Getting Frame'd

Posted by Unknown at Thursday, May 31, 2012

Hi everyone! My name is Roxanne and I am on the Bone Marrow Transplant (BMT) service with Dr. David Frame for my very first rotation.

Day 1 of rotation: Awesome! Showed up at 11 am, was assigned 2 patients, and sent home after 1 hour to work up patients!

Day 2 of rotation: Frame’d.

If there was an urban dictionary equivalent for the UM College of Pharmacy Advanced Pharmacy Practice Experience (APPE) one term that deserves a definition is, getting “Frame’d.”

“Frame’d”: not being able to answer one or many of Dr. David Frame’s questions such that you realize how much pharmacy you don’t know. 
Roxanne: “Aw man, I just got Frame’d! I don’t know anything!”
Melinda: “I’m so sorry. Try not to let it get you too down. It happens to the best of us.”

Getting Frame’d sounds discouraging but it’s really a rite of passage for us all. It doesn’t matter who the preceptor is, or what rotation you are on, in some way or another expect to get “Frame'd.” Though the process is rough, know that you are picking up a TON of information everyday!

As for the rotation itself, the Adult BMT unit is on the CS Mott side of the UM Hospital. It's really nice. Patients get their own rooms to hopefully help protect them from acquiring infections especially since their white blood cell counts are so low. Every morning we round with the team. The attending and PAs/NPs acknowledge us students and like showing us conditions we may only have seen in textbooks. Throughout rounds, Dr. Frame will ask us for recommendations on our patients. He will also ask us really random questions that are actually completely relevant but to which we never gave any thought to. When these questions are asked, I'm sure my lower jaw slightly opens and an "uhhhh" can vaguely be heard.

If you’re placed in the BMT service with Dr. Frame for your APPE, know that you are going to have to work extra hard to learn everything you need to learn. We are definitely being questioned on a ton of topics we learned in class, like anticoag, antibiotics, and anti-nausea for example -- managing nausea is a major issue in the BMT population. But we are also getting introduced to a ton of things that we haven’t learned about in class, like conditioning regimens for stem cell transplants, GVHD prophylaxis, and neutropenic fever. Protocols are key in BMT. However, for learning purposes, understanding the reasoning behind these protocols is even more important. A word of advice: know mechanisms of action and half-lives. After one and a half weeks of rotation, all I know is that I have a long way to go to master this material. Two other bloggers are on the BMT service with me this month so read up (!) and you’ll get to see this rotation through a few different sets of eyes.

Pharmablogging from Detroit!

Posted by Unknown at Thursday, May 31, 2012

So after a few weeks of decompressing following my (last ever) finals, it’s back to the grind, but P4 is a different kind of beast.  The first 3 years of pharm school are like trying to drink from a fire hydrant, and what P4 will bring remains to be seen.  Thus far, it seems like it will be a lot of juggling various responsibilities (PharmD investigations, work, rotations, seminar, preparing for meetings, life, applying for jobs, etc.). 


My first pharmacy rotation is Drug Information at the Detroit Medical Center (DMC), and I’m excited to be back in the D!  Prior to pharmacy school, I worked & went to school in the Motor City.  I love the city.  Great place to work- Detroit has always been incredibly progressive in terms of pharmacy practice, particularly health systems pharmacy.  

DRH is 1 of 8 hospitals part of the DMC medical campus

This rotation is housed within Detroit Receiving Hospital (DRH), a 284 bed trauma level 1 center, where about 85% of the business is contingent on the emergency room.  It’s a unique patient population and as the rotation goes on, I’ll elaborate on that point.  Our drug info service responds to queries from across the DMC, and sometimes from outside places, such as an outpatient pharmacist with a patient recently discharged from DMC.

Drug information isn’t exactly the sexiest topic but is one of the key skillsets that pharmacists need, so it’s a good way to familiarize myself with the resources we’ll be using for the rest of our lives.  During a drug information rotation, you’ll learn where to find information, interpret it, synthesize it, and communicate recommendations.  You’ll learn how to know what you’re looking for because sometimes the question you’re asked isn’t really the one they want answered.  You’re kind of like a detective trying to get to the bottom of something, so the more information you can get out of the person asking you the question, the easier it will be to find an appropriate answer and provide a response.

For most of the drug info questions and curbside consults, the nurses and physicians will contact the pharmacist rounding with that team or in the inpatient pharmacy.  The questions we get in drug info can be more obscure, and the answer isn’t immediately apparent, so they require some digging.  We look not only at drug references, but also the available literature (secondary sources like review articles and meta-analyses are great for this, but sometimes there are only case reports or primary literature, depending on the topic).  Sometimes, there is no right or wrong answer, just a response that you can provide based on available evidence.

So far, I’ve fielded questions regarding a variety of therapeutic topic areas, including immunization schedules (read:  Tdap can be given without regard to interval between shots), drug stability (succynlcholine is stable at room temp for 14 days), how to minimize drug interactions causing serotonin syndrome (i.e. how soon to give sertraline after discontinuing metoclopramide), medication administration policies specific to DMC (i.e. there are none for giving dextran, a volume expander, in a non-ICU setting).  And then there are more involved questions such as whether or not there are increased bleeding risks during heparanization of patients on the hypothermia protocol post cardiac arrest. 

As a student, I’m also responsible for presenting an article to journal club, and doing a formulary review for a drug the DMC is considering adding.  I also attend meetings on antimicrobial stewardship (also known as ‘everyone get together at my preceptor’s place and hang out to discuss naughty prescribing behaviors’- see the IDSA and/or SHEA if you are interested in the topic), infection control, P & T, journal clubs, pharmacy grand rounds, etc.

Regardless of your first rotation, you’ll probably feel like a deer caught in headlights, unless you’re a self-proclaimed rockstar of pharmacy (you’ll meet these folks).  But gradually, you will become more comfortable in applying the skills you’ve acquired during pharmacy school in the real world.

To date, my only complaint about this rotation is that I have to wear a tie everyday.  Worse things can happen in life though.

More to come from Detroit!

Avoiding the Dogma House: Rotating with Dr. Regal

Posted by David Plumley at Tuesday, May 29, 2012

I have been looking forward to my Internal Medicine rotation since the day we found out our rotation schedules.  I had ranked Dr. Regal number 1, 3, and 5 for rotation preferences hoping I would get him.  I had heard many good things about his rotation and knew how hilarious he was from previous classes (I think he is the only professor to ever use a picture of Flavor Flav on one of his lecture slides).

One the first day of rotation Dr. Regal gave me and Chuck (my rotation buddy) a syllabus of what a normal day would be like for us, what the major focuses would be, and revealed a somewhat unexpected "bench test" that would be given at the end of the rotation to test the knowledge we would be accumulating over the next 5 weeks.

As far as what we would be doing on a day to day basis, each of us would be assigned to one medical team who we would round with and be responsible for all of the patients on that service.  My service is Med Dock; the team consists of an attending, a senior medical resident, 2 interns (1st year residents), and two med students.  Each morning rounds start at 8am and by that time I should have worked up all the patients and have a general idea of what issues may come up on rounds.  My major focuses are antibiotics (choice and dosing), anticoag (dosing, monitoring, education), overuse/misuse of PPIs (a Dr. Regal pet peeve), and other chronic condition therapies that are not being maximized.  Each morning after rounds we meet with Dr. Regal and discuss briefly questions that came up on rounds and recommendations we should make, we then follow up with our teams and make sure these recommendations are relied to them and either taken or have a reason why they are not.  After that we have some time for lunch and time to work up any new admits (each team is on call 2 days a week) or read any articles that were given to us.  Then in the afternoon we meet up with Dr. Regal to do some topic discussions about articles we have read or common themes that he has seen come up on rounds.

The most interesting this so far about this rotation has been the wide variety of cases I see on a day to day basis.  So far in my first 5 days I have seen your more common infections like pneumonia, cellulitis, many UTIs, and  several heart failure exacerbations, but I have also seen some rare conditions only seen in case studies like POTS (Postural orthostatic tachycardia syndrome), plastic bronchitis, and cardiogenic autonomic neuropathy.  These are conditions that most health care providers will never see; but because of this rotation I get to see these conditions and hear the medical team discuss their treatment.

