Q: What has been your favorite rotation?

Posted by Kristen Gardner at Saturday, February 23, 2013

This was an EXTREMELY popular question during residency interviews. Actually, I believe it was asked at every interview. My answer: the rotation I just completed in Ambulatory Care Cardiology at the Ann Arbor VAMC with Dr. Michael Brenner as the preceptor. I am going to pursue psychiatric pharmacy, not cardiology; therefore, I have to be telling the truth!

Overview

Mondays: anticoagulation clinic AM

• Manage patients on warfarin, dabigatran, and LMWH
• Construct periprocedural bridging calendars for patients with upcoming procedures.
• Complete anticoagulation consults for questions and hospital discharges
• Meet with patients new to anticoagulation (1-hr appointments)

Thursdays: post-discharge heart failure clinic AM

• Meet with patients 1-2 weeks after D/C following admission d/t CHF exacerbation
• Staff with the preceptor and cardiologist, Dr. Scott Hummel, who is an amazing physician! The attending will perform a physical exam and you discuss how to best manage the patient together
• You really see how this clinic works to reduce readmissions as we caught patients whose status was tenuous (BP=80/50, on 2 diuretics vs. 1, on the verge of acute on chronic kidney failure, edemous/ascites, etc.)

All other days/time: Pharmacotherapy clinic

• These are 1-hr appointments for amiodarone monitoring, hypertension (including resistance hypertension where he will use aldosterone/renin levels to guide therapy), dyslipidemia, angina, and CHF
• On some Tuesdays there will be a medication education group for the cardiac rehabilitation class; there are two 1-hr sessions and then a 30min review. You will lead the 2^nd med education group and the review session.

Friday: no clinic; telephone calls (he may open up this day for clinic apt in the future)

• You will also have to call patients on other days

I loved this rotation for many reasons!

1. For students who want to pursue a residency program and demonstrate strong work ethic, he will throw you into the workflow. For me, this happened on the first day with him. He would have me observe him interact with a patient for each new type of appointment, he would observe me once, and then I would be on my own and staff with him. For those that do not understand what staffing means, it essentially means you are interacting with the patient on your own in the room. You provide a synopsis to the preceptor/attending on your recommendations with a brief explanation.
2. Everybody at the clinic is SUPER nice! The NPs, nurses, medical students, medical residents, fellows, and attendings are great.
3. You engage in a variety of experiences (teaching cardiac rehab classes, updating order sets, electronic consults, direct patient care, telephone calls, journal clubs, topic discussions, formal topic discussions, etc.)
4. He encourages scholarly activity with each student by having them summarize the articles on theheart.org every Friday.
5. Dr. Brenner LOVES his job and loves pharmacy.

It was challenging because I had never worked with the computer system at the VA; therefore, it took me a good 2 weeks before I was moving around at a fast pace to find the info I needed and pull in data/info to the notes to complete them. Additionally, you cannot access anything from home meaning all work-up and completion needs to be done on site. This could mean very long days if you have full clinic days back to back, especially with new patients. Also, the medical team outside the NPs switch on a daily basis; therefore, it is difficult to build a relationship with them where they are asking you questions all the time.

Best part= seeing/chatting with patients after you made recommendations that made a difference in the lives of the patients. 

Email me with questions!!! Oh, and you should rank this rotation #1. He only takes a few students/year.

Rotation 6: Cherry Street Health Services

Posted by Alison Van Kampen at Wednesday, February 20, 2013

If you are looking for autonomy, this is the rotation for you. This was a pretty cool rotation and I got a pretty good idea of what it is like to be an independent practitioner in an Ambulatory Care Setting.

About Cherry Street/ General Info:

Cherry Street Health Services is an outpatient clinic that serves the underserved. The patient population consist of people that meet specific criteria (low or no income, lack of access to health care, etc) and the clinic provides almost any service they could want. There is an adult medicine unit (where I spent most of my time), a pharmacy, vision, dental, pediatrics, and mental health services.

At this rotation I mostly worked with a specific group of patients who were part of the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC) or Spread (I know the letters don't exactly match up but just go with it). These patients entered the program with uncontrolled blood pressure and the goal of the group is to help the patients gain control of their BP through additional contact with them. I also did counseling and medication reviews for patients that were not part of this group when requested by one of the physicians, nurses, dieticians, etc.

