Out-of-Here!

Posted by Tony Lin at Friday, April 26, 2013

September 8, 2009 seems like yesterday. In fact, this “overnight” event consists of 1,328 days of laughters, cramming, caffeinated beverages, friendship, and hard work. Many of us have grown while some have chosen to hide from reality for just a tad longer—either way, becoming a PharmD is imminent and hitting the stage at Rackham this Saturday will be bittersweet.

In case you are not familiar with the Class of 2013, here are some unofficial records that were set:

-         Highest occupancy for the first 5 rows in the classroom

-         Most married/engaged individuals

-         Most pledge amount at over $106k

-         Highest exam averages

-         Highest Rho Chi cutoff

-         Highest out-of-state students percentage

As I have been sitting here next to David (aka Dr. Plumley) and Anna (aka A+) for the past 5 weeks at St. Joe’s Ann Arbor, I realized how much I’m going to miss all of my classmates. Judging from all the Facebook activities, I don’t think even infliximab can treat our senioritis. It’s been a long time coming.

I will be honest—the past 4 years have not been the best years for me. However, it is the challenging times that will make the next 40 years even more worthwhile. I have met some of the best people in the MACE (Most Amazing Class Ever) and will be sad but happy (definitely more happy) to see everyone going their separate ways.

Enjoy the moment, live happily. Because when we take off “candidate” in our signature, the world will be ours.

To quote President Mary Sue Coleman: 

      For today, goodbye. For tomorrow, good luck. Forever, go blue!

Rapid-Fire Reviews...

Posted by Unknown at Thursday, April 25, 2013

As a result of a long-winded bout of writer’s block, I’m in debt several blogs! Here’s some rapid-fire reviews of my latest rotations.

Ambulatory Care at Briarwood Medical Group with Dr. Marcelino

After rolling off 3 clinical rotations at UMHS, my ambulatory care rotation was a huge shift in pace. At the hospital, my norm became working up patients the night before, catching up on any new information in the morning, and picking up new patients during the day. Often, I’d follow a patient for several days, and then they’d be gone – for good. Conversely, in an ambulatory care clinic, you know exactly which patients are on your schedule days or even weeks ahead of time. While patient volume was often high, reaching 15 patients a day at times, knowing schedules ahead of time allowed me to pace myself with work-ups. The thing I liked most about this rotation compared to some of my other ones was the rapport I got to build with the patients. Follow-up visits are often scheduled at two-week intervals, which mean that I got to follow a patient’s progress with controlling their diabetes and hypertension over 2-3 visits. The staff at BMG was phenomenal, and it is clear taht the physician-pharmacist relationship established in this practice is one of mutual respect and utility. Dr. Marcelino’s patients are very grateful for her involvement in their care. She has high standards for her P4 students, and it’s a great rotation for anyone looking for a good challenge. 

Drug Information (Lexi-Comp) with Dr. Streetman

This was an untraditional rotation if there ever was one! My weekly routine involved writing from home, and meeting with Dr. Streetman and my co-colleague twice a week to discuss progress on various projects. These projects included anything from researching and answering questions that Lexi-Comp received about drug interactions, updating old interaction monographs, or drafting new monographs from scratch for interactions that were never entered into the database. I had 3-5 projects “open” at any time. Some of them were longer-term projects that I chipped away at all rotation, and others were time-sensitive assignments that required fairly quick turnover because someone was waiting for an answer from us at the other end! The most satisfying aspect of this rotation was having my direct words published on a reputable database. My work on this rotation is forever immortalized! Until another P4 comes and updates it with hot-off-the-press research years from now, that is.

Institutional

Last but not least was my experience down in UMHS’s very own B2 pharmacy. I spent a week each at Mott’s, the central B2 pharmacy, sterile lab, IDS and had an admin week in which we attended various meetings and prepared a CE presentation which my classmates and I presented to the pharmacy technicians in our final week. Throughout the rotation I found myself thinking, ‘Wow, I wish I had had this rotation first! I certainly would have appreciated having faces to go with all the people who are working hard to prepare the medications I was recommending on my various rotations at UMHS. It was a nice full-circle to finally be able to see some of the medications I had never physically seen. I never knew that tigecycline was bright yellow! Kathy Kinsey and all of the preceptors involved with the rotation did a great job of making sure we got a varied experience at all of our sites. It certainly was a great rotