Eric Zhao

You may want to come to the NICU..

Posted by Jenna at Sunday, October 23, 2011

I've gone back & forth, trying to decide if I should post this or not. Ultimately, I decided to post this because some of you will go through this and I want my blogs to be a real reflection of the ups & downs of rotation. It may not be an easy read but it's what I experienced my last 3 days of rotation.


Wednesday was just a crappy day. Instead of going on the 2nd set of rounds, I was in the PICU working on a presentation that I was giving to the team the next day. Around 9:15 Allison paged me and said 'C isn't doing well, you may want to come to the NICU.' I didn't even think to save what I was working on; I just logged off the computer and briskly walked to the NICU. When I got there, the team was gathered around her bed but to me, she (& her monitors) didn't seem any different than normal. But everyone seemed to be preparing for something bad to happen and eventually I figured out that they were right. They had called her mom to let her know that she needed to come in immediately. At this point, C was still full code, as a palliative care meeting with the family yielded the statement 'Do everything you can to save my baby.'

Well, who can blame them? They're parents who adore their 3 month old child and had dreams & aspirations for her. Unfortunately though, we had done everything & more that could've been done for C and her little body was still failing. I think that's the hardest part, to say 'there's nothing more we can do.'

Before I knew it, her heart rate started to steadily drop and they couldn't find a pulse. A code was called and then things were kind of a blur. It was very organized and as calm as could possibly be given the fact that this beautiful child was slipping away. A nurse quickly got a wooden board, which was placed under C so that she'd be on a flat surface for chest compressions. She ended up getting two rounds of chest compressions & Epi before they found a pulse. After this, she ended up holding her own and her nurse very sweetly put a beautiful headband on her so that she would look even more beautiful when her mom got there.

I've never seen chest compressions done on anyone, much less a baby. I've never been in a code situation either so this was a new experience, one that I don't think anyone looks forward to.

There was a very eloquently written piece in the New York Times last weekend that really makes you think. It's not an uplifting reflection but it really makes you think about the power of a parents love. http://goo.gl/sm9Ay

The next 48 hours were very sad and filled with ethical questions. Ultimately, she was made DNR Thursday and comfort care Friday. She was constantly held, either by her parents or her nurses, until her little body gave in Friday evening. Rest in peace, baby girl .. may your parents find the strength to get through this hard time.

Am care and critical care review...

Posted by April at Sunday, October 23, 2011

Let us go back two months ago to my ambulatory care rotation. I was excited to start this rotation because the pharmacist plays an integral role in the management of the patient’s diabetes, hypertension and hyperlipidemia.

The most memorable moment was a quote from a patient that went something along the lines of “I do not believe I have diabetes.” Luckily, I was observing this moment and did not need to convince the patient that they did indeed have diabetes. This however did serve as a great way to integrate motivational interviewing into this interaction. We asked why the patient thought that and discussed how his symptoms and lab values were in accordance with a diagnosis of diabetes.

I also thought this rotation was valuable because of the drug monitoring focus. It reinforced how to manage and monitor diabetes medications.

Last month I started my first inpatient rotation, critical care. This environment was unique in that in was in a cardiothoracic intensive care unit. This unit is dedicated to the care of patient post cardiac surgery such as coronary artery bypass graft (CABG) or receiving a ventricular assist device. Suffice it to say there was a huge learning curve because none of this kind of stuff was taught in pharmacy school.

It was all good though. My preceptors were great. I had two of them and I learned so much. I also had topic discussions with other pharmacy students who were on a critical care rotation. I thought these were very helpful in fielding possible questions that I would get from the healthcare team. For example, we had a discussion topic on stress ulcer prophylaxis. The question that came up in regards to this topic was if a PPI was better than a H2RA. I felt like a real pharmacist being able to answer this question.

Overall, I am glad that I had this rotation and now I feel more prepared for my next inpatient rotation, transplant.

I ♥ Cardiology!