I worked very independently at this rotation. I typically saw my preceptor, Fred Schmidt, for about 15 minutes of the 8 - 9 hours that I was at the clinic each day. He worked primarily in the outpatient pharmacy while I spent most of the day in my office in the Adult Medicine Unit working up patients or working on projects.

Typical Day:

On a typical day I would first work up any PSPC or Spread patients that were coming into the clinic for an appointment that day. Each time one of these patients came to the clinic I would do a medication review with them to check for compliance, understanding, efficacy, and side effects. After each of these meetings I would touch base with the primary health care provider for that patient, bring up any issues I noticed, and make any recommendations that I felt may be appropriate.

I would also work up any patients that were scheduled to meet with me for medication education, medication review, or follow up after starting a new medication. I would meet with patients at various times throughout the day and record all of my interactions and any recommendations I made to the primary health care provider. Documentation takes up a good portion of the day and I'm fairly certain I developed a mild case of carpel tunnel syndrome.

In the afternoons I typically made phone calls to check in with PSPC or Spread patients. I would call if the patient had not been at the clinic in at least 3 months or if they had uncontrolled blood pressure at their last visit and the visit was over 1 month ago. Patients were often difficult to contact because they do not always have permanent residences or old phone numbers were on file.

In addition, I answered any drug information questions that came up throughout the day, and I maintained the warfarin log book.

Projects:

There were several small and large projects that I completed through out the rotation. Here is a list of the projects I had (most of them at least)

• Short paper on MTM services
• P&T projects: one on therapeutic substitution and reviews of the new medications Tudorza (aclidinium bromide), Quilllivant XR (methylphenidate ER Susp), and Xeljanz (tofactinib)
• Group Meeting Presentation: The PSPC and Spread patients meet once monthly to work together to meet goals and there is a presentation on a relevent topic fer them which I gave.  My topic was low-fat cooking for the holidays.
• Legislative Review Paper: Call MPA and ask about current bills that could impact pharmacy, research the bill(s), and write a paper on the topic
• Student Handbook:  I updated the student handbook with relevant or helpful information along the way for the next student.  The student handbook is really all the orientation that students get on this rotation.  I was lucky to have the previous student come in one day to explain my responsibilities and how to do things.  I otherwise would have been lost for the majority of the rotation
• Data collection for new Spread patients:  My preceptor was planning to expand the Spread group to include more patients and I complied information on all of the patients that could have potentially been added to the Spread group.
• Once again all of these things were documented and put in my student profile for Fred to evaluate at the end of the rotation.

Additional Things I Did:

Each week I attended and took notes for a PSPS/Spread team meeting (consisting of me, my preceptor (Fred Schmidt), and the primary care providers for the patients in the PSPS/Spread groups. The next student came in one day to be oriented to the sight and my preceptor's mentee came in one day to shadow me.  There was also a day where my preceptor was going to the University of Michigan to speak with the P1 students and I joined him and gave them some information on what I was doing as a P4 student. I also attended the P&T committee meetings monthly.

Overall Impressions:

This was a good rotation for Ambulatory Care.  You get A LOT of independence and stay really busy throughout the day.  There really is not much guidance from the preceptor throughout the rotation and you are kind of thrown in to the rotation in a sink or swim fashion.  It can be stressful on days when you have a lot of patients to see or a lot of work to get done but there are also days when there are no patients scheduled for you to see and so things tend to balance out.  Overall, a good rotation if you self motivated and can handle working on your own a lot.

The 8 week slump... let's go back to community

Posted by mariarx at Wednesday, February 20, 2013

Wow am I behind in blogging. Having a 6 week off block full of residency applications, interview prep, and lots of traveling really made me lose track of time and I sadly neglected my blogging.

I last left off with the end of rotation 5, Emergency Medicine at UMHS. Rotation 6 saw me at Meijer Pharmacy for my community rotation block. I do have a fair amount of community experience, and my preceptor Alan Tanabe definitely took that into consideration in planning out my time with him.

Alan is a great preceptor who is an example of the difference community pharmacists can make. He does a lot of MTM and medication review interviews, in-store A1C and cholesterol checks, and a LOT of patient counseling. The pharmacists at the Meijer store in Ypsilanti are pretty vigilant about making sure they fix gaps in medication therapies and working with their patients about medication costs, side effects, and OTC recommendations.

