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).
Summary
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.
Reflections
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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