Posted by Anna Polk at Sunday, October 23, 2011

We are already a third of the way through rotations!  I guess everyone was telling the truth when they said this year would fly by!  I spent the last month at Allegiance Health in Jackson, MI on a cardiology rotation.  This was my first inpatient rotation and I was nervous going into it, but my preceptor was really great at making me feel comfortable in the CUB (cardiac universal bed) unit.  She helped me get a feel for how to prioritize the patients and taught me who all of the different practitioners were that I would be interacting with.  

The pharmacy model was a little bit different than what I was expecting.  We didn’t round on the patients and there were not medical students or residents.  Instead, I made most of my interventions by interacting with the nurses or physician’s assistants.  This could get a little bit confusing as there are several different groups practicing in the CUB- Michigan Heart, Jackson Cardiology and then there are the surgeons and each group has different PAs and physicians.  Once I figured out who was following the patient I would try to track down the appropriate PA and let them know what my concerns were.  All in all, the people I worked with were very receptive and happy to have pharmacy there.  My other main task was patient education.  Many of our patients go home on warfarin or amiodarone and we tried to counsel on these separately from their discharge counseling as it can get overwhelming to give the patient all of the information at once.  Luckily we had a great discharge planner who gave me an idea of when each patient would be going home so I could get in to counsel them early.  

I also had the opportunity to watch an open heart surgery.  The patient had coronary artery bypass grafts placed and also had valves repaired- since it was a valve surgery you could actually see into the heart!  I spent most of the surgery with the perfusionist and he explained to me exactly what drugs and infusions were being given to the patient and why.  It was really useful to see what had happened to the patient before they arrived on the unit and why they had to come up on all of the different drips that I had been seeing on their profiles.  I also watched a cardiac catheterization.  

All in all I loved this rotation!  I was so sad on my last day, even though I am excited for what lies ahead.  Next up, I’ll be doing psych at the U of M (which looks great according to Eric Zhao!)

aDmIn RoTaTiOn

Posted by Melanie at Friday, October 21, 2011

Today marks the last day of my administration rotation at UMHHC with Dr. Jim Stevenson and Dr. John Clark. I have to say this month has really flown by. My days were filled with meetings and project work. I definitely learned a lot and had great mentors to learn from.

I was able to attend the Pharmaceutical Benefits Advisory Committee (PBAC) meeting where I learned how drugs are put into different tiers for the employee drug plan. I also saw a Pharmacy and Therapeutics (P&T) Committee meeting where drugs are selected for the formulary in the hospital. I was even in attendance for a meeting with the Provost where Dr. Stevenson gave a presentation on 340b, a program the hospital qualifies for to receive medications at a discounted rate.

I completed several projects during this past month. These projects ranged from quality improvement to medication safety. I also learned how to analyze numbers based upon drug cost to the hospital and insurance reimbursement to justify an additional full-time equivalent (FTE). I learned about Medicare Part D and how a patient would move in and out of the doughnut hole and into catastrophic coverage.

Did you know that in 2011 a patient will only pay 50% of the drug cost for eligible brand-name drugs while in the doughnut hole and the manufacturer will pick up the other 50%? As part of the federal health care reform, discounts for patients will continue to increase through 2020. The following figure illustrates a Medicare Part D plan taken from Novartis Oncology:

http://www.novartisoncology.us/reimbursement/pp/part_d_gap_closure/index.jsp

Administration definitely gives a different perspective on pharmacy. I encourage every pharmacy student to spend at least one day shadowing a pharmacist in administration so that this viewpoint can be observed. It gives you an appreciation for the work that goes into operating and maintaining a pharmacy service. I am very glad I had this experience.

Drug Info Wrap Up

Posted by Nina Cimino at Thursday, October 20, 2011

As my drug information rotation comes to an end, it's been a week of wrapping up projects for me! In my last post I talked about the monographs I've been writing for rotation, and while I've continued with those, I have also been busy working on long term projects. Since a month isn't that long term, I have generally been working on small portions of projects that will get picked up by someone else after I'm gone.

One of the projects I have been working on is searching for primary literature about vitamin and mineral drug interactions. Tons of supplement products contain vitamins and minerals, so rather than having a general interaction for "multivitamin" the company is moving toward identifying interactions with specific components such as iodine, iron, or selenium. This way, multivitamin products would only be implicated in an interaction if they contain the specific interacting component. Practically, this meant searching PubMed for published studies about drug interactions occurring with vitamins and minerals, which challenged me to identify which information was relevant for our purposes.