As a P4 my time was primarily spent doing patient counseling. Alan would have me walk through the aisles looking for those people standing in front of a huge shelf of medications with a confused look on their face. By my second week I got pretty good at knowing where most things were in the aisles. I would also spend time in the pharmacy, counseling on any new medications being dispensed, answering questions, and calling doctor offices to make changes to therapies. I had the chance to sit in on medication review meetings with Alan and his MTM patients as well. Seeing the trust the patients have in their pharmacist was great! I also put together a poster about tylenol/acetaminophen and pamphlets about tylenol, and OTC cough and cold products. These I presented in my final week.

I know hospital pharmacy is a growing field, and one I hope to pursue, but it was nice being back in the trenches talking to patients regularly, and being an advocate for them when things got confusing and difficult. My time there was fun and interesting; the pharmacists and technicians working there are a great team.

I haven't decided if I want to write about Midyear/residency yet... I know a lot of my classmates went through the process and last years group wrote a bunch too. If anyone is interested in experiences about midyear and PPS for residency purposes, the administration programs in particular, then I'll write something up. Till next time!

Rotation 5: Pine Rest Christian Mental Health Services

Posted by Alison Van Kampen at Tuesday, February 19, 2013

So I am way behind, I know, but I hope to remedy that over the next week or so :)

General Info:
So this post is going to be about my rotation at Pine Rest Christian Mental Health Services with Dr. Kevin Furmaga.  First, this is a pretty unique experience and I would definitely recommend it.  This is an inpatient mental health hospital meaning all of the patients at this hospital are there for mental health issues. There are four adult units, and older adult unit, and a pediatircs unit so there are typically 60-70 patients staying there at a time. This is a very specialized and respected institution so there are people that come from long distances to receive treatment. 

Dr Furmaga is the only pharmacist on site (medications are dispensed by and delivered from St. Mary's Hospital in Grand Rapids), so he primarily acts as a consultant for particularly difficult patients to treat instead of following patients on a daily basis. He also attends the team meetings for each unit (except pediatrics) once weekly.  You go along with Dr Furmaga to team meetings (and sometimes alone near the end of the rotation) as well as looking at profiles for patients that require consultation.

Typical Day:
The typical day varies quite a bit.  There were several occasions where I spent most of the day shadowing the psychiatrists, PAs, or NPs while they talked with each patient on their unit to assess their progress.  I really developed a greater respect for these professionals as working with patients with mental health issues could be very difficult.  Some of them could be hostile and they can be difficult to read.  Deciphering patients thinking patterns and feelings just from talking with them is really a skill that I think needs to developed over a lot of time and with a lot of experience.

Other days I would work on projects, go to grand rounds, attend (or teach) medication education groups (more on that later), work up patients for consultation, or do topic discussions with Dr. Furmaga.

Topic discussions were really beneficial because it was almost like a mini lecture where Dr. Furmaga explained indication, mechanism of action, side effects, and unique characteristics of medication classes and individual medications within a class.  I found this to be really helpful when considering drug therapy selection.  Potential side effects especially played a big role when choosing therapy for a patient.  For example, the 2nd generation antipsychotics (olanzapine or quetiapine) that have more metabolic effects were often avoided in patients that had diabetes or were overweight because of there potential to increase weight or negatively impact diabetes.

Projects:
The project that I was assigned was compiling a database of information on the effects that different psychiatric medications can have on pregnancy and breastfeeding.  For this I created a large table to easily look up a medication and evaluate the safety of a medication for pregnant or breastfeeding women.  This was assigned to me because Pine Rest was starting a new service for pregnant women with a history of mental health issues.

I also created a documents describing adverse drug events and how they were addressed in the past few months which was then used in the P&T committee in the drug safety evaluation.

Cool Things I Got to See:
First cool was getting to hear the stories from all of the patients.  Many of them have interesting and often very sad histories so it is important to be understanding.  I did not speak directly with them very often but giving them respect and sympathy was often very important.

I also got to see patients under going electro-convulsive therapy (ECT).  These patients are often the ones that are refractory to medication therapy and they can achieve really remarkable results from ECT.  Also, the therapy is much simpler than you would imagine.  It usually consists of giving the patient a short acting anesthetic and paralytic, the patient is given a shock for about 10 seconds (no physical convulsion usually just tightening of the face and legs), and they wake up (all within about 1-2 minutes).  It was interesting to observe.

Cool Things I Got to Do:
The coolest thing was getting to teach the medication education group to the patients.  The first few weeks I just observed Dr. Furmaga teach the group but the last few weeks he let me teach the group essentially on my own.  I followed his format and the class usually lasted about an hour (I know sounds scary, but the time actually passes pretty quickly and the patients usually ask a lot of good questions).  I also was able to answer questions from the patients as well.  Dr. Furmaga usually left me on my own for the majority of the hour but returned at the end to answer any questions that I was unsure about. It was a really neat and rewarding experience.

