A Re-Tale of Two Students. On Community Rotation.

Posted by Unknown at Friday, August 31, 2012

In my defense, it was pretty much my first retail experience ever. Unless you count P3 IPPE at the Krogacy, but I was only there once a week.

Here’s a brief account of the first few days of my community rotation. Don’t judge. The positive thing is that I had room to improve.

… because it would be impossible to be doing any worse.

Good thing it wasn’t a busy pharmacy! Oh wait.

Day 1

-          Filled a prescription using a bottle of the right drug and strength; too bad it was the wrong manufacturer. Redo! CHECK THAT NDC.

-          Called the patient to request a refill (instead of the Dr’s office). Why yes, yes. I would like to authorize my own refill. Please and thank you.

-          Made it rain atorvastatin. Oops. (THE PERSON BEFORE ME DIDN’T CLOSE IT RIGHT! I SWEAR!)

Day 2

-          Opened (and counted) 2 bottles of Aggrenox to fill a prescription. Oops. Apparently you NEVER open Aggrenox bottles. Good to know. PS Pradaxa.

-          Spilled an economy sized bottle of folic acid.

-          Apparently when someone drops off a prescription, you have to ask them which doctor they’ve seen (if it’s not obvious). Sometimes there are 15 different names at the top of the script. And then the typist doesn’t know which one it was. And then the patient has already left.

Day 3

-          Went to pick up lunch for the team. Was super excited to be able to do one thing right. Demonstrate one act of competence. Naturally, the restaurant got the order wrong, and I paid $12 extra.

-          Did all the paperwork to “owe” a patient medication, thinking we didn’t have it—only to realize that HCTZ tablets are in a different place than HCTZ capsules.

-          Learned the hard way that I can’t handle casual conversation (or even two other people having a casual conversation ANYWHERE in the vicinity) when I’m counting. Was I on 45? Or 40? ….55? SHOOT. Starting over.

Day 6

-          Car accident during lunch break, with a Jimmy John’s delivery boy. Who was late. (Freaky fast delivery! It’s dangerous!) Incidentally, I was (again) picking up lunch for the team. At the same place that previously messed up our order. They chose that place so I could get my $12 credit. Never volunteered to pick up the food again. Also, driving jokes for the next four weeks. Awesome. That’s probably going on my eval.

Don’t worry. My car is fine (my bumper is not), I am fine (thank you Macey- it was my first accident ever!), and overall I think mostly my pride was hurt.

This rotation was difficult for me because I had next-to-zero retail experience, and had to dive right in from the start- but I definitely learned more about how retail pharmacy works.

-          I learned lots of brand names. (Note to self: Dexilant is not dextroamphetamine. Even though to a brand-naïve person, it sounds like it should be). Everything here was arranged by brand name. Sometimes more than one brand name!

-          Macey and I did a huge chart of derm products for our project, which was a really nice refresher. I even used what I learned about steroid potency to counsel someone on the phone right afterwards!

-          I got more confident with OTC counseling, which was my favorite part. Counseling is so gratifying in the community setting. Sometimes it was a challenge to explain things in terms people understood, but I always came away from helping a customer feeling great! I still have so much more to learn about OTC products, and I think some of it will come with experience.

Rotation isn't always a breeze, and sometimes you feel stupid. Don't be afraid of it! Just go back day after day and try again. Even if it's WAY outside your comfort zone. Good luck to everyone on rotation 4. I can’t even believe it. We’re growing up so fast!

Knowledge is good but...

Posted by Kristen Gardner at Friday, August 31, 2012

Tomorrow concludes Rotation 3: Inpatient Psychiatry.

This week was fabulous because I was afforded the opportunity to lead the medication education groups for both the adult mood/anxiety patients as well as the adult schizophrenia patients here at the NIMH (side note: NIH= National Institutes of Health is composed of various institues, one being NIMH or National Institute of Mental Health. Although I am at the NIH Clinical Center, the behavioral units in the building are under the umbrella of the NIMH...hopefully this makes sense).

With the mood/anxiety patients I had planned to discuss chronic fatigue- both causes (lifestyle, medical conditions, medication induced) and possible management strategies per the request of one patient whom suffers significantly. However, the agenda is set by the patients. If they have questions about their medications or clinical care, that comes first! It so happened that they were chatterboxes this week. There were many good questions, particularly related to effectiveness of psychotropic drugs.