Another project involved journal surveillance and required me to go through recent issues of journals to identify research about drug interactions and make sure the database was up to date. My preceptor identified a list of journals which typically publish research relevant to drug interactions, and I read through the article abstracts of recent issues. When I found a research article about a drug interaction, I would check the company's database to see if that drug interaction was represented, and if the information needed to be updated in light of the new research. If the information did require updating, I would revise the drug interaction monograph to incorporate the new research findings.

This rotation has challenged me to improve my technical writing skills and literature searching skills. Also, because I was often balancing a variety of projects and assignments simultaneously, I learned to manage my time effectively. I enjoyed experiencing a pharmacy environment that was new to me, and I'm continually pleasantly surprised by all of the varied opportunities available to pharmacists!

Holy Motivational Interviewing!

Posted by Christine Rabah at Monday, October 17, 2011

So rotation #3 is almost over, but this is the first chance I had to finally blog about it!

Currently I am on my Ambulatory Care rotation at the Brighton Health Center with Dr. Trisha Wells. I can't tell you how excited I was for this rotation ever since I had realized my love for Am Care during P1 year while shadowing Dr. Choe for a project.

So, what do we do in Am Care?

Diabetes, hypertension, and cholesterol - oh my! (<-- yes, I know that was super dorky :P)

Typically, I check Dr. Wells' schedule the night before rotation, and work up our patients. Important things to check are their hemoglobin A1c, blood pressure readings, LDL-cholesterol, and of course- their medications. It is very important to note when these readings were done because they must be frequently monitored in these patients, especially if they are not within goal. Dr. Wells has a collaborative practice agreement with the physicians in this office so that she can adjust their diabetes, HTN, and hyperlipidemia medications as she sees fit. Awesome, right?? Each day, we will either have phone conversations (these are scheduled just like office visits, so that patients know to be available when we call), or we will see patients in clinic, the same way they would come see their PCP.

I've noticed that Dr. Wells' patients are very receptive to seeing a pharmacist to manage their medications. A few of them are doing so well, they don't need to be followed anymore but they refuse to stop seeing her! One patient even told her "Every time I want to eat something sweet, I see your face so I don't eat it!" This is definitely an area where pharmacists can have a major impact on patients and their well being.

Another thing I've noticed is that pharmacists actually use motivational interviewing! Who woulda thought that would come in handy? :P As silly as we felt asking mock questions in class such as "On a scale of 1 to 10 with 10 being the worst, how bad is the pain in your knees?" and "What do you think is a good goal for you to work on for our next visit?" it actually happens in practice. Patients seem to be receptive to this type of dialogue, because it makes them feel as if they are making decisions with the healthcare provider, instead of the provider telling them what to do.

During this rotation, I have done topic discussions in diabetes, diet/exercise, hypertension, and hyperlipidemia. Also, all of the students doing an Am Care rotation this month recently had a group journal club discussion where we each had to analyze a journal article relating to Am Care practice.

We only have 4 days left in this rotation, and I definitely don't want it to end.

FDA Part I

Posted by Bernadette at Saturday, October 15, 2011

It's now officially been three weeks since I've been in the D.C. area and my FDA rotation at the Office of Regulatory Policy. It hasn't been exactly the experience I had expected, but good nonetheless. The FDA rotation is actually focused on student lectures more than anything else. These lectures are scattered throughout the D.C./Maryland area and are given by various branches of the government in which pharmacists can work. For example, I've been to the headquarters of USP, DoD (Department of Defense), APhA, and of course, various divisions and offices of FDA. (As you will see while on rotation, you become quite familiar with acronyms.) Your preceptor will also assign you projects, depending on the workload of the department.

There are both pros and cons with these student lectures. Yes, you do get to learn what these branches are, but because there's no outline for the talks, you don't always get to hear what pharmacists can actually do in the organizations. Rather, you get a plug for the organizations and learn more about what they do. This isn't always the case - it just depends on your speaker and how and what they wish to address in the 1-2 hours given.

