Drug Information at the University of Michigan

Posted by Alison Van Kampen at Wednesday, September 19, 2012

Well, rotation number 3 is over, and I had a blast.  Most people will tell you before P4 year starts that Drug Information is a boring rotation, but I must beg to disagree.  I found this to be a really fun rotation that really suited my personality. 

The environment was very low key, which I like, and it didn't hurt that we had lots of space to work as opposed to being crammed down in B2 and fighting to find an available computer.  It also helped that all of the people in the Drug Information Service were great to work with (and I'm not just saying this because I know that they will be reading this post).  My primary preceptor was Dr. Stumpf and I also spent a lot of time with Dr. Bazzi, Dr. Dasse, and Dr. Sweet.  In addition, my fellow student, Matt Perez, and I spent a lot of time with the new resident as wekk. Everyone was very nice, they were helpful when I worked on projects and answered question, and they gave some pretty sound advice for the future.

I found the tasks and projects that we were assigned to be helpful, interesting, and often challenging.  Everyday we were responsible for taking a phone shift.  On the phone shift we would take calls from various people regarding unusual drug questions.  Questions would come in from everyone from physicians, pharmacy faculty, nurses, outpatient pharmacies, and lay-people. The majority of questions had to do with stability of a drug that was left out of the refrigerator (which often resulted in a long call to the manufacturer) but other questions were very interesting and required extensive research.  Here are just a few:

Is it safe to use sedative hypnotics in a patient that has insomnia related to Lewy Body Dementia? and if so, which ones?

Why is it that for all SSRIs, increased risk of bleeding is listed as an interaction with Clopidogrel, but fluoxetine has the added interaction of decreased efficacy of fluoxetine? What is different about fluoxetine?

Should a woman taking medications that compromise her immune system avoid contact with her grandchildren who recently received a live varicella vaccine? and if so for how long?

Are there any concerns, other than lack of efficacy, for a 14 month old patient that was being administered expired CellCept for the past 2 months?

In addition to answering these questions, we also had small projects like filling out MedWatch forms, learning about and determining the pros and cons of various sources of information (there are way more out there than you can imagine), finding ways to critically evaluate journal articles and the statistics they publish, and attending meetings at the hospital.  

We had two larger projects as well.  One was writing a newsletter article, mine was about the possible association between maternal use of SSRIs during pregnacy and Persistent Pulmonary Hypertesion of the Newborn, which was pretty cool.  The other large project was creating and delivering a P&T presentation on a new drug to the Drug Information staff.  This was exciting because I got to research and learn everything about a new drug, Carfilzomib, and learn more about the disease state that it treats, multiple myeloma.

Overall, I really liked this rotation.  There was very little patient interaction, which was good and bad.  Also because I'm not good at being put on the spot, I really liked that I was able to thoroughly research my answer to a question before delivering an answer. AND I was able to learn a lot of interesting and unsusal things about drugs (interesting and unusual has always been very attractive to me).  I would definitely recommend this site to anyone for their Drug Information Rotation.

A little bit of Everything

Posted by David Plumley at Tuesday, September 11, 2012

Sorry for my absence and delay in posting, but the last 6 weeks have been very busy for me. I recently finished my non-traditional rotation with Dr. Lindsey Kelley, as well as my PharmD. seminar presentation with Dr. Randy Regal.

I most definitely felt a ton of pressure to perform during my seminar, especially with Dr. Regal as my preceptor.  While I didn't steal all his jokes or puns I borrowed a fair share from him. I felt like my presentation went well overall and, hopefully, the people in my room managed both to stay awake and learn something about the use of protease inhibitors in treating HCV.

As far as my administration rotation with Dr. Kelley, I very much enjoyed working with her and would recommend her rotation to anyone interested in administration or anything to do with transitions of care.  My 5 weeks with her flew by, both because we were very busy with many projects but also because I was having so much fun.  It was possibly my favorite rotation thus far.

Dr. Kelley is involved in UMHS's specialty pharmacy program, transitions of care, 340B contracting, and ACP.  I will talk a little bit about each area and do my best to explain what took me the better part of 5 weeks to understand.

Specialty pharmacy(SP) is something new to Michigan and an area that is rapidly evolving.  Basically SP involves the dispensing special drugs to specific populations — transplant and cancer patients to name a few.  These drugs are special because they are limited in distribution from drug companies, require special monitoring, are very expensive, and often times insurance companies restrict where a person can get these drugs.  As a healthcare institution UMHS's goal is to provide these drugs to their patients and employees on their own or by partnering with other parties. My part in this effort was to compare different SP companies to see what they offer, what UMHS currently offers, and what we should offer.