A few questions posed and summary of response:

1. Does it make sense that a medication would work in the beginning and then stop working after several weeks? Their definition of stop working was either no more improvement or falling back to baseline symptom presentation. We discussed it could be due to several factors: large degree of improvement followed by more gradual decreases, to see more improvement the dose may need to be increased, the disease is cyclical and frequency, intensity, and nature of symptoms can change, and there are psychosocial stressors that substantially contribute to response which is why adjunct therapy with medications is valuable.
2. How would the team choose between valproic acid and lithium to treat bipolar disorder? We discussed history of prior within the family (if applicable), drug-drug interactions, the way the drug is eliminated by your body (liver or kidney and if patient has co-morbidites which would complicate this, e.g. hepatitis or renal impairment), side effect profile/patient intolerances, patient allergies, and type of manic episode (valproic acid has more evidence for rapid cyclers and mixed episodes vs. lithium as the mood stabilizing agent) to name a few. 
3. What is the difference between SSRIs and stimulants? Discussed different neurotransmitters- serotonin vs dopamine. These patients are quite sophisticated! They understand talk of neurons, cells, receptors, what SSRI vs. SNRI vs. DNRI (e.g. bupropion) vs. TCA mean, firing of cells, receptor down regulation, reuptake blockers, etc. It is amazing what a little education can do! And they LOVE knowing this information because it makes them understand, objectively, the importance of treatment and why a certain agent may be chosen over another.

The second medication education group I led was with the adult patients with schizophrenia. This group was VERY different from the mood/anxiety patients. The level of detail needed to be drastically pulled back, they needed to do the majority of the talking (posing questions was absolutely essential as a lead in to any topic or point you wanted to make), and they needed to be consistently redirected because we have some very sick patients displaying tangential thought, pressured speech, laughing and smiling to themselves during group, extreme difficulty understanding basic information. For these patients I really wanted to empower them to monitor their illness more closely, be on the lookout for side effects, and advocate for themselves. We had a great discussion- all were engaged (some more than others), all asked questions, and shared their personal experiences.

Now, the entire rotation was not always this fabulous for me. I struggled for the first few weeks in this rotation because I came in expecting that the site would still be providing a platform/opportunity to develop my clinical skills. As I mentioned in earlier posts, the research nature makes this site very unique; this is definitely not an acute psych rotation although they are admitted to the unit. When I realized this was not the case, I had a rough time since this was my expectation- I was so excited to build off my current knowledge and practice what I had been reading about for the past 3 years. BTW- rough time is code for emotionally charged conversation with one of my mentors at our College to help process my emotions followed by emotionally charged discussion with preceptor. Also, emotionally charged conversation = on the verge of crying or crying at times. For real. Simultaneously, I was also dealing with being homesick as I have been away from my husband (and dogs!) for the past 10 weeks- this was harder than I thought it would be. And not just because he cleans and cooks for me. While this situation was really hard to process, I became much stronger as a result, and ultimately, extremely grateful for what this site did provide.

What I came to really appreciate by the middle of the rotation was that there was still learning to be done. A different type of learning called gaining perspective! This appreciation coincided with the increased one-on-one patient interaction and emotional processing/reflecting.

I gained a tremendous amount of insight and perspective from the patients. They taught me SO MUCH! My counseling skills were enriched, my interviewing skills were developed, and my ability to process contextual cues/make observations to adjust how I interact with a patient on a second-second basis was sensitized. I am become more adept at quickly developing rapport with patients, empowering/encouraging them, and conveying my passion and sincerity.  These patients have a keen sense and can easily detect someone who does not trust them, is not sincere, and will not follow-up with their concerns (persistence is important with them!). Most of these patients also assume these things until you show them otherwise as paranoia, suspiciousness, and withdrawal are common attributes. I am confident I will be a better clinician because now I can weave a little subjectivity with my objectivity when providing patient care.  Knowledge is good but....it is more than that.

At the end of the group session today with the patients with schizophrenia, a few told me they were going to miss me! This gesture made this whole rotation worthwhile. To hear patients that have struggle with the negative symptoms of schizophrenia describe and convey such an emotionally charged statement was so touching. I am going to miss the patients on the unit, but I will keep the lessons learned from them forever!

Next up: Inpatient Pediatrics/Infectious Disease. Buckle up.

Pharmacy Administration

Posted by Anonymous at Wednesday, August 22, 2012

This first quarter of P4 year is going by quickly! Between finishing my seminar, doing PharmD investigation data collection, and preparing for each day of rotation, this summer has been a busy one!

My second rotation was Pharmacy Administration with Dr. Stevenson and Dr. Clark at the University Hospital. Going into P4 year, I ranked this rotation because I wanted to learn more about the roles that administrators have in the department, and what advances in pharmacy practice they are advocating. Both Dr. Stevenson and Dr. Clark are very involved in numerous projects, within the health system and on a national basis, and I was able to see what dedication it takes to be an effective leader in their positions! 