The great bonus about these lectures, however, is the networking you do. All the P4s rotating through the FDA are invited to join, so at least for me, it's been a great way to meet other students from across the country. The speakers are also very open and willing to help out inquisitive students, so if you have any questions, want to learn more, or meet more people, they are happy to lead you in the right direction. There's no other rotation that can offer this type of networking opportunity in this restricted length of time, but it does require you to be proactive and seek out what you want. For me, it's been great making new connections and seeing what other students and professionals are doing and what they're interested in, and because we see each other on a daily basis, it's not a meet-and-greet once-a-year thing, which is starkly different from the usual networking events I've been to.

...more to come after my lectures!

Interning as an Internalist

Posted by Amanda at Thursday, October 13, 2011

I am halfway through with my third rotation. This time I am on the General Med or Internal Medicine rotation. This one is a lot different than my last rotation in the PICU because I have 2 medical teams that I round with as opposed to the one last time. Also I spend most of my time in a room with the other two students on this rotation.

I follow 4 medical teams. Two of which have an attending, residents, and medical students. The other two teams consist of just an attending. The ones with residents go on rounds. I round with one team for 2 days and the other one for 2 days. The ones with attendings meet with the pharmacists every day around 1:30 in a meeting room to discuss any problems and ask questions. With this rotation I follow between 20-40 patients. I mainly deal with antibiotic dosing, adjustments for kidney failure, and anticoagulation dosing.

I also get a pager with this rotation and I was very excited when the medical resident paged me with a question. And I even knew the answer. Yay!

From the D to DC, from the Bedside to the Benchtop

Posted by Bernie Marini at Wednesday, October 12, 2011

Wow. These last two months have been a whirlwind. I've been so busy that I haven't posted in a while, so I'll try to summarize two months of rotation into one blogpost. Hard to accomplish? Probably. But the Detroit Lions are 5-0, the Tigers are clawing to stay alive in the ALCS, and the Wolverines are undefeated. I'd say anything's possible at this point (haha! See what I did there...).

CABG Patch Kids
My second rotation was my institutional rotation at the Detroit Medical Center - Sinai Grace. Institutional rotations typically have a bad rap for being boring. However, this was certainly not the case. Because I had also completed my Institutional IPPE at the same site, they were extremely flexible with allowing me to see basically anything that I wanted - within reason, of course. (That's one rotation tip for any P3's, 2's, 1's, 0's (is that pre-pharmacy?). If you want to do something on rotation, just ask. They will likely say yes. If you are not getting everything you want out of your rotation, tell them. They will likely accommodate you.)

Because Sinai-Grace is well known for having an extremely busy and exciting emergency room (for students, not so much for patients), I decided to shadow and help the ER pharmacist for a couple of days. Because the ER is typically slower in the mornings, and I wanted to get the full Sinai-Grace ER experience, I started around 10 AM and left at 1 AM. That's almost two full shifts! I was really tired the next day, but it was truly an awesome experience (again, for me it was great. For the patients... eh, probably not an ideal Friday night).

Another great experience I had on rotation was when I spent the day in the OR. For a good chunk of the day, I was able to hang out with the anesthesiology residents and watch a coronary artery bypass graft, or CABG. It's truly an amazing surgery. Several surgeons work simultaneously; it's like a well-choreographed dance, but with scalpels. The heart is chemically stopped to allow the surgeons to operate on the heart and a cardiopulmonary bypass machine (or a "heart-lung machine") takes over. Clearly, the institutional rotation at Sinai-Grace is anything but boring.

Au Bon Pain? Or "Oh Bone Pain"!

For my third, and current rotation, I am at the National Cancer Institute (NCI; part of the NIH) in Bethesda, MD, just outside of our nation's capital.

Julie and I outside of the ASHP headquarters in Bethesda

My initial impression of the NIH campus in Bethesda: WOW... I was seriously blown away on my first day as I strolled nervously past the National Library of Medicine (yes, that NLM - the world's largest medical library... i.e. PubMed!) towards the clinical center (where NCI patients are treated). The size of the NIH medical campus in Bethesda is about the size of UM's central campus. The clinical center is nearly as big as UM's University Hospital. And every patient is a cancer patient.