Transitions of care (TOC) is something that Dr. Kelley is very interested in and an activity we spent a lot time working on.  This is because it is a important initiative for health systems and crosses over into other areas we were working on.  TOC from a pharmacy standpoint involves medication management/reconciliation at every transition (change in location) a patient goes through.

I was involved in projects relating to better ways to get patients discharge meds (there were some very interesting ideas for this), how we help patients get access to their meds as an outpatient, and the inner workings of our own ACP.  This  was specially fun because it involved a lot of creativity and I was able to work with many different groups all over the hospital.

Finally 340B, in my own simplistic view, is a special drug pricing strategy that UMHS has access to due to out patient population.  Again, UMHS is very cutting edge with these programs in order to better serve our patients and make our health system more sustainable.  This activity involved many meetings with many different groups, and took me weeks to understand.  I will not go into too much detail on this latter topic, but if you want to know more I have a sweet diagram I can share with you.

Being involved in all of these different activities required many 10+ hour days filled with meetings and special projects.  But it did not feel like work all the time, Dr. Kelley allowed me tons of autonomy to work on my own and to select projects that I was interested in.  This really helped me succeed. I hope to take the skills I learned from this rotation and bring them to bear on all of my other experiences this year.

If you have any questions about this rotation feel free to find me and ask.

Thanks for reading.

Life in Virginia: Week 1

Posted by Krystal Sheerer at Saturday, September 08, 2012

My fourth rotation is in Alexandria, Virginia at the National Association of Chain Drug Stores (NACDS). Tyler (my husband) and I drove out here Sunday, September 2^nd. Well, Tyler drove and I slept most of the way. 

I am still not used to the driving out here or the roads! Thankfully I found a great APP that will take me wherever I need to go. The first couple days in Virginia I spent finding all the essential places: my rotation site, the nearest grocery stores, and a couple coffee shops! After a few trial runs I was ready for my first day!  So far most of my time has spent getting familiar with the foundation and their mission/goals. 

I am definitely ready for week 2!

Just when I thought I had the next five years planned…

Posted by Krystal Sheerer at Saturday, September 08, 2012

My last rotation was Cardiology Ambulatory Care at the Ann Arbor VA with Dr. Brenner. Dr. Brenner definitely challenged me and I am so thankful he did. 

Overview of my rotation: 

 

My first day consisted of orientation and discussing with Dr. Brenner what his expectations were and what expectations and goals I had.  

THEN THE FUN BEGAN

On Day 2 I gave my first topic discussion. This was my first topic discussion of my P4 year and it was definitely not what I expected. My first topic was hypertension. Basically, during topic discussions you tell him everything you know about the disease state (definitions and goals) and the medications (indications, doses, MOA, ADRs, interactions, contraindications, and monitoring parameters).  He does not want you to use any notes… he wants you to know it! Even if you thought you knew everything he will find something you do not know and that is okay. You can look it up and get back to him as soon as you find the answer.  This is how all topic discussions went. The first week and a half we covered hypertension, anticoagulation, antiplatelet therapy, CAD and stroke secondary prevention, hyperlipidemia, heart failure, amiodarone monitoring, and arrhythmia therapy.  The information he expected you to know was realistic it was information that could appear on our boards and information you should know. You definitely leave his rotation more comfortable and confident about the above topics. Did I mention that he will quiz you throughout the rotation? He will ask you questions about your first topic discussion on week 2, 3, 4, or 5. This is to make sure you actually know the material and do not just memorize things for topic discussions. The topic discussions prepare  you for the patients you will be seeing as he sees patients in anticoagulation clinic on Mondays and then Tuesday through Friday he see patients with hypertension, hyperlipidemia, heart failure, CAD, and patients taking amiodarone.

The second week I was seeing patients in anticoagulation clinic. I saw both therapeutic and non-therapeutic patients. After interviewing the patients I would discuss with Dr. Brenner what my recommendations would be. It is important to be able to state why you want to make dose adjustments or why you want to keep things the same. By week 3 I was seeing patients with hypertension, hyperlipidemia, post-discharge heart failure patients, and patients taking amiodarone. During this rotation you definitely have the opportunity to work on patient interviewing skills, therapeutics, and soap note writing.    

Other activities on this rotation included leading/presenting a topic discussion on heart failure to a resident and pharmacist and leading two cardiac rehabilitation classes on medication therapy. I also had an opportunity to write a paper on using ambulatory blood pressure monitoring to guide antihypertensive therapy. If you haven't heard of this I encourage you to look it up. I also would recommended theheart.org (its free you just need to sign up). Additionally, I was able to spend a few hours observing in the cath lab.