During the rotation, I was able to shadow my preceptors during meetings, and also interact with several assistant directors. Since Dr. Clark and Dr. Stevenson have different priorities within the Department and College, I was able to split my time between shadowing them. Both preceptors have excellent insight into the current trends in pharmacy practice- it was helpful to get their perspectives as I think more about life after graduation! I was also impressed by all the progressive initiatives the Department of Pharmacy was moving forward with to improve patient safety streamline the medication use process.

I completed several written projects- the ones that I enjoyed the most were deriving the total cost estimate of outsourced compounded products per fiscal year 2012, and analyzing the monetary value of recruiting a pharmacy technician compared with the financial modeling of base pay increases. Another component of the rotation was hold a journal club discussion with all of the assistant directors during a management meeting. I feel these activities helped me gain confidence in my presentation skills, both verbal and written, while becoming familiar with the tasks administrators tackle within this organization.

I would recommend this rotation to anyone who would like some "hands-on" experience in the world of pharmacy administration, and the opportunity to work with two of the nation's top pharmacy leaders! 

A little behind... Rotation 2...

Posted by Krystal Sheerer at Sunday, August 19, 2012

I am a little behind on posting this blog… It is amazing how fast time goes by.

Rotation 2 has come and gone.

I was in Indianapolis for my drug information rotation (rotation 2). The first week of rotation was an adjustment. I went from my community rotation where I was on my feet all day… to sitting in a cubical all day. I spent my five weeks evaluating literature and writing interaction monographs. A typical day consisted of reading and evaluating literature in the morning followed by meeting with my preceptor or the other pharmacist in the afternoon to summarize the findings and discuss the details of the study (the pros, the cons, and the clinical relevance). After our discussion, I revised or added to interaction monographs. I also was assigned a presentation for the last week of rotation on a topic of my choice. Someone near and dear to me has had MS for several years and will be starting treatment soon. Therefore, I decided I wanted to research and compare the various first line treatment options for MS and present the findings. I was not familiar with all the first line treatment options available for MS so I thought this topic would not only be interesting but it would help me to better answer some of their questions surrounding the available treatments. The presentation went well and I was able to gather feedback that will help me for my senior seminar presentation.

Additionally, I was able to stay with my Aunt and Uncle and their four kids (10 year old boy and 8 year old triplets) which made the adjustment a little easier.  Most of my work was completed on site; therefore, I was able to come home every night and play with my cousins. I had a blast with them! We went to on bike rides, walks with the dogs, visited the parks, and visited the zoo. I definitely miss my Aunt, Uncle, and cousins!

Overall, I enjoyed my time down in Indianapolis and would recommend this rotation. Due to confidentiality, I cannot post the name of the company. Please feel free to contact me if you would like to know more about what I did and where I was at.

I heart behavorial health

Posted by Kristen Gardner at Wednesday, August 15, 2012

I continue to gain experience with adolescents as I attend morning reports from the nurses to get the scoop on the kids behavior. Then, we round every morning and speak for about 10minutes with each kid. We ask, how are you doing today, what emotions are you feeling, was there anything hard about yesterday, any concerns you have? Currently, we have a child on the unit with complex, severe tics. For those of you that do not know what tics are, they are semi-voluntary and often repetitive movements which can manifest as physical or vocal movements. They can be described as “suppressible yet irresistible.” Thanks Wikipedia, good to know. Some drugs can induce tics such as stimulants and neuroleptic (antipsychotics). The patient on the unit is always tugging at her shirt (complex tics), flailing her arms and legs, and twisting and turning constantly. Additionally, it is interesting because she is very somatic (e.g. my eye hurts, my tooth is infected, etc.). She is such a sweet heart though! I have included a link to a youtube video of a brave girl I found who recorded herself when her tics were particularly bothersome. This way you can observe what I mean.

Another girl on the unit has this extremely inappropriate voice- very low pitch, rough, old man voice. She speaks in this tone all the time. It is very unusual! She also has a problem remembering people. Add this to her social awkwardness and you get things like staff members being referred to as Mr. Weirdo. I never thought I would be so excited to hear a child call someone Mr. Turtle because at the least the staff member’s name actually starts with a “T.” And lets be honest, it is better than Mr. Weirdo.

One focus of my preceptor for this rotation is to develop my interviewing skills by teaching me how to perform not only a mental status examination but a complete psychological evaluation (mental status exam, history present illness, psychosocial history, past psych history, family history, social history, medication history, medical history, etc). I am really thankful for this opportunity, as one of my goals was to gain this experience coming in to this rotation. It can take about 1-1.5 hrs to conduct such an interview; therefore, it is quite an extensive evaluation. Sometimes, it can be very challenging when patients have a disorganized thought processes (loose associations, tangential thought, circumstantial thought) or they are extremely guarded from paranoia or preoccupied with psychotic symptoms. It is just something you have to work through by gaining experiences and empathy is critical. Even something as simple as, “I am sorry you had to go through that. It must have been very hard for you.”, after a patient describes a past suicidal attempt.