Take Away Points:
This is a really unique and rewarding experience.  I learned a ton and got to do some pretty cool things.  Keep in mind when considering this rotation that you will spend the majority of your rotation sitting in on patient interviews with psychiatrists, PAs, and NPs, or working on projects. You do not follow the same patients on a daily basis so you often do not give input on therapy unless some one on the unit asks for it directly. Overall, this is a great rotation and I would definitely recommend it.

Institutionalized, hehe.

Posted by Michelle at Sunday, February 17, 2013

Hi all! I am woefully behind on blogging, so this entry is reaching back a bit to my block 4 rotation, which was institutional pharmacy at St Joseph Mercy in Ann Arbor. All my rotations have been great, so I don’t want to miss telling you about them! More entries to come in the future as my life craziness level falls just a bit. :)

 

So, back to St. Joe. Institutional rotation is a little bit less glamorous than some rotations like ID or transplant or critical care. Nevertheless, it is very important, because the activities you do on institutional rotation are building blocks and basics of much of the pharmacy world, the meat and potatoes if you will.

A typical day was as follows:

1. Arrive at 7:30 AM, check cartfill. “Cartfill” is essentially all of the unit dose medications needed by patients in the next 24 hours that are not available in on-floor medicine cabinets like Pyxis or Omnicell. While an overwhelming percentage of medication doses may be available in Pyxis, the 5% that are not can add up to a lot, especially in a large hospital. These all need to be hand-picked in the main pharmacy, checked by a pharmacist, and sent up to the floors.

2. Perform renal dose adjustments and resolve duplicate medications. St. Joe identifies renally dosed medications and potential duplicate medications by computer program. It was the task of fellow student Kristin Lee and I to make sure renally eliminated medications (mainly antibiotics, but a few others), were dosed correctly according to each patient’s calculated creatinine clearance. Duplicate medications mainly consisted of proton-pump-inhibitors with H2-blockers, and heparin with certain other anticoagulants. In many cases, especially in the first category, there is no reason for a patient to be using both PPIs and H2 blockers. By identifying which duplicate med should be discontinued, Kristin and I helped reduce unnecessary medication use.

3. Huddle: This was the daily pharmacy department meeting that occurred mid-morning. We went over important information for the day. Daily trivia questions were asked as a fun diversion; Kristin and I performed masterfully in this arena. ;)

4. Patient’s own meds: After lunch, we performed “Patient’s Own Meds”, which meant going up to the floors and barcoding medications that patients had brought in from home and were using in the hospital. This allows nursing able to scan the medications in and record their use in the MAR. It is also a patient safety measure; we needed to certify that the medications are what the patient says they are, and that they are not expired, adulterated etc.
5. Paramedic boxes: After completing Patient’s Own Meds, we had to check paramedic boxes. Each time a medication box is broken open for an ambulance visit, it must be refilled and checked by pharmacy before it can be sent out on another run. It was our responsibility to check the boxes filled by pharmacy techs; in a large hospital, this meant a lot of checking!
6. Other: There were many other activities that I participated in, although not necessarily on a daily basis. During this rotation I was responsible for completing a Medication Use Evaluation (IV midazolam) and a journal club. Kristin and I also spent a couple days in the IV room with the checking pharmacist and the TPN pharmacist, in addition to attending Grand Rounds lectures once per week. We shadowed a nurse, answered drug info questions, and occasionally did some compounding.

 

Finally, the best part of this rotation, you ask? If you are someone who *lives* for patient interaction, this rotation does not necessarily cater to you, simply due to the nature of the duties. But, dear reader, there is opportunity everywhere. On very last day of rotation, I went up to visit a patient for Patient’s Own Meds. When I walked into the room to ask about this particular woman’s seizure meds, she seemed rather upset, and I ended up talking to her for more than a half hour. She was pretty anxious and concerned about several things: some architectural components of the bathroom, the struggles she had with making sure she had her own specified generic brand of seizure drugs, problems with frequent reactions to drugs etc. I was able to talk to her and listen to her concerns, as well as explain some of the details of the difference between generic and branded medications and the differences between drug allergies and drug intolerances/side effects. When I left, her mood was much improved, and she said that while she still wanted to voice some concerns via our patient feedback pathway, she would be sure to note that PHARMACY DID A GREAT JOB! I was so proud to be part of this patient’s good experience at our hospital! Taking time to really listen to patients will always improve results for everyone. :) :)

ID in the D

Posted by Anna at Saturday, February 16, 2013

I spent the last six weeks on an Infectious Diseases (ID) rotation at Sinai-Grace Hospital located in Detroit, MI. An ID rotation was a top priority for me when scheduling my P4 year, and after finishing up this rotation I stand behind my decision! Infections are seen across all areas of practice, and it was great to have a rotation specifically focused on improving my ID skills.

