Wednesday, October 31, 2012

VA Ambulatory Care: Cardiology

Posted by Beejal at Wednesday, October 31, 2012

Hello everyone!

It’s been 2 months since I’ve posted, but rest-assured that it was intentional!  My block 4 rotation was Cardiology at the VA with Dr. Brenner.  Krystal already posted a blog about it, and her descriptions mirrored what I would say to the T!  I encourage you to read her September post before reading mine.  Hopefully my post will be supplemental to hers with some added challenges I faced.  I will also speak to the impact this rotation had on my block 5 rotation (why I waited to post!)!  First, here’s a short summary of my experience at the VA! (My definition of “short” ha).

While it is very true that everyone has a different experience with Dr. Brenner, the topic discussions, anticoagulation responsibilities, and types of patients you see are very similar to students prior.  My topic discussions were done TIW over the first 3 weeks, then BIW thereafter :).  He wants you to know everything about the topic you’re presenting.  Like Krystal noted, when you give a topic discussion he will not allow you to read your handout; he wants you to know it and just use it as a reference.

I saw my first patient on day 4 of rotation.  I was nervous, but I ended up doing great with patient interactions- it’s the therapeutics that I lacked! (Naturally!)   As with topic discussions, Dr. Brenner wants you to know everything cardiology-related about your patient when you work them up.  The patients that are referred to his clinic are ones that are difficult to manage.  You will rarely see a patient in this clinic who simply has hypertension and is well-controlled with first line therapies.  His referrals tend to need more investigation.   

When working up patients, you have to know which medications have ever been tried for all of the patient’s cardiac conditions (not just the condition the patient is being referred for).  You should know what happened with each medication and why they are on their specific regimen.  Even if atorvastatin was used 8 years ago and the patient is now taking rosuvastatin, you should know when and why they were switched, and if they ever experienced muscle pain or had elevated CPK levels.  You should know their last ECHO and ECG results, whether they had a CABG or stent placed (when and what kind), and what other conditions may be related or may impact their cardiac conditions (kidney injury, BPH, etc).  Specific to hypertension, you should be able to use home blood pressure readings and serum aldosterone and renin levels to drive therapy changes.  Specific to heart failure, you should be able to probe the patient to determine how well controlled they are, and if they are on the verge of an exacerbation.  Many of these patients are older so you should always be mindful of orthostatic hypotension, dizziness, and chest pain.  You really learn how to assess a patient from every cardiology disease state inside and out.  Finally, you write SOAP notes for every patient you see.  He knows how valuable this is, and he challenges you so that you have an easier time in residency. 

Specific challenges
Besides re-learning topics like hypertension, heart failure, dyslipidemia, and arrhythmias in a short amount of time, the biggest challenge was being comfortable making therapy changes.  For example, in one of my patients with multiple cardiac problems, we changed 2 medications and discontinued 3 medications.  This was the first time I realized the extent of the impact we can make in an ambulatory care setting, and the relevance of having prescribing abilities.

The other challenge was entering my appointments not knowing what I was going to recommend.  All your recommendations change once you talk to the patient!  You find out what symptoms are really bothering them, and what their home blood pressure and heart rate readings are.  You also generally don’t have lab values back until the middle of the appointment, so you cannot assess dose changes or abnormal lab values ahead of time.  If lab values return when you get to that portion of the appointment, you think out loud through each value, explain to the patient what the significance is, and inform them of whether they have met their goals.   Based on their lab values and their signs/symptoms, you make a recommendation for what the next step should be.  The only way to prepare for these interviews is to have different plans for if A happens, B happens, C happens, and D happens.  More than likely neither A, B, C, nor D will happen!

Cardiology is the field I had always considered for a residency.  This rotation reminded me of how much I enjoy it!  I have my favorite topics (heart failure, post-ACS, and anticoagulation) and ones I’m not so fond of (hypertension, arrhythmias).  Despite having an “interest-bias,” I am now comfortable and confident in most (if not all) of the topics that we discussed. 

Impact on my community pharmacy rotation at Meijer:  I consider myself to be proficient in assessing a patient’s cardiology regimen.  Dr. Brenner challenged me to know my therapeutics very well, and I am truly thankful.  Knowledge of heart medications is very important to any practice of pharmacy.  I am blown away with how much I have retained, and how spot-on I can be with patient profile reviews in the community setting.  I even gave a hypertension topic discussion to the P2 IPPE student and my preceptor during this rotation!  Again, I can’t describe enough how relevant cardiology is in pharmacy practice, and how much I learned during Dr. Brenner’s VA cardiology rotation. 

Time management:  I was fortunate to have 3 clinical rotations before the Mid Year meeting, and now I have a better direction for my future. This, however, was very overwhelming.  Having this cardiology rotation immediately after Peds Hem/Onc left me burnt out.  When I added my seminar presentation to this, I was working all day, every day … including weekends… for 10 weeks.  This is something to mentally prepare yourself for when you have a series of inpatient rotations.  P4s always say how busy they are, but it’s a different kind of busy.  I now know what they mean!  The best way I can think of to describe it:  you have real responsibilities as a P4- it’s not just about showing up, it’s about being prepared.  You get out of your rotations what you make of them.  Be mentally prepared to work hard during your inpatient rotations, and keep up!

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