I have had so many great patient experiences on this rotation. Now, all my experiences are not 1:1 interactions with patients. Many of them are simply observing them during research rounds where the psychiatrist interviews the patient in front of the entire clinical and research team (sometimes 40 people depending on the day and service).  This setting also offers it benefits though.  For example, this setting would benefit people who are intimidated at the thought of interacting with a patient that has severe mental illness such as schizophrenia, severe depression, and patients expressing suicidal thoughts and discussion of past attempts at self-harm or suicide. The benefit comes from being allowed to get comfortable with the difficult discussion topics that will arise when speaking with patients. 

Difficult conversations.

#1. A patient with severe depression was asked, “What bothers you the most?” Answer: Described frustration with the fact that they do not care and that they just want to be able to love someone.

#2. A patient with schizophrenia was asked, “What bothers you the most?” Answer:  Described problems with memory and concentrating and how they wanted to be able to read their books again.

#3. A patient describing a past suicide attempt. He started having dark thoughts. He asked his mom to come home because he didn't want to be by himself since he was having those feelings. The mom could not come home because she was out shopping.

These interactions evoke such strong emotions. It makes it difficult for me to comprehend how anyone with experience working with these patients does not feel compelled or motivated to devote their entire life to improving their care. That is how passionate I am about this specialty. These patients are struggling with things that people without the illness take for granted: the ability to read, to think clearly, not be distracted by hallucinations, to love someone, to be happy, to live freely without paranoia that someone is after you….I think you understand my point. Also, you have to respect the resilience of the patients from enduring countless medication trials. I just look up to these patients so much!

I hope each of you will consider this specialty! Until next time!

I've got higher standards for a mitral valve

Posted by Tom Vassas at Sunday, August 12, 2012

Rotation 3 cardiology is well underway! Since a few other fellow bloggers have already gone through their cardio rotations and posted I will not do a descriptive analysis on the rotation, but really just give some fun insight to what I went through.

Update-wise, I'm at UMHS with the affable Dr.s Dorsch and Pogue...even though Dr. Dorsch has been on a well timed vacation. We also have 2 PGY1s, Brad and Kylee, and the cardio PGY2 Claire. The past two weeks have run their introductory scheme on me and we will be starting rounds within the week hopefully. So aside from the usual med rec (and the unusual med recs too...of which there are many), the many anticoag initiation/monitoring/discharging notes, and topic discussion running longer than everyone expects, we get to add on morning rounds. Time to start getting up earlier.

It has taken some time to get the daily operations down to where I can finish them fast so I can get on analyzing the patients. Ideally, I should be able to go over each patient on my service and make sure they're getting the correct drug therapy and that I get to counsel them on any new or changed meds.

Among all the normal patient care stuff I so eloquently described, topic/patient discussions have been where the brunt of learning occurs. Some of the refreshing clinical pearls that have come up are:

• Mitral or aortic valves matter! Aortic valves require less anticoagulation because the pressures and flow around it are higher than mitral. So ANY mitral valve patient has an INR goal 2.5-3.5
• Cyclosporine can raise serum crestor levels by up to 10 times, while tacrolimus does nothing
• IV drug users destroy their tricuspid valve first....
• An ICD will actually start pacing the heart rate a little faster than a concurrent V-tach to reset it before a shock, so a patient could feel their heart racing before the shock!

So next post will probably be a highlight of the glitz and glam that is cardio rounds but I will leave another tidbit of wisdom:

Do practice the names of your drugs well, because no one likes getting laughed at for taking 2 weeks to learn to pronounce Eptifibatide.

-TV-

This Community is full of Love & Other Drugs

Posted by Tony Lin at Friday, August 10, 2012

No Anne Hathaway. No steamy movie scenes. No ridiculous plots.

It's just an indepenent pharmacy that's led by a seasoned pharmacist that truly cares about everyone that ever walks up to the counter.

The 5 weeks I spent at Village Pharmacy II with Mr. Al Knaak in Ann Arbor was career-changing and eye-opening. Having interned at a major pharmacy chain previously and rotated at another community pharmacy just 7 months ago, I thought I've seen the best (and the worst) of community pharmacy. Boy was I wrong.

To start off, I would like to brag that students on this rotation never have to deal with insurance, count pills, or be a cashier! The emphasis of this rotation is to learn (or refresh) the over-the-counter (OTC) medication knowledge, top prescription medications, patient counselling skills, and hopefully find interest in community pharmacy. Al was a great pharmacist and a even better mentor. He assigns OTC patient cases frequently and would come in early before his shift everyday to discuss them with the students.