Reflections 

I did not know it was possible to learn as much as I did in 5 weeks. Dr. Brenner is a great preceptor. He provides feedback all the time. You never have to guess how you are doing. He will find your weakness and help you to improve it. He also is sure to compliment you if you doing something well.  I have really enjoyed my experiences at the VA. I would encourage anyone that may be interested in cardiology to rank Dr. Brenner's rotation. You will definitely have a great experience. He tells every student that their experience may be different than their peers. The cardiology physicians are great and welcome pharmacist involvement. They work closely with Dr. Brenner and engage in conversation with the pharmacy student.

 

 I would recommend Dr. Brenner’s Cardiology Ambulatory Care rotation at the VA in Ann Arbor to anyone!

Adventures in Babysitting -errr, Pediatrics!

Posted by mariarx at Tuesday, September 04, 2012

Oh man, I can't believe it's already rotation 4! The quiet summers of empty Ann Arbor are gone... soon we'll be entrenched in computer turf wars with the P3s on their direct care IPPEs. Before we get too far into rotation 4, I wanted to look back at my adventures in peds.

Our PY team. I like to think I'm the girl with the gold viking helmet hanging on for dear life.

The generalist rotation, new and required this year, gives you the option of working on the adult (UH) side or the pediatric (Mott) side. I decided to take the plunge and go with peds. Who doesn't love kids? Me. But I did like working with their meds. My mom would be so proud. 

My day on the generalist rotation started with rounds prep. On any given day we had between 2-6 patients admitted to the PY (pediatric gold) team. That isn't a lot of patients... until you realize the work that goes into peds dosing, indications, etc. For each patient I tried to get a good idea of their problems and what all their diagnoses meant (helloooo Google), their dosing regimens, weight based dosing, daily maxes for the medications, indications, and any alternatives that I may be asked about. Safe to say my monitoring form looked like a rainbow in trying to keep all the info divided. My preceptor, Jenny Hlubocky, was really good at giving pointers for keeping everything straight and reminding me to focus on the drugs and not get lost in the world of googling mowat-wilson disease.

One aspect of peds drugs and dosing that I didn't really think about before this rotation was the taste of oral meds. Unfortunately, tiny mouths and esophagi are not made for swallowing tablets - which is where solutions come into play. Doing the taste test with Dr. Streetman and the medical students was really fun, even if I did get a headache from all the random drugs we tasted. Note to the public: linezolid, clindamycin, MVIs, and iron taste GROSS; and chocolate syrup is Dr. Streetman's gift to little kids everywhere. 

After rounds my partner-in-crime Vince and I would go over our patients with Jenny, maybe work on orders for our services, and then have the afternoon to do individual work. Besides our general PY patients, we also worked up the rehab patients in Mott. These patients are usually in the hospital for a really long time (and have a really long MAR), so we would make sure that doses were appropriate and make recommendations for cleaning up the med list - such as getting rid of PRN meds that hadn't been used in a while. 

Our final patient interaction component was med reconciliation. I feel like I spent the majority of my afternoon work hours trying to find parents to speak with about their kids medications... the laws of not speaking to minors alone make medrecing quite the difficult task. 

Besides patient interactions and monitoring, we also had some mini-projects and 2 bigger presentations. Mini-projects consisted of topic discussions about things that may have come up in our talks about patients or just interesting topics in the world of peds. In the effort to bring my own interests into the pediatric world, I ended up presenting my journal club and larger topic discussion about pharmacy administration and its role in the inpatient stay and discharge. Dr. Brummond and Dr. Kelley would be proud (I think). 

Overall, I'm really glad I picked the pediatric side of the generalist rotation. I don't have any other peds rotations on the horizon so this was a good adventure to have. My 4th rotation is ambulatory care in oncology... you'll hear about that soon enough if I make it out alive. Till next time, keep saving lives fellow P4s! 

Canton Meijer Pharmacy = Counseling!!!

Posted by Anna at Tuesday, September 04, 2012

My third rotation was at Meijer Pharmacy in Canton, MI. Having had about two years of retail pharmacy experience, working in the community pharmacy setting for five weeks was definitely a nice break after two very unique rotations.

                            

The primary goal of this rotation was spelled out by my preceptor on the first day: maximize patient interaction. This meant that when on-site, I was the initial resource for any pharmacy-related questions from patients, any new medication counseling, and all over-the-counter medication recommendations. The site was a very busy pharmacy, functioning with one to two pharmacists and four to five technicians at any given time. I was not treated as “free labor,” and I was not expected to perform pharmacy technician activities. Essentially, I was a supplemental pharmacist, which provided the opportunity to review and reinforce much of my therapeutic and pharmacy law knowledge. This rotation also required little off-site preparation, leaving more time at home to work on other projects and deadlines.