This rotation was an Antimicrobial Stewardship rotation, which meant I worked behind the scenes monitoring antibiotic treatment for patients and contacting physicians with any recommendations to optimize antimicrobial therapy. Sinai-Grace Hospital has a unique ID consult service which is run by independent ID physicians who round on the patients, which meant that rounding was not a component of this rotation.

One of the highlights of this rotation was the fact that although I did not have a team to round with, I was surrounded by my own pharmacy “team.” Beyond my primary preceptor—Dr. Jason Pogue—I worked under the ID PGY-2 resident for the first four weeks of my rotation. Also on my “team” was the Sinai-Grace PGY-1 resident as well as a fellow P4 student from Wayne State University. I absolutely loved having such a diverse group of individuals to work with, and I was sad when each person slowly left for other rotations leaving me all alone on my final week.

A typical day consisted of:

• Following up on my “old” patients to see how they were progressing and if anything needed to be modified or addressed
• Work up new patients and develop a care plan for their infections
• Present new patients to my preceptor and comment on any follow-up needs for “old” patients
• Call/page physicians to make recommendations as needed
• Topic discussion / Journal Club / Follow-up questions

I was responsible for my patients from the time they were assigned to me until they were either discharged or no longer had any infections requiring antimicrobial therapy.

Overall, I really loved this rotation and highly recommend any ID rotation for a P4 student. I feel that this rotation specifically provides a lot of benefits:

1.       The patients. The patient population in Detroit has a lot of infections caused by multi-drug resistant organisms. Obviously, this is not so great for the patients; however, it is the perfect setting for pharmacy students to learn about how to treat complicated and challenging infections. It also allows you to see the significant role pharmacists play in this aspect of patient care.

2.       The preceptor. Jason is a fantastic preceptor. (I’m writing this after my final evaluation so you know I’m being honest and not just trying to get a good grade). He does a great job of asking questions and challenging you to know the information without making you feel bad when you don’t. He also tries to work with you on your personal weaknesses, and he will modify the rotation to complement your specific professional goals. For instance, he knew I was trying to obtain a PGY-1 residency position post-graduation, and for my final week he cranked the workload up to “resident” mode which forced me to work at a much higher level and also allowed me to focus on some areas for improvement.

I also want to touch on some of the possible drawbacks of this rotation to provide a well-rounded evaluation:

1.       Commute. The hospital is in Detroit. I live in Ann Arbor. This meant I had a 40+ minute commute (one way) to the hospital with the other billion people on the road. Coupled with the potential for bad January/February driving weather, I was a little concerned going into this rotation. That being said, I got used to the commute and lucked out with pretty mild winter weather for the most part. I would not let the commute deter you from choosing this rotation, particularly as the weather is only a key player in a few months out of an entire year that you could take this rotation!

2.       Interviews.  Although this rotation block was designed to provide a week to take off for interviews, an interview day is not really a relaxing day “off,” and on busier weeks I found it challenging to switch from interview mode to rotation mode. Even though my interviews were all located in Southeast Michigan, I still felt overwhelmed at times. On the flip side, having rotation responsibilities prevented me from stressing out about interviews too much—no one has time for that stuff when you have patients to take care of! I also want to say that the preceptor worked with me on scheduling and I never had an issue where rotation conflicted with a possible interview. Again, this “con” really only applies for the rotations that typically fall during interview/job search months.

After the past six weeks being surrounded by ID, a possible future as an ID pharmacist is definitely on the table. It is a really interesting area of practice and (now that I am starting to get the hang of it) I get why people love it so much!

My next rotation takes me… nowhere. I am tired, and luckily I have the next five weeks to recuperate on my “off” rotation. Once I catch my breath I will attempt to tackle a huge to-do list which includes a lot of figuring out what my next steps will be as graduation approaches.

I also want to send good luck to all of my classmates starting it all over again on Monday—only two rotations left, we can do it!!!