I hope you enjoyed my first entry.  I will try to keep you up to date with some of the more interesting cases I see and give you an idea of what I do on a day to day basis over the next 4 weeks. 

 

Color coding your schedule helps a bit

Posted by Tom Vassas at Monday, May 28, 2012

My name is Tom, and so begins the first rotation.  I'm on my non-traditional rotation, Hospital Administration, with Dr. Lindsey Kelley.  As a heads up, my schedule this year (and where you'll follow me the next 12 months):

          1) Hospital Administration at UMHS

          2) Ambulatory Care: Internal Medicine at UM Canton

          3) Inpatient Cardiology at UMHS

          4) Inpatient General Med at UMHS

          5) Drug Information at St. Joseph Mercy

          6) At home! Month off.

          7) Institutional: Hospital at St. Joseph Mercy

          8) Inpatient Critical Care at St. Joseph Mercy

          9) Community: Independent at Chelsea Pharmacy 

The administration rotation is quite.....unique. On the one hand, you have the inexhaustible supply of meetings to go to, along with the millions of peoples' names you won't remember. Then there is the equally inexhaustible supply of projects to work on. When you get out of a meeting and have 5 minutes to spare, you really don't have 5 minutes to spare because you need to work on your projects! Time management is not only essential, it is the lifeblood of being a hospital administrator.

One of the amazing things I have been a part of from the first day is improving the logistics behind patient discharge.  With so many players, systems, and opinions surrounding patient care at our health-system, there is ample opportunity for the end stage to be go wrong.  Luckily, as I saw in many meetings thus far, there is a huge host of hospital employees who strive to make that flow of patient care and discharge optimum.  Much of this rotation will involve working with transitions of care, and the projects I am working on really show how essential pharmacy is in it. The biggest thing I took away from talking to other professionals and at meetings this week was simple; pharmacy needs bigger representation! A lot of this comes from prevailing notions prior to the pharmacy practice model initiative generation (PPMI), and it surprises so many other healthcare professionals to know how much pharmacy can help and what we already do to help. 

In the next 4 weeks I will get to share the various unique parts of this admin rotation and my thoughts on how the rotation itself will evolve. In fact I'm creating the ctools site and syllabus for it right now! Aside from that, topics like 340B pricing, transitions of care (TOC) and specialty pharmacy will hopefully be ingrained in the minds of my readers, so stay tuned.

-TV-

Meetings, meetings everyday...

Posted by mariarx at Saturday, May 26, 2012

Week one of rotation one is done. Woo!

If I've learned one thing in my first week on the UMHHC Administration rotation, it is how to eat on the go. Running around the hospital from 0800 - 1700 with no break on day 1 was pretty overwhelming. Nothing like learning to swim by being thrown right in the pool. Besides the long day, I got the opportunity to see a full range of administrative task meetings - RFP presentations, team meetings, pharmacy practice rollout and planning.  My second trial by fire happened on days 2-4 since my preceptor, Dr. Brummond, was in the land of Badgers and I was braving meetings on my own. Most meetings have consisted of taking notes (about medication safety, pharmacy operations, IT, drug shortages, Joint Commission) and then looking up all the terms that I'm not familiar with.

Besides meetings with my preceptor, other administrators, and various pharmacy teams; this rotation includes a 5-week (or more) long project. Thanks to fellow blogger, Andre Harvin, the admin team has a database of over 6.5 million points about medication dispensing in the hospital. My job will be to compile a workload analysis; one of many projects that will be done with the data. The past day has been spent fiddling around with Microsoft Access and googling tutorials. Thank the internet for "Access for Dummies." Also, it stinks that Access isn't available on macs. Boo!

I hope to also use the next 4 weeks to work on my leadership skills, hone in what I need to get done for residency applications, and maybe even create a hospital glossary. I think that's all I have for now.... I'm sure the next 4 weeks will be a great roller coaster, and I'll keep everyone posted!