Overall, I would highly recommend this community rotation site. The pharmacists were incredibly welcoming and gave me the freedom to step out and apply my knowledge. The pharmacy technicians were efficient and self-sufficient, and they were quick to call for me me whenever a patient had a question or needed additional counseling. It was a great work environment, and I could not have asked for a better community experience.

My next rotation will be quite a change from the hustle and bustle of a large retail setting: I will be working primarily from home for the next five weeks completing a drug information rotation with Lexicomp!

Hooked on PHO: Pediatrics Hematology/Oncology (PHO) at Mott

Posted by Beejal at Tuesday, September 04, 2012

Hi everyone,

I’ll begin by noting that words just don’t give justice to how great this rotation is! There is so much that I’d like to say about it, so of course this means that this is another extremely long post! O:-)

I wish that more people knew about PHO!  Dr. Howle is an exceptional preceptor, and you get to interact with Dr. Frame and Dr. Christen a fair amount as well!  You are surrounded by experts in cancer, and while it can be overwhelming, about half way through the light bulb goes off in your head and you say “I get it!”  Dr. Howle describes it well:  We have never been taught anything about PHO in school so our 5 weeks consist of building from the ground-up.   Also, this experience would be very different if I didn’t have the support of my classmates.  I had the rotation with Meenakshi and Tony, and we really worked well together.  We studied together, we motivated each other, and we helped each other with advice about our patients.  

A typical day

We round with the team every morning and attend meetings with them (Tumor Board and Presentations).   For a majority of the day, we work up patients and look up what we don’t know about their medications.  Almost every afternoon, we spend a couple of hours on topic discussions (sometimes with the BMT and Peds Surgery students) and patient presentations.   We discuss chemotherapy agents, children’s cancers, and supportive care.  Below are a list of the topics that we got through (it looks overwhelming… and it was indeed).  In the evenings, we usually check on patient notes and prepare for the next day’s topic discussions.

·         Acute Lymphoblastic Leukemia

·         Acute Myeloid Leukemia

·         Osteosarcoma/ Ewings Sarcoma/ Rhabdomyosarcoma

·         Neuroblastoma

·         PTLD/Burkitt/Hodgkin/Lymphoblastic Lymphomas

·         Brain Tumors

·         Sickle Cell Disease

·         Radiation

·         XLP1/XLP2

·         How cancer arises                                           

·         Neutropenic Fever

·         Chemotherapy-induced Nausea/Vomiting Pain

·         Colony Stimulating Factors

·         Oncological Emergencies

·         Anemia

There are many things great about Dr. Howle.  She does weekly evaluations and is very receptive to our feedback.  We get the opportunity to let her know if we’re overwhelmed, what might help us more, what we don’t feel comfortable with, what works really well, what should and should not change for her future students, and what more we would like to see or do.  A couple of weeks after starting, I asked to see a bone marrow biopsy, a lumbar puncture, and a patient education on chemotherapy.  Dr. Howle made it happen for all three of us within the next two days.  Furthermore, Dr. Howle’s teaching style worked very well for me.  She would quiz us every day about our patients, their chemotherapy, their disease state, and their labs.  Repetition is my friend!  She really made sure we were comfortable and ready to be independent.  She gave us constant feedback and made sure we knew what was expected of us.  Pharmacy aside, Dr. Howle is also such a fun person to be around!  She is dynamic, has much sought-after work-life balance, and really cares about us beyond our abilities to be pharmacy students.  Her main concern was to get enough sleep, and I’ll be the first to admit that sleep was ENTIRELY necessary to stay focused during this rotation.  

The Attending Physicians are excellent teachers, experts in their fields, and very open to pharmacy input.  The team consists of one senior resident, two interns, and two-to-three medical students.  This is a “Sub-Intern” rotation, so not every medical student will circulate through our service; it is selected by only those 4^th year students who want to specialize in it. 

Reflections

Until now, I always said I liked working with geriatrics.  I never thought that I would enjoy kids, but they are all SO cute!  The little ones are so playful!  The older ones have had a tough course so far, but you have respect and admiration for how much they’ve been through.  I have always wanted to have a relationship with my patients, and I really like what I found in PHO.  I ask myself if pediatrics in a different specialty would be as fulfilling, and I don’t think it would be.  I also ask if I’d like Hem/Onc on the adults side, and I am planning on learning that by shadowing.  