The National Library of Medicine

My rotation at the NCI is unique in that it combines elements of research with some clinical experiences. Every Monday, I get to shadow an oncology fellow in the clinic. Every patient in the clinic is on a clinical trial, so patients are monitored closely for recurrence of disease and toxicity from the treatments. The lab that I am working in primarily studies prostate cancer, the leading cancer in men and the second highest cause of cancer-related death in men. The lab studies everything from the pharmacogenomics of cancer to molecular biology to the pharmacokinetics of anticancer agents. I've worked in a lab in undergrad at UM, but I've never experienced research that is so closely related to what is happening clinically.

Let me clarify this with an example. When a patient comes into the clinic with an unexpected side effect or toxicity, serum samples are sent to the lab, where analytical chemists and other researchers can determine drug concentrations using HPLC and Mass Spectroscopy (Oh no... time to dig out those Medchem notes!) to find out if the patient's drug levels were outside of the normal range. If they were, new questions arise. Is there a genetic polymorphism affecting the way that patients are metabolizing the drug? Is there an interaction with another agent? Can we modify the structure of the agent to minimize toxicity and maximize efficacy? These are just some of the ways that clinical trials "at the bedside" at the NCI make their way back "to the benchtop", or vice versa.

As you can see from the lack of me blogging this month (and answering emails...), this rotation has kept me extremely busy. I'm currently writing a review article on bony metastases in prostate cancer. When I'm not in the lab doing benchtop research, or working on my review article, I can usually be found in the coffee shop studying for the oral quizzes my preceptor gives me every Friday on a different cancer. The name of this coffee shop is "Au bon pain", which apparently means something like "place of good bread" in French. I don't speak French, so for me, it sounds ironically like "Oh bone pain..."

The rotation at the NCI has been an amazing and emotional experience so far. Seeing patients and their families deal with the struggles of cancer can be overwhelming. When my wife was diagnosed and treated for a glioblastoma in 2009, we needed all of the support we could get. Walking through the clinical center, seeing patients and their families stay strong throughout difficult times truly puts things into perspective. The worries of everyday life that usually circulate in my head - "I hope I do well on my quiz", "I wish I had known that answer on rounds", or "I really hope I get a residency" - seem small in comparison to their worries and concerns. It makes me think about how lucky I truly am. I am lucky because my wife is healthy right now... My family is healthy... I am healthy... Many people are not this lucky, and experiences like this remind me not to take life for granted and to "not sweat the small stuff", as my Mom always says.

Sometimes you've got to have a little fun!

Keeping It All Straight: Drug Information

Posted by Nina Cimino at Wednesday, October 12, 2011

Wow does P4 year fly by! I can't believe fall is here so soon! This rotation, my third one, has gone by particularly fast since the rest of my P4 commitments are kicking into high gear now. For this month, I am on a drug information rotation, focused on medical writing. My preceptor for this rotation is a pharmacist working for a company that publishes drug information resources such as an online database and textbooks. He works specifically on the drug interactions portion of the database, so I have been reviewing a lot of drug metabolism topics.

Although I am not directly involved in patient care during this rotation, I have found myself juggling many different responsibilities. My preceptor works remotely from home, so I do too (outside of our rotation meetings). Here is what a typical week looks like for me: I typically meet with my preceptor and the other P4 rotation student 3 times a week, on Monday, Wednesday, and Friday mornings. We use these meetings to provide updates on our work, have topic discussions, and present journal articles. Outside of meetings, I work on updating drug interaction monographs to reflect the latest literature, and longitudinal projects.

Writing monographs is a really good opportunity for me to refine my literature searching skills, and to practice triaging information to decide what is important for clinicians using the database. Sometimes the interaction monographs just need simple updating, while other times they may need to be re-written to reflect major changes in knowledge. Occasionally, database subscribers send in particular questions about an interaction, which may generate a monograph revision as well. Updating or writing monographs requires me to use PubMed to search for relevant information, and summarize concisely to reflect the clinically relevant data for our subscribers.