Pre-Rotation #1: Hospital Pharmacy

Posted by Kristen Gardner at Wednesday, May 23, 2012

 It is the second day of our P4 orientation. We have just been released for our lunch break, and I am working by preparing this blog. Some things never change.

I wanted take the time to compose and share my thoughts about this new chapter of life! I am so excited to begin P4 year that it made the last few weeks of P3 year very difficult to get through! Most students ask, “Aren't you scared of P4 year or worried?” I can honestly say that I am not scared for the most part. I am confident in myself (this has come with years of pep talks with amazing mentors) and the preceptors to which I am assigned for my rotations. I know I have a lot of development ahead of me, but I find that exciting rather than fearful. Additionally, I know I have prepared well for rotations by appropriately focusing on school and even stretching myself to explore other educational opportunities on my own (which have proven very useful throughout the course of my pharmacy school education!). The only fear is the time crunch that comes with P4 year. Fore example, I know I can find the answer to X question, complete X project, or work up a patient case. However, can I work-up 8 patient cases in a night after one day of rotation? To be determined! On the bright side, I generally consider myself to be efficient and familiar with fundamental resources so this provides some relief for mild anxiety.

My focus throughout the past semester and the few short weeks of our break between P3 and P4 year was continuing to research residency programs, finishing up my Pharm.D. Investigations project, tying up loose ends with extracurricular activities, and thinking of time-management strategies for P4 year. For example, in addition to rotations, I need to derive a short list of residency programs and prepare for ASHP Midyear (by December), develop my Pharm.D. seminar presentation (date TBD), draft a manuscript for publication related to my Pharm.D. Investigations project (December), and participate as an active member of the College of Psychiatry and Neurologic Pharmacists (CPNP) Student Committee. These are all good things to keep in mind considering my rotation schedule is very difficult July-September! AH!

My first rotation is Hospital/Health Systems Pharmacy at the University of Michigan Health System (UMHS). Therefore, it would be very wise to be productive during this less intense rotation. The rotation schedule consists of being on-site from approximately 7am-3:30pm daily with additional work as needed for a project or patient case work-up here and there.

Here is my rotation schedule in case you would like to determine your interest level in following my blogs!

• Rotation 1: Hospital Pharmacy (UMHS)
• Rotation 2: Walgreens’ Specialty HIV/AIDS Clinic (Howard Brown Medical Center, Chicago, IL)
• Rotation 3: Inpatient Psychiatry (National Institute of Mental Health, Bethesda, MD)
•  Rotation 4: Inpatient Pediatrics/Infectious Diseases (UMHS)
• Rotation 5: General Medicine (UMHS)
• Rotation 6: OFF (Midyear Preparation and Residency Applications)
• Rotation 7: Ambulatory Care Cardiology (VAMC, Ann Arbor, MI)
• Rotation 8: Drug Information (UMHS)
•  Rotation 9: Pharmacy Administration (UMHS)

·      GRADUATION! (Saturday, April 27^th)

For today, goodbye; for tomorrow, good luck; and forever, GO BLUE!

Posted by Melanie at Sunday, May 20, 2012

The last four years have just flown by!  I learned so much and met many amazing people along the way.  Make sure you take time to enjoy pharmacy school because it will be over before you know it.

I began my fourth year at the Generalist Rotation (UMHHC), which taught be about anticoagulation and aminoglycoside/vancomycin dosing and monitoring.  I also rounded with the medical team and learned the impact a clinical pharmacist could have on patient care.

I continued into Pediatric Hematology and Oncology (UMHHC).  Here I was able to ensure that the kiddos received supportive care with their chemotherapy treatments.  I also learned about the Children's Oncology Group (COG) and made sure that the proper protocols were being followed.

Next I moved into Administration (UMHHC).  I attended P&T meetings, completed medication safety projects, and decided on carpet and paint for the Victor Vaughan building.  This rotation exposed me to the opportunity to work on an FDA grant with Dr. Jim Stevenson to help standardize oral liquids compounded for pediatric patients. 

