Saturday, October 13, 2012

How did October get here so quickly?

Posted by Janis Rood at Saturday, October 13, 2012

Rotation #5: Lexicomp Medical Writing

It's hard to believe that we are already on to the fifth rotation.  This time around I get to stay at home with Lexicomp.  I will be honest and say that it has been a difficult transition.  I prefer the hustle and bustle of teamwork and patient interaction.  I like leaving my house with a purpose, then coming home when the work is done.  None of that happens now.  I feel a little lonely at home, but you can't beat waking up, having no commute, and working in your pajamas.  So what am I actually doing?  Well, my preceptor maintains the drug interaction database.  He has assigned me three drug interaction monographs.  My job is to perform literature searches checking the most recently published data and editing the monographs for wording and content.  I've had to dig for interest in these projects and find new things to learn and ways to challenge myself.  So far I've learned how entertain myself for 8 hours while being productive, how to tweak out the best lit searches, and dig deeper into the clinical pharmacology of common drugs like beta-blockers and calcium channel blockers.  Up next week is a review of stats and study design.

Now to what I did for the third and fourth rotations.

Rotation #3: Institutional at UMHS

This rotation was split up by week.  Week 1 I worked in the Investigational Drug Services with Rivka Siden.  She has amazing amounts of energy and insight into the research process.  This week consisted of understanding the intricate process of dispensing investigational drugs, all of the documentation involved, 9 assigned readings with discussions, preparing dispensing guidelines for an investigational drug and completing an audit.  The hours were very nice, an 8 to 4:30 work day with breaks and lunches.  Week 2 was admin week.  This week I worked with the other three P4s on rotation with me on various projects, including: a CE presentation for technicians on medication safety, revamping the APPE evaluation process for institutional experiences, and revamping the IPPE experience with relevant readings, checklist activities, and additional sites.  We also had scheduled meetings throughout the week with different administrators, asking questions, hearing their stories, and hearing different perspectives on the administrative side of pharmacy.  We were able to finish all of our projects on the job, so nothing came home with me.  Definitely a good exercise in efficient team work.  Week 3 I was in the clean room, checking prescriptions, putting together batches, ordering batches, going on runs, and generally being part of the team.  Week 4 I was in the eight floor satellite pharmacy checking prescriptions, following chemotherapy protocols, investigating the Clinical Home Page, and making interventions as needed to any orders than came through.  Week 5 I was in the Central Pharmacy working with drug shortages, PacMed, and any interesting projects that came up.  The major challenge from this rotation was staying challenged.  To do this I set daily goals.  I asked myself, what about this practice site have I not experienced yet?  What do I not know?  Who do I not know?  I took it on myself to fill in these gaps every day.  I also adopted the motto "No job too small."  I was willing to do anything that the team needed me to do.  I found that  by doing this, I learned a lot about little details that can slip through the cracks, never got bored, and built a strong rapport with a large pool of technicians.  I came away with a sense of satisfaction, knowing I had gotten the most out of a less-challenging rotation.

Rotation #4: Generalist at UMHS

A generalist pharmacist is a hybrid between staff pharmacist, reviewing orders as they come through, and clinical pharmacist, working up patients and rounding with medical teams.  I was assigned to Dr. Andrew Lucarotti for a preceptor.  He graduated recently from the UM COP (2011), which made it easy for him to help me with the transition from student to practitioner.  The focus of our service was renal dosing, anticoagulation, and antibiotic stewardship, dosing and monitoring.  My general routine was as follows: 1) arrive at the 5th floor satellite pharmacy between 6:30/6:45 and work up my morning patients, 2) go over my findings with my preceptor before rounds, 3) round with the medical team (around 8 am), making my recommendations as we went, 4) report back to my preceptor after rounds the updates on patients and recommendations taken, 5) make any notes on my interventions, 6) educate patients on anticoagulation meds and log my notes, 7) work up my afternoon patients, 8) go over my findings with my preceptor before rounds, 9) meet with my physician on afternoon rounds at 1:30, 10) report back to my preceptor, 11) make any notes on my recommendations, and 12) attend or give a topic discussion, case presentation or journal club from 2:30 to 3:30.  I will describe what each of these things entailed:
1) I worked up my patients by doing the following things: reading CareWeb H&P notes, checking renal dosing, spot checking DDIs, precursory med rec, checking appropriateness of all antibiotics and their doses, monitoring INR, PTT, drug levels and coordinating timing of drawing levels and pharmacokinetic calculations.  I started out with 3 patients on day 1, and by the end of week 1 took on anywhere from 10 to 15 patients.
2) I presented what changes, levels or results I discovered.  We compared our work, confirmed my recommendations and sent me off to rounds.  This process helped to build my confidence in working up patients and making recommendations.  By the end my recommendations were mostly the same as his and I even found things he didn't.
3) Rounds could be sitting in a room and just talking through each patient with the medical team, working in your recommendations as each patient came up.  Other possibilities were walking from room to room, visiting and discussing each patient.  This took anywhere from 1 to 3 hours depending on the attending physician.  Some teams loved me and wouldn't make any changes without my advice.  Other teams tolerated my advice and made my recommended changes if they agreed.
4) Reporting back did not take too long, but helped me to work through the times when my recommendations were not taken and discuss the role of a pharmacists.
5) Making notes was very important.  It meant that anyone who touched that patient or worked them up could follow the trail of what had already been done and what still yet needed to be done.  At times this was laborious, but over time you could see the way your work impacted a patient.  Very cool indeed.
6) Educating patients was one of my favorite things.  We had standard education forms that we brought to each patient on warfarin, Lovenox or dabigatran.  Some patients didn't really want to talk with you, but most really appreciated your insight and asked lots of questions.  I found this to be really rewarding.
7) This was much like what happened in step 1), with another 10 to 15 patients.  This meant a total of 20 to 30 patients in total.  The first day working everybody up is hard (each week you move to a new service).  You miss stuff and don't get through everybody.  But by Wednesday you've got the whole of it worked through and things are a little smoother.
7.5) Please note that no lunch is in here.  We often ate lunch at the computer working patients up.
8) This is much the same as step 2).
9) Afternoon rounds were very different from the morning.  We meet with only the physician in a little conference room between 1:30 and 2.  Often times they don't show up.  Either you find them in another office or just page them with any recommendations that are critical.  Not as exciting as morning rounds, but a good experience in resistance and triaging recommendations.
10) This is much the same as step 4).  I want to note here that he did accompany us a few times, but let us be as independent as we wanted.  I appreciated this.
11) Again, much like 5).
12) The first week the different pharmacists gave topic discussions on anything from pneumonia to geriatric consideration to pain management.  Very interesting.  Each student was also assigned a topic discussion, journal club and case presentation.  These were staggered throughout the last four weeks, always in the 5th floor satellite pharmacy, always from 2:30 to 3:30.

I was almost always done with my work by then and could go home.  However, as discussed in a previous blog, I knew I wanted to get the most out of this rotation, so I asked my preceptor to assign extra homework, since you never had to work patients up at home.  Over the five weeks I completed the following projects: hypertensive emergency and urgency topic discussion, APAP overdose topic discussion, ECMO topic discussion, LVAD topic discussion, therapeutic drug monitoring chart, Top 100 renal dosing/side effects chart, pulmonary hypertension topic discussion, and a total patient review and work-up.  I appreciated the added challenge and learned so much from this rotation.  The areas in which I grew the most would be coumadin management and pharmacokinetics.  I hope to continue to grow in antibiotic stewardship.

That's all for now.  Stay tuned for more on Lexicomp and Rotation #6: Teaching Skills at Washtenaw Community College.

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