Before this rotation, I really loved the patient and inter-professional interactions in the Generalist rotation (Block 1, blogs 1 and 2), but PHO took inpatient pharmacy to another level.  Similar to the Generalist, PHO had patient interactions; however, these patients and their families are fighting chronic disease and you are helping them through their acute problems.  You have a relationship with the patient and their family, you are in a more critical environment, and you are monitoring very sensitive drugs.  I liked the intensity of this unit, and I think I would be great for this type of pharmacist position.

I walked into this rotation having a slight interest in hematology as it relates to anticoagulation.  During my Generalist rotation, I had a very interesting Sickle Cell Disease patient which prompted me to ask, Why not hematology as a career specialty?  I always enjoyed learning about cancer, and even worked in a basic science cancer lab, but I never really considered pursuing pharmacy in the cancer field.

My advice for anyone thinking about taking this rotation  

I really didn’t have a good reason for ranking a rotation like this except that an upperclassman gave it exceptional reviews.   I think I’ve found my niche here, but it is a very specific field and it could be a difficult 5 weeks if you had no interest in cancer.  I worked day and night learning about the cancers and my patients.  Know that it will be your life 18 hours a day (with built in 6 hours of sleep!), 6 days a week (you can have 1 day off!), over 5 weeks.  You also should be mentally prepared both to see the cutest kids ever and the sickest kids ever.

Looking to the future

The other field that I’ve considered is Cardiology.  The Experiential Training gods were looking out for me when formulating my rotation schedule because my next site is Cardiology at the VA hospital in Ann Arbor.  I’ll be able to directly compare my two interests and decide what I’ll be looking for in a career.   

Tune in next time!  If you’ve been keeping up, it seems like every rotation I get a little bit closer to what I want to be when I grow up!

TEE or TTE? I'll go for the overestimated EF thank you

Posted by Tom Vassas at Sunday, September 02, 2012

My cardiology rotation has ended to my dismay. Since starting rounds 3 weeks ago, each day has been a tremendous blur.

Generally getting to the hospital by 7, I had an hour or so to work up patients and identify any issues with med therapy I wanted to bring up on rounds. Our team (the Johnston cardiology service) had one attending, one fellow, two interns, two med students, one PGY1 and one pharmacy student. Due to how our rotations are structured it wont always be like that but this month was jam-packed, and it was a hoot every morning.

Rounds started around 815 and each day our attending wanted to go over new patients and had either the med students or interns present them, then interspersed the PGY1 and me would give our recommendations based on home meds, upcoming therapy, better options etc. For the most part, our attending Dr. Labounty, was pretty versed in the most up to date med options for patients and most of the research behind them. In that respect we didn't need to do much, but some issues they just didn't know too much about and deferred to us. Here's a brief list of topics that came up we got to make a difference on:

• Aspirin dosing has changed in the latest recommendations and it was interesting to get the attendings to go lower more often...none of this 162 or 243mg garbage.
• Spironolactone is great for heart failure but I never got Dr. Labounty to start someone on it after an MI, something about borderline EFs not being accurate...surrre
• For the rare patient with contraction alkalosis or simple metabolic alkalosis, he was all too eager to try acetazolamide when he's never used it once before and had no idea what to monitor for it
• Identified possible amiodarone induced pulmonary fibrosis - win
• Pentoxifylline is a great thing to D/C...especially when the patient is going into GI bleeds and needing blood every few days
• Dr. Labounty does not like pradaxa, never heard of xarelto, and will implicitly trust us to dose coumadin...even if someones INR only budges 0.1 with 15mg
• Diuretic conversions are apparently born hither unto all pharmacists and we are presumed to reproduce them as we could our ABCs
• Despite the eagerness of the fellow to load up vitamin K AND FFP, got the attending to think "hmm couldn't I just hold coumadin and not make his INR sub therapeutic for a week?"

These were just highlights and there were a lot more times when it was just a matter of him saying "I wanna do X, is that right?" But being on rounds gives a new appreciation for exactly what your recommendations do to the patient. Not only that side but you learn so much more about that field as far as what actually gets practiced. 

Of all the things I loved about the cardio rotation, two things come to my mind; I have seen many an angiogram and many a TEE/TTE that I will never forget the bright blue colored mitral regurgitation (in fact some guys terrible angiogram with total LAD occlusion made me ok sticking with ASA 325!). The other is on the second to last day when Dr. Labounty asked us if every cardio team gets a pharmacist and we said it isn't always likely. The look of disappointment and the soft spoken "Oh, ok. That's unfortunate" from him really made my month.

Next week is peds general medicine! Stay tuned. And by the way, TTE = trans-throacic echocardiogram and TEE = tran-esophogeal echocardiogram. And TEE is way better.

-TV