My fourth rotation was my Community Rotation (Village Pharmacy).  I learned how to help patients understand Medicare Part D options, did MTMs, and helped counsel patients on prescription and over-the-counter medications.  I learned how valuable a community pharmacist can be and what a large impact on patients he/she can have.

My fifth rotation was Institutional (UMHHC).  I was able to spend some time in investigational drug services and I learned how to verify/dispense orders in the satellite pharmacy.  I also gave a CE to pharmay technicians on aseptic technique.

Next I did my Drug Information Rotation (Michigan House).  I completed a drug monograph and wrote a newsletter article.  I also learned how to answer drug information questions.

I had the next rotation off where I was able to interview for residency positions.  I matched to the VA of Ann Arbor! 

After my month off, I moved on to Neurology (UMHHC).  I rounded with a team in the Neuro ICU as well as the neurology floor.  I was able to provide medication recommendations and learned how to adjust/monitor anticonvulsants.

Then I did my Ambulatory Care Rotation (UMHHC).  I had sites in Saline, Chelsea, and Livonia.  I was able to make recommendations for patients with diabetes, hypertension, and hyperlipidemia.  I also did polypharmacy consults and focused a lot on diet and exercise options.

My last rotation was Long Term Care (HomeTown Pharmacy).  I reviewed charts for patients in skilled nursing and assited living facilities.  I was able to make recommendations to nurses and physicians based upon my findings (Beers List medications, renal dosage adjustments, indications). 

I posted at least one blog from each rotation, so for more details on any of the rotations, please feel free to review them.

My email address is mengels2012@gmail.com.  I encourage you to email me with any questions about rotations, blogging, pharmacy school, or anything else.

For those who are considering blogging, I highly recommend it.  It really teaches you the art of self-reflection which is very valuable.  Time and time again during interviews I was asked to provide examples from rotations and I was able to use the material I blogged about to formulate a response. 

Best of luck and much success to all of you and thank you for reading my blogs.

This is Melanie Engels, PharmD, signing off.....

Reflecting Back & the Mysterious World of 9C

Posted by Jenna at Thursday, May 10, 2012

Seriously, where in the world has time gone?! I feel like everything post-Midyear is a complete blur but yet here we are, a mere 9 days away from graduation. 9 days?!!? We're in the single digits, people! It seems like almost yesterday that I packed up my car to make the 8-hour journey from NY to MI, moving to a completely new area where I knew no one. And now here I am 4 years later, ready to pack a Penske truck (who knew you could acquire so much in 4 years?!) and make the 8-hour journey from MI to TN, again moving to a place where I know no one. 

My four years at the University of Michigan have been some of the best years of my life. I love this University, I love this town, and I love the memories that I have made here. Not everything has been sunshine and roses though! There were plenty of times that I found myself in Dean Perry's office, whining that I had just bombed an exam and that I wasn't going to make it. To that, I heard "Oh girl, stop it!" followed by a pep talk. This place won't be the same without her, she is like the unofficial COP mascot. Though, I can't blame her for wanting to leave after the BCE graduates - it's the perfect time for her to retire, after graduating her favorite class evaa.  :-)

I cannot believe how fast this year went by. I've had 3 rotations since my last post: Inpatient Cardiology at Oakwood with Dr. Larry Diamond (Uncle Larry), Nontraditional Home Infusion at Walgreens OptionCare with Dr. Gabe Kaptur, and my current rotation is Inpatient Psychiatry with Dr. Jolene Bostwick. 

Psych is one of my secondary interests, behind peds of course! I shadowed Dr. Bostwick as a P1 and just find the patient population very interesting. What I didn't expect, however, was that I would find this rotation experience emotionally draining and depressing. Everyone knows that hem/onc and the ICU's are sad environments but I really didn't expect similar emotion with this rotation. Reading my patient's stories of past verbal, physical, sexual, & emotional abuse is rough. Your heart just breaks when you read about & hear these patient's life stories. So yes, I have some interesting stories and have had some pretty psychotic patients but most of all what I have had is a very humbling experience. 