As I have gotten further into the rotation, my preceptor has given me longitudinal projects to work on too. I'll describe these in more detail next time, but so far I have found that they build on the monograph writing skills I have been working on. Overall, I have a lot of different things to keep me busy, so I think this rotation is great practice for juggling different responsibilities, and identifying relevant information.

Women's Health and Compounding... What a learning mix!

Posted by Elizabeth Kelly at Wednesday, October 12, 2011

So this month I have been on rotation at Clark Professional Pharmacy, which is a compounding women's health pharmacy in Ypsilanti across from St. Joe's. And boy is it an interesting side of community pharmacy. I have never really spent any time in an independent pharmacy before, especially one like this.

First off let's talk about the compounding aspect: they have a very professional compounding lab in the back of the pharmacy. This is where they have specific technicians making capsules (much easier than compounding lab by the way), creams, injections etc. They even make serum eye drops for people from the person's own blood. I thought that was super cool.

Second, is the whole women's health aspect. Many of the drugs they compound are hormone replacement therapy medication's. They also focus most of their OTC products as herbal products for thyroid function, cholesterol, and PMS symptoms. It has been great learning about the different therapies used and how helpful they can actually be. One of the best aspects of this experience is seeing Dr. Worthing, my preceptor, help so many different ladies. He is a major referral for many doctors in the area. For example, we had a lady come in yesterday with complaints of low libido, but she was very nervous about talking about the entire subject, especially with a male. He made her feel so comfortable and really did a fantastic job explaining to her his recommendations, potential side effects, and overall evidence of therapy. He makes patients want to come back and really dedicates himself to his patients.

It's also extremely interesting to learn the whole business aspect of things. How they network, how they keep track of their finances, and how different their overall process is for processing scripts has really made me learn a whole new aspect of community pharmacy.

I highly recommend this rotation for anyone looking to get outside the normal community pharmacy experience that they may have experienced as a job. It has been challenging (all the cross multiplication for the compounding!) and a lot of fun. It is a great atmosphere to work in and when I am done I will miss everybody there.

AdMiNiStRaTiVe RoTaTiOn

Posted by Melanie at Sunday, October 09, 2011

For rotation 3, I am on my admin rotation at UMHHC with Dr. Jim Stevenson as my primary preceptor and Dr. John Clark co-precepting. So far, it has been very interesting seeing the management side of pharmacy. The admin team has been amazing and I have learned a lot of things so far.

First, the structure of the administrative team at U of M has recently changed. So let's get to know some of the players.

Dr. Jim Stevenson is the Chief Pharmacy Officer; he is also Associate Dean and the chair of the Clinical, Social, and Administrative Sciences department.

Dr. John Clark is the Director of Pharmacy Services.

I have also had the opportunity to meet with the following assistant directors: medication use system, surgical and cardiovascular, medical and oncology, and ambulatory pharmacy services; the following coordinators: medication safety, ambulatory initiative and transitions of care, and contracting and purchasing. During these meetings, I have learned about the roles and responsibilities that come with each of these positions. I have also had the opportunity to find out what each of their career paths were - each is different and unique.

I am also working on two projects right now. The first project is the Bedside Medications Policy. Currently, certain products are allowed at the patient's bedside, while others are allowed to be locked at the bedside, and others are not allowed to be stored in the patient's room. I observed 70 bedsides to assess compliance with the policy. I am currently analyzing the results and preparing to make a recommendation for updating the policy.
The other project involves dispensing medications in larger quantities than ordered. For example, if a patient was to receive 250 mL of a product and the standard practice was to dispense 500 mL, I would make note of that. I am currently analyzing my results and preparing to make a recommendation on what should be standard practice for situations like these.

I am also responsible for presenting a journal club. My article is called "Tech-check-tech". This concept would utilize pharmacy technicians for completing the final check of a product and allow pharmacists to spend more time doing clinical activities. I am going to present this idea to the leadership team and see how it might fit in at UMHHC.

The final two weeks of this rotation should be exciting as my projects are finalized and I see how my recommendations are perceived!

Early Impressions of the Top Floor

Posted by Eric Zhao at Sunday, October 09, 2011

I'm on the top floor of UMHS where you need a keycard to access to the unit. Two weeks into my psychiatry rotation, I feel safe in saying that I doubt I will ever experience a patient population more interesting or empathy-inducing.

