Sunday, October 14, 2012

Amb Care and Cardiology

Posted by Courtney K at Sunday, October 14, 2012

Hello all,

I apologize for the delay in this post, P4 year really picked up all of a sudden and we're now HALF WAY DONE!! Here's a recap of my last 2 rotations:

Rotation 3
My ambulatory care rotation with Dr. Wells has been my favorite one so far! I hadn't really considered amb care as a possible career for me prior to this rotation, but my experiences on this rotation have made me think more seriously about it. I was on this amb care rotation during the big switch to the MiChart computer system, so that changed my experience a little bit in the following ways:

-I got to see how health care professionals handle a big switch in technology. This put many employees outside their comfort zone and it was quite an adjustment for them. Luckily there were "super MiChart users" available all day for the first few weeks of the change and they were able to troubleshoot a lot of the problems.
-As a student, I had read-only access to MiChart (so i could no longer write notes in the medical record like we can with Careweb). I was still able to access MiChart to get all the patient information I needed, such as lab values, medication lists, and notes from past encounters. The main difference for me was that I now had to email my visit notes to Dr. Wells instead of forwarding them through Careweb.
-My patient load was smaller (50-75% of normal) to allow for the adjustment to MiChart. On average I had between 6 and 8 patients for a morning in clinic, and normally this would be doubled.

My responsibilities for this rotation included:
-working up each clinic patient ahead of time and discussing with Dr. Wells. This means having multiple plans ready to go depending on if the patient's blood sugar and blood pressures are improving, staying the same, getting worse and based on how their diet/exercise is going.
-interviewing and assessing patients during their visits
-insulin teaching and diabetic foot exams
-writing up notes of the encounter
-4 topic discussions (diabetes, hypertension, lipids, diet/exercise)
-2 journal clubs
-1 patient case presentation

The large majority of the patients I saw had uncontrolled diabetes so they are referred to the clinical pharmacist by one of the primary care physicians to help get their sugars under control. Dr. Wells has a collaborative practice agreement with each of the physicians at the clinic so she is able to prescribe new medications and make any dose changes she wants to for their diabetes, hypertension and hyperlipidemia management. She has a great relationship with all of the staff and they really value the work she does. Seeing the big impact that pharmacists can make in chronic disease management was really awesome to see and be a part of. I learned so much on this rotation and feel much more confident about managing diabetes, blood pressure and lipids. I learned something new from each patient I talked to and one of my favorite things was following up with patients I had already met with and seeing them improve throughout my 5 weeks. This rotation was also a good lead in to my first inpatient clinical rotation at U of M.

Rotation 4
Cardiology with Dr. Pogue was my first inpatient clinical rotation of the year. I was really nervous and excited to finally have a clinical rotation that involved rounding with the medical team. Luckily, this rotation didn't throw us straight into rounding the first day, which I appreciated. And I wasn't alone either- I had my partners in crime, Dave and Edwin on the other 2 cardiology teams and Corrine on heart failure. The first 2 weeks we worked on our own to get familiar with the patients on our team, and our responsibilities for the rotation which included medication reconciliation on each patient, anticoagulation management, educating all patients on anticoagulation meds, and pharmacokinetics for vanco/aminoglycosides. Once we figured out how to get all of these things accomplished, we through rounding into the mix. When rounding started, my schedule looked like this:

7am- arrive at the hospital and work up any new patients, follow-up on labs and med changes for current patients and formulate my recommendations for rounds
8-8:30am- Rounding with the team. My team consisted of 2 medical students, 1-3 interns, 1 resident, and the attending physician. This could take anywhere from 2-4 hours, depending on the number of patients and how complicated they are. One particularly long day when my team had admitted 7 new patients over night we rounded until about 1 pm. Needless to say I was STARVING and forgot a snack that day. *Note-ALWAYS keep a snack in the pocket of your white coat.
12/12:30pm- Follow-up on any questions/issues that came up on rounds ("Let me look that up and get back to you" was my go-to phrase), and check-in with Dr. Pogue on any issues that needed attention before our afternoon meeting. Then I'd eat a quick lunch and make my way through med recs and warfarin educations. Rounding in the morning helped me to prioritize my work, because I would have a good idea of which patients were having procedures done that day, when patients would be going home, etc. This was especially important for patients new to warfarin because we had to make sure that the team knew who was going to manage them outpatient (PCP, UMHS anticoag service, other) and make sure that they had coverage for enoxaparin if they were being sent home on bridging. One of the main goals of the pharmacy managed anticoag service is to ensure safe transitions of care and making sure everyone is clear on who will be monitoring and when the next INR check will be. For patient's being sent home on new medications for antiplatelet therapy (clopidogrel, ticagrelor, prasugrel) we also worked to make sure these drugs would be covered by their insurance and if not, work with the patient to get them started in assistance programs.
2-3pm- meet with Dr. Pogue to go over patients, recommendations, and follow-up on any other issues that have come up throughout the day. We also did afternoon topic discussions, 8 total throughout the rotation. The topic discussions that I lead were on hypertension and arrhythmias. The discussions covered background of the disease state, classes of meds used to treat (MOA, DDIs, PK/PD, side effects), and a summary of assigned primary literature and clinical applications. Cardiology is very evidence based and there are a LOT of studies. One day my attending brought up the HOPE trial on rounds and I actually knew what he was talking about because we had just talked about it in our topic discussion.
4:30-5pm- leave for the day and get ready to do it all again. This rotation was a lot of work, but very worthwhile. On days that my team was admitting I would work up new patients from home in the evening in hopes of saving time in the morning. Even then, sometimes I would only have time for a brief look at a patient before rounds. Topic discussions also took a lot of time outside of rotation to prepare.

One of my favorite aspects of the rotation was all the patient educating I got to do. The most unique counseling experience I had was a warfarin education with a hearing impaired patient. I had to call and schedule an appointment with the hospital's interpreter service and an interpreter met me at the room so I could go through the education points with him. The patient was already pretty familiar with anticoagulation so that made my job easier, but it was a great experience nonetheless.

This was a really great clinical rotation. Each patient had very complex medical history and many of them were transferred to U of M from outside hospitals because of their high risk status or for special procedures. I saw a wide range of disease states from acute coronary syndrome, pulmonary hypertension, endocarditis, heart failure exacerbation, atrial fibrillation, pulmonary embolism, digital ischemia, and the list goes on. I learned so much from rounding and topic discussions and one of the biggest lessons I learned was how much I still don't know. The cardiology pharmacists all know SO MUCH and can rattle off study results, half lives, and max rates/doses without batting an eye. This rotation solidified my decision to want to do a PGY1 residency because if I can learn this much in a 5 week rotation, think of how much I'll learn in a whole extra year!

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