I think psych is one of those areas you're either interested in or you're not. There is such a horrible stigma surrounding mental illness but really what I wish people would understand is that a diagnosis of schizophrenia is no different than a diagnosis of COPD. Patients with a psychiatric illness have exacerbations that require hospitalizations just as patients with COPD do. It's not uncommon for psych patients to undergo multiple medication trials before the 'ideal' medication or combination of meds is identified. There is a lot of opportunity for pharmacists (& students) to educate patients on various medications and what to expect. Dr. Bostwick is a phenomenal preceptor and will try to arrange for any experiences that you're interested in. She's a great example of what you can accomplish in a short time after graduation - she has a great rapport with all of the psychiatric docs, who value her input, and is a publishing machine! :-) I would highly recommend her as a preceptor and also the experience. It will open your eyes to the world of mental illness. Believe me, the patients are anything but scary. As healthcare practitioners, I think it's important to expose yourself to and have an open mind about all of your patients.

Almost there!

Posted by Matthew Lewis at Tuesday, May 08, 2012

My last rotation is incredibly interesting to me, and I think I like it even more than solid organ transplant. I am currently on an ambulatory care rotation at U of M's Brighton Health Center. What I do on this rotation is see patients with Dr. Wells, who has a collaborative practice agreement(CPA) with the physicians in the group. You're thinking it's just another rotation where you follow a preceptor and make recommendations to physicians while really having little impact on the patient. That couldn't be further from the truth. The CPA allows Dr. Wells to completely manage diabetes, hypertension, and hyperlipidemia. This includes, patient interviews, charting, having patients scheduled to see her directly, and even prescribing (within the CPA scope)! She also gets to submit claims to insurance companies for using her cognitive ability and training instead of working behind a counter, which is a recent development. I find it wonderful to have positions out there where you can manage a chronic disease state as a pharmacist. A few words of caution though. The CPA is essentially a marker of trust between the physician group and the pharmacist, and many places require one, if not two years of residency. I believe ambulatory care is an expanding role for pharmacists and that every student should be required to take at least one rotation in that setting. Not only does it give students a chance to have many direct patient interactions, but also really test your therapeutic knowledge on topics which are prevalent in a large percentage of the population, such as hypertension. As for graduation, wow. I've been a student for 22 years. Now, I end that career for a new, rewarding career as a Doctor of Pharmacy. I will continue to learn and grow, but it is certainly going to be different now. I've never been a doctor before, so it will be a unique experience to see how people interact with me and what they expect of me. In any case, I'm done with school and I am excited to move to the next stage of my life.

Long Term Care

Posted by Melanie at Sunday, May 06, 2012

My final rotation (can't believe I am blogging about my final rotation) is Long Term Care at HomeTown Pharmacy.  It is a nontraditional rotation and is something very unique that is not covered a lot in school.

My home base is at the HomeTown Pharmacy in Chelsea.  My preceptor works four 10-hour days (which can sometimes go longer).  Three of these days she is consulting (which basically means chart review) for nursing homes/assisted living facilities across the state and the other day she works from the pharmacy.  She is responsible for reviewing each patient's chart once a month.  She has homes she consults for in Ann Arbor, Southfield, St. John's, Saginaw, Bad Axe, Okemos, and Ingham County.  Each month she reviews ~700 charts.

When she reviews the charts, she looks for appropriate drug-dosing, renally adjusting medications, appropriate medication for diagnosis, drug-interactions, appropriate lab monitoring, and gradual dose reductions for antidepressants, antipsychotics, anxiolytics, and hypnotics, as appropriate.  The maximum number of charts that she is allowed to review each day is 100; however, as many of you have spent some time working up patients, this is a rather large number of charts to review in a single day.  She usually reviews about 70 a day.  On my first day, I reviewed 2 patient charts, which she says is typical for students.  Of course, it takes longer to review a chart for a new patient than it does for a patient you have reviewed before because you can spend less time on the background and past medical history and focus on picking up where you left off (basically focus on the past month).

If you think you may be interested in Long Term Care and becoming a consultant pharmacist, I would highly recommend this rotation.  Do not be intimidated that your sites are all over the state because my preceptor and I meet in Chelsea and she drives the company car.  It really is a unique experience because you are at a different place/city almost every day.