A Day in the Life
7:45 am: Patient workup prior to team meeting

8:30 am: Team meeting with attending physician, medical residents/students, nurse practitioners, physician assistants, and social workers. During this meeting, we talk about the patients, their progress overnight, and our therapeutic plan. If you see any pharmacy interventions, speak up here.

10:00 am: Rounding with the medical team. Now's the time to see the patients and view how they're doing. Pharmacists make sure that the medications are working as intended while minimizing any side effects. For example, in an obese patient or an athlete, recommend an antipsychotic that minimizes weight gain and other metabolic complications; aripiprazole and ziprasidone are good choices, while clozapine and olanzapine are not. As always, consider the patient profile as a whole, but you knew that.

12:00 pm: Patients are usually at lunch or group therapy, so we spend time chatting with our preceptor about our patients, giving journal clubs, and attending grand rounds.

1:00-4:00pm: Follow-up with patients and ask any questions. This is a good time to write up pharmacy notes, visit patients again with the team, and provide therapy recommendations.

Variety is the Spice of Life
As you can guess, no two days are the same. Diagnoses may be similar, but no two hallucinations, delusions, or psychotic episodes are alike. Also, there are few things more inspiring than seeing a patient's mood improve as their medications take effect. One of the strategies used to manage severe, drug-resistent forms of acute metal illness is called electroconvulsive therapy (ECT). Tune in next time as we explore the clinical dimensions of ECT.

-Eric Zhao

Staff pharmacist

Posted by Matthew Lewis at Thursday, October 06, 2011

This rotation is all about figuring out what it would be like to be a general staff pharmacist, and it's at the VA (veteran's affairs) if you haven't read my previous post. The first thing that stuck me was where this VA is, which is right next to a college (Wayne State) and several other hospitals (Detroit Medical Center and Karmanos Cancer Institute to name a few) so it's at the heart of a medical complex. I've already done quite a few different things. The life of a staff pharmacist can pretty much be what you want to make it. You could be asked to take charge of the anticoagulation clinic, or make decisions about non-formulary medications. Your job might be to check physician orders and medication fills mostly.

Speaking of checking medications, the hospital inpatient setting employs a tech-check-tech system where properly trained and trusted pharmacy technicians check each other's work for accuracy. You might think it unsafe, but literature has shown that this system is just as accurate as a pharmacist check. tech-check-tech is an up and coming practice which allows pharmacists to get out onto the floor more often and help the medication ordering and administration process, which is where most medication errors occur.

Making IVs was fun, and interesting. You have to scrub in and gown up according to our fairly new industry practice of USP 797 guidelines which dictates how sterile IVs should be made. The actual mixing of the standard IVs isn't hard since most medications aren't toxic to any degree. I did not get the special chemo drug training though, since that is so dangerous even to people who follow the guidelines and have the two pairs of gloves on, the sterile disposable jacket, hair covering, mask, eye protection, mixing hoods with particular airflow and filters put in place among other things (As you can see, there are a lot of things to consider when implimenting USP 797.).

Now I'm just going on rounds and offering suggestions to the team to best manage the medications. Part of the job the pharmacist I round with is to make sure the vancomycin troughs are appropriate, and all the anticoagulation pharmacy follows is done by this pharmacist as well. I've learned quite a bit from that pharmacist as to the real-life application of medications which have narrow therapeutic ranges. In school, we learn with the impression that we can get patients' drug concentrations to the exact middle of our precise desired range, but in real practice there are mistakes as to when patients get lab draws, physicians of varying experience might not take your recommendations, or the patient might not "fit the mold" and metabolize the medication in some super fast or slow manner just to name a few things fighting against a pharmacist trying to get that perfect concentration.

That's what this rotation is all about for now, I'll keep you updated as things change.

My Patients are Cuter than Yours!!

Posted by Jenna at Sunday, October 02, 2011

To say that I LOVE my third rotation (& preceptor!) would be the understatement of the year! I started my Pediatric Surgery rotation with Dr. Allison Blackmer on Monday. I was a little nervous for 2 reasons:

• She knows that I'm interested in peds so I thought she was going to be extra hard on me because of this.
• This is her first year precepting @ UofM so I had the idea that she was going to be super hardcore.