Having been a preceptor for 37 years, the knowledge and experiences he provides to students are invaluable. Who knew people could possibly be addicted to Lasix (a blood pressure medication), using a horse (yes, horse) shampoo and complaining she's going bald, insisting that ONLY brand name (not generic) medications work for them and more. Al has been a pharmacist here for decades and majority of his patients trust him more than their own physicians. Thanks to him, I've seen my share of interesting individuals and patients out in the real world.

 In addition to get my OTC knowledge down pat, I learned the most important thing in patient care is to LISTEN TO YOUR PATIENTS. This should always be your #1 choice to find out more about your patient and gain their trust. It sounds like a clinche--and it is--but it works.

Throughout the 5 weeks, I have never once witnessed a moment that Al lost his cool regardless how crazy the day might be. The pharmacy is always well staffed with 8-11 people between pharmacist(s), technicians, cashiers, interns and pharmacy students. The same amount of scripts at a large chain would staff 4-5 people at the most. This simple comparison effectively illustrates why Village Pharmacy II have patients returning decades after decades. Generation after generation.

Drug Information (Sudekum)

Posted by Charles Berklich at Tuesday, August 07, 2012

Hello readers! I have finished up my second rotation and am actually knee deep in my third currently-more on that later. My second rotation had me playing 'guinea pig,' as I was the first student through this particular rotation. Drug information at Botsford Hospital was a great experience.

Botsford Hospital is an osteopathic hospital, which differs from an allopathic hospital. This means while here I was mostly working with physicians who were D.O instead of M.D. It was very interesting to see the difference is how the physicians practice medicine compared to what I have previously seen.

This rotation had a lot to offer, and once again I got out what I put in to it. I was able to participate in many different and unique activities and projects which included but were not limited to:

• Writing up a drug review for P & T committee (2 actually)
• Participating in meetings discussing advancement of the cancer center
• Going on critical care rounds
• Attending review board meeting for research
• Working with the oncology pharamcist, as well as other floor pharmacists
• Participating in pharmacy informatics meetings
• Participating in nursing informatics meetings
• Participating in mock interviews
• Attending CPOE meetings
• AND ANSWER DRUG QUESTIONS

My preceptor, Mary Jane, had me answer a lot of drug information questions. Usually, another pharmacist or doctor would approach me or page me and I would write up an answer for them, sometimes multiple times per day. Mary Jane is a great preceptor, very knowledgable and great to work with. I was able to participate in several pharmacy informatics meetings and attend CPOE implementation meetings, which was valuable because that is what I am interested in.

Overall, this was a great rotation and I learned a great deal about not only drug information and the various resources, but several other aspects of pharmacy practice.

Newsflash: Its August. (Part 2)

Posted by Kristen Gardner at Tuesday, August 07, 2012

I am one week into my inpatient psych rotation at the National Institutes of Health (NIH) Clinical Center in Bethesda, MD!

Anyone who knows me knows that I want to be a psychiatric pharmacist! Therefore, I was super pumped for this rotation. I was first introduced to my preceptor, Dr. Gerald Overman, by Dr. Ellingrod, a researcher at the College, at the 2011 CPNP Annual Meeting a few years ago. I was really excited to get to know him better.

The rotation is very different from what I expected. I knew that it had a research focus because it was in the Clinical Center; however, I did not realize how this component would both develop and limit the experience. We cover 4 units, 2 adult and 2 pediatric. The 2 adult units are a schizophrenia unit and a mood/anxiety disorders unit which is similar to the Maize and Blue team at UMHS. The child units include a childhood onset psychosis team and a bipolar spectrum disorders team.

Positives

• It has been great to experience and observe mental illness in children and adolescents- that is something that you would not gain with a psych rotation at UMHS.
• Gaining experiencing with tapering meds as most patients need to be taken off their med to start on study medication
• Tapering a stable patient with schizophrenia off their antipsychotic = unpleasant
• I am learning how to conduct a mental status examination (AMSIT) this week!
•  AMSIT is an acronym used to help remember the major domains assessed in the mental status examination (A=appearance, speech, and behavior; M= mood and affect; S= sensory, I=intellectual, T=thought)
• This is NOT the same as a mini mental status exam (MMSE), a screening tool for dementia
• This is analogous to how critical the physical exam is in the work-up for a physical complaint
• I am really brushing up on my pharmacology because of the research nature of this rotation and reading through the protocols with the background evidence, hypothesis, and specific aims.
• There are active studies examining cognitive enhancing medications for the treatment of schizophrenia (modafinil, tolcapone), ketamine (+/- riluzole) for treatment resistant depression, and learning about one research group’s argument for a new diagnosis of severe mood dysregulation and how that differs from pediatric bipolar disorder using extreme irritability as a hallmark trait with a standard treatment of a stimulant/antidepressant. This is actually VERY fascinating so I will leave a reference JUST IN CASE you need to stop everything you are doing to understand their rationale. 

§  Leinbenluft, E. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. Am J Psychiatry. 2011 168(2): 129-42.

Negatives

•  The research focus limits creativity with treatment as well as patient turnover. We tend to keep the same patients on the unit that are mostly stable and just progressing through the defined protocols. Therefore, my clinical experience is not progressing as much as I had hoped it would. My preceptor and I do have huge topic discussion weekly though which provides some supplementation.

This rotation was definitely an adjustment since I had to wait to get computer training and an assigned username which didn't happen until Friday of the first week. Also, I had to learn all the major active protocols on the unit with each being nearly 100 pages. Woo-hoo! I was also introduced to at least 60 people during the first week. Normally, I am good with names; 60 names is an exception.

Additionally, I attend IRB meetings. To prepare for this, I only have to skim through 500 pages at least. No biggie.

Projects for the rotation include leading two medication education groups, one for each of the adult teams (schizophrenia and mood/anxiety), and developing a presentation to deliver to the pediatric behavioral health team. Now, normally I love giving presentations and I am not nervous so hopefully that feeling wins out over the nervousness associated with teaching top notch professional at the NIH….re: research team investigating new diagnosis. I am also writing a quick submission for the pharmacy and therapeutics (P&T) committee.

This rotation, even with its limitations, has solidified my interest in the specialty. I have really gained an appreciation for how devastating depression can be as we have many patients with treatment refractory depression on the unit. Hearing them talk about their frustration with apathy is difficult. One patient stated, “I don’t want to work because people work to buy things that make them happy, but nothing makes me happy.” I did witness hypomania after one dose of lorazepam! Oh my, it was remarkable! This patient had a mask-like facial appearance, no eye contact, barely spoke, and was apathetic. After one evening dose of lorazepam, the patient did not sleep, was a chatterbox with me (someone he has never met before), and was trying to talk his wife into buying a new home. The psychiatrist thought the patient might have been mildly catatonic (a state of immobility), and, in patients with catatonia, BDZs are first line treatment choice.  However, that did not work out as we hoped. Clearly, we stopped treatment and then re-initiated at a lower dose.

I have enjoyed learning about the patients with schizophrenia the most. I have so much respect for these patients and their strength. I always try to put myself in the patient’s shoes when providing care. For these patients, I cannot imagine functioning normally in your environment and then having your world be turned upside down and basically taken away. Not only do they have to deal with auditory hallucinations (very common) of people talking to you telling you that you are worthless and how to kill yourself, for example, but they also suffer severe cognitive deficits. In tasks related to cognition they function 20-50% of normal healthy volunteers. Some cannot spell WORLD backwards or even count backwards from 100 by 7s- they cannot even make it to 93! This is one of the things I am most passionate about as no medications substantially improve this dimension of the illness. Some treatments are being investigated- modafinil, tolcapone (a COMT inhibitor- watch out for liver toxicity!), and the second-generation antipsychotics SUPPOSEDLY help from a theoretical/mechanistic standpoint, but clinically? Who knows. 

Until next time!

Rotation 2: Warren Prescriptions - Independent Community

Posted by Alison Van Kampen at Tuesday, August 07, 2012

Hello All!

For rotation 2 I was scheduled at Warren Sav-Mor Prescriptions in Farmington Hills.  This is an independent community pharmacy, which I chose because I have experience in a retail pharmacy and I thought this would be a different experience.  In some ways it was, but as a rotation, I don't think it was really much different from other community rotation sites.

For an independent pharmacy, this was a very busy store and here is a basic breakdown of each day.

• Start out the day by calling doctor's offices to request refills, request prior authorizations, ask questions to clarify prescriptions, and verify prescriptions that were not signed or sent properly.
• Next, is a combination of counting pills, answering the phone, taking prescriptions (over the phone and brought in by patients), and answering the occasional patient questions until lunch (basic tech work, except the answering questions part of course).
• After lunch, continue tech work and discussion with the pharmacist if he/she has time.
• Discussion consisted of
• OTC products
• Dispensing laws and insurance requirements for reimbursement
• Business concerns for independent pharmacies
• Student questions

What I learned:

• Brand/generics - drugs are organized by brand name so I was forced to learn brand names better
• Laws and Insurance policies - since it is a small store they are much more concerned about following laws and filling prescriptions to the exact specifications set forth by insurance companies. They do this because they are more acutely aware of monetary issues and want to ensure that they minimize financial penalties.
• Small business concerns - this mostly consisted of costs and possible profits for filling prescriptions as well as providing additional services and maintaining customers
• Frequent checking - the store had an older computer system and did not use the barcode system.  This meant constantly checking NDCs and and paying attention to additional steps in the filling process.