Well neither of these were reasons to be nervous because neither ended up being true. Since Allison knows that I want to practice in peds and knew that this was my only peds rotation, she is making sure that I'm getting everything out of it that I want to. Now, obviously, there are certain pediatric topics that we need to cover and only 4 weeks to explore my huge interest in peds but I really appreciate her willingness and desire to tailor this rotation to my interests. (This isn't just because of my interest in peds, she tries to tailor her rotation to what her students want to learn, see, & experience). I feel like she is a demanding (in a good way) preceptor but she realizes the fine balance of pushing you to the max while also knowing when to let up a little. 

Rounds happen twice a day, working rounds from 5:45-7:30 (the senior fellow then goes into the OR for the remainder of the day) and teaching rounds from 9-12. Because rounds start so early, the expectation is that I just get in about 10-15 minutes before rounds start. For clinical rotations you would usually pre-round for 1-2 hours prior to rounds, depending on how long it takes you to look up labs, med changes, overnight events, etc before rounds. I typically get in at 5-5:15 so that I can look up a few things before rounds, which start in the NICU and then move up to the PICU! I've never shadowed in the NICU at Mott before so this was exciting to me.

The pediatric surgery service is made up of an attending, a junior & senior fellow (only 1 of them rounds), 2 fellows, 1-2 PA's, 1 med student (M3 or M4), 1 dietician, 1 social worker, and 1 pharmacist. They have a very specific order in which the information on rounds is presented so the first few days, it felt like I was just hearing a bunch of random numbers. They definitely rely on Allison for a lot and she has clearly built a great relationship with the team in the year that she's been here. There are 2 teams within the service, the floor team and the critical care team. Unfortunately, they both round at the same time, so Allison attends the critical care rounds and then follows up with the floor team to see what they need. When I first started the rotation, I didn't realize that I was going to be going on rounds and following the patients in the NICU, PICU, & PICU II (aka 'the deuce,' or moderate care), so I was pretty excited when I learned that. I've spent a fair amount of time in the PICU and so I'm happy to be back, although the NICU may be my new favorite. :-)

The first day of rotation, Allison handed me a pager. I'm not gonna lie, I was actually kind of excited (yes, excited) .. it made me feel like a real healthcare professional! This past week she used it as a means of communicating with me.  But on Friday, I actually asked if we could give my pager number to the team starting tomorrow. Maybe that's crazy and maybe I'll regret it but I wanted to have the full experience of being asked questions, having to look them up/analyze the literature, running it by Allison, and then getting back to the team with my recommendation. So tomorrow is the day .. the day that my pager will start beeping nonstop all day like everyone else's does at the hospital. I'll keep you updated on that experience!

I've seen some interesting things already, including an abdominal washout and a trach change. I've watched the abdominal washout twice now, which allowed me to see an open abdomen. I find that having a smaller, or average sized team is nice because the members know each other quite well. The babies and kids are absolutely adorable, which can sometimes makes it hard to pay attention! Some of the infants and toddlers are exceptionally cute and so it's hard for me not to stare at them or make silly faces to make them smile or laugh and then I end up missing things that are being said on rounds. Oops! Darn kids and their cuteness!

Outside of rounding, we also have a topic discussion daily about some of the common surgical issues seen on her service, such as gastroschisis, short bowel syndrome, PNALD (parenteral nutrition associated liver disease), etc. Preparing for topic discussions and making a handout everyday gets to be a lot but it's stuff that I enjoy learning about. I'll also have 2 journal clubs and various other activities, including attending the MSPEN (Michigan Society of Parenteral & Enteral Nutrition) meeting with Allison. 

So far, my days have averaged out to be about 12 hour days. Honestly though, I really don't mind. I am loving the rotation, the patients, the learning, and the preceptor so the 12 hours doesn't seem so bad. Life's about doing what you love .. well, if I needed further clarification, this is it. I love peds. I come home with a smile on my face every day and look forward to going in in the morning, even if it means waking up at 4am and getting 4-5 hours of sleep a night; it's worth it in every way.