Overall Impression

• At this rotation, you get out of it what you are willing to put into it.  If you want to slide through and count pills the entire time, you can easily do this.  The student is often responsible for initiating discussion with the pharmacist and making an effort to counsel patients. 
• All of the technicians are really nice and the pharmacists are helpful when they are not busy.
• If you want to learn anything in depth you often have to take the time to look it up yourself but because the store is so busy you usually can't use one of the computers in the store and will have to rely on your personal mobile technology (smart phone, iPod, etc)
• In general, I would say that I spent at least 80% of the time doing tech work (calling doctors, counting pills, answering the phone, etc), and that combined with the hour drive there and back from Ann Arbor is not worth the experience.  Also, for anyone that does not have experience in a community setting, there is a harsh learning curve because you are thrown in with little explanation of the system.
• Suggestion: For those of you doing this rotation in the future, ask the preceptor if you can take an hour or so each day to work in the back on projects or address learning objectives.  This will hopefully make the experience more meaningful.

Newsflash: Its August. (Part 1)

Posted by Kristen Gardner at Tuesday, August 07, 2012

I need to catch up. Rotation 2 first.

Rotation #2 at Walgreens specialty pharmacy (HIV/AIDS) in Chicago, IL was AMAZING! If you can find a way to financially survive in Chicago for 5 weeks, you should definitely apply for this rotation site.

I did not find the rotation site to be as intense or too steep of a learning curve as others have described it previously (I am not saying it is laid back by any means!).  This is likely explained by the following:

•  I quickly realized that I was really lucky in the information I ended up reading to prepare for the rotation prior to starting because even though he tells you what you should know prior to the first day, it is a lie! He quizzes you on 80 million other topics too! Well, maybe just 3 other topics.

• My personality is similar to his. Lets get down to business, focus, and be productive and efficient.

•  I have thick skin. I am not a super sensitive person and often unaffected by intense personalities.

• I love tests! So the 75 question final exam did not bother me. It is fun to see what you know, what you do not know, and laugh when you think, “How did I choose that answer?”.

I will admit the first day or two was intense because he does not yet know you or your abilities. This quickly changes as you engage in discussions every single day and he begins to learn your strengths and weaknesses.

The site is a low volume store. This allows you time to focus on patient care and engage in discussions constantly. You will be going about your activities in the pharmacy when you hear, “OK. Let’s talk about non-nukes.” This means you run to get your notebook, a pen, smart phone with drug apps, and your water bottle because you will be talking for the next hour and a half. Then, you learn to keep your resources very handy. He expects you to be ready 5 seconds ago. And to be organized. VERY organized. Particularly for clinic as you need to keep track of which patients require follow-up as you zip from room to room. 

I am really appreciative for the site and the 3 great pharmacists we worked with throughout our time there. They allow you to function independently as quickly as you can prove yourself. A few extra perks we experienced:

• Janis and I attended two study sessions that area pharmacists orchestrated to study for the board certified ambulatory care pharmacy (BCACP) certification exam. There are about 8 pharmacists in the study group which meets weekly. They designate one person to serve as the topic expert and lead discussion. They go to each other’s home and out to restaurants to study. Janis and I were the study experts for the psychiatry section (YAY!) and the statistical section (little yay). It was amazing because they were excited to have us. They were SO HAPPY we understood statistics (props to UM) because they honestly had no idea. But, by the end they were speeding through the practice questions and choosing correct answers!

•  The other pharmacist, Brittany, recently started staffing in a hepatitis C clinic at the HBHC. She invited Janis and I to come to clinic with her one day! Therefore, we also learned about the new hepatitis C protease inhibitors, boceprevir and telaprevir. Those drugs are confusing even after completing 3.0 of continuing education credits! We practiced counseling sessions with ribavirin, peg-intron, and the protease inhibitors. We went over a detailed patient case for practice too.

After completing this rotation, I realized I really enjoy managing patients with HIV/AIDS. I met some awesome patients and am sad I will not see them again! I will definitely be looking at the patient population served by various residency programs and what percentage of patients have this diagnosis. I am hoping it works in my favor because there is a lot of co-morbidity between HIV/AIDS and mental illness with each disease having similar complications (side effects, adherence, significant drug-drug interactions with treating both).  

Retail adventures

Posted by Michelle at Sunday, August 05, 2012

Hello all! Michelle here, reporting in post retail rotation. I spent the last 5 weeks at HomeTown Pharmacy, a midsize chain which owns a number of formerly independent pharmacies and attempts to maintain that feel in their stores. I enjoyed my time there and had some unique experiences one might not find at a major chain.

1. Medication therapy managment programs and heart failure study – My store chose to participate in a Medicare Part D MTM program with Mirixa (http://www.mirixa.com/). This program allows us to contact patients associated with Mirixa’s Part D program, offer MTM services if the patient wishes to receive them, and then be reimbursed for our efforts toward improving the patient’s medication use and health outcomes. Cool! Additionally, my store also conducted a “One-Minute Clinic” on heart failure designed by COP professor Dr. Bleske. This was a quick survey performed in person or via phone that asked patients questions about key symptoms of worsening heart failure – fluid retention, shortness of breath, fatigue, etc. The goal was to identify patients with deteriorating HF and encourage them to see a physician *before* an ER visit is necessary. Cool part deux!

2. Audits – I heard a great deal about audits on my previous admin rotation, but I had the opportunity to actually witness two in person during this rotation. One of our pharmacies was audited by Medicaid/State of Michigan; I spent the day pulling boxes of old records and sorting through them to find select prescriptions for costly drugs like Abilify. The auditing pharmacist gave some insights on the minutiae of auditing – if you didn’t write “per Doc” on a telephone prescription received from the actual physician and not the nurse/secretary, you could be out your reimbursement.

3. DME! – Our store had a significant durable medical equipment business, and I assisted with this aspect of pharmacy by helping patients choose between three different models of Bayer diabetic meters and then processing some of the billing, which is much more complicated than a prescription. Our second audit by the National Boards of Pharmacy focused largely on this aspect of our sales and certified that we were meeting CMS standards for DME.

That about sums it up! My rotation was also full of the regular retail routine, filling scripts, solving insurance issues, Zostavax immunizations, etc. The patient counseling is always my favorite part – it is the best sort of feeling to help out a patient who is looking confused in the OTC aisle. ‘Til next time – valete omnes!

Long Term Care, a HomeTown Experience

Posted by Courtney K at Sunday, August 05, 2012

Hello!

It's been a busy week with the start of Rotation 3 last Monday, so I'm overdue for my Rotation 2 blog. I spent the last 5 weeks at a Long Term Care Pharmacy (associated with HomeTown Pharmacy), in Chelsea, MI. This was a very unique experience, and it served as my Non-Traditional rotation. Although this rotation was based out of Chelsea, I spent most of my days going to different nursing homes and assisted living centers all over the state with my preceptor. Some of the places they service are FAR away, so I chose to stay at home in Owosso a few nights to lessen the drive time. The biggest nursing home they service is in Ingham County, so we traveled there most often, but we also went to homes in St. Johns, Saginaw, and Southfield. So, what exactly did I do at these homes, you're probably wondering. My preceptor is a consultant pharmacist, so she reviews EVERY patient chart once a month and makes recommendations to the physicians, nursing, and pharmacy staff. Her work averages between 50 and 70 charts a day. That seems like a crazy amount to get done in a single day, but I was with her and sure enough she does it. It goes a lot faster for her because she is familiar with the patients and their medications, since she reviews them each month. For me, on the other hand, I was expected to review only 2 charts the first day (one in the morning and one in the afternoon) and I worked up to about 4-5 charts a day by the end of the rotation.

What are we looking for in the chart? and what kinds of recommendations are we making? are probably the next two questions. A lot of the recommendations we made involved Psych Meds, believe it or not. There are a lot of rules regulating the use of these medications in the elderly. Depression is very common in the elderly, so antidepressants are commonly prescribed. Antipsychotics are also used quite a bit for delusions and paranoia associated with dementia. Gradual dose reductions must be attempted for these medications to get patients at the lowest effective dose. Other types of recommendations include appropriate  renal dosing, optimizing the timing of medications, appropriate indications for therapy, PRN med use, and lab orders to monitor for efficacy and toxicity. The recommendations are all submitted at the end of the month in a single document, so unfortunately I didn't get to see if most of my recommendations were taken. However, since the rotation spanned over two months, so I did get to see when one of my first recommendations was taken by the physician and an ineffective antibiotic for UTI prophylaxis was discontinued. Exciting!

I spent 1-2 days a week in the pharmacy in Chelsea where they do all the dispensing from. Drivers make 1-2 trips a day to the different nursing homes to deliver the needed medications. In the pharmacy I got to make lots of IV's and do some compounding (ativan cream!). The rest of the time I worked on various projects, including a new drug article for the Pharmacy newsletter, a patient case presentation to the pharmacy staff, and a 30 minute presentation to assisted living residents about the management of Parkinson's Disease.

Overall, I really enjoyed this rotation and I would definitely recommend it! It was a good lead in to my current rotation, because both involve the management of diabetes, hypertension and hyperlipidemia. My next post will be all about AmbCare in Brighton with Dr. Wells. Enjoy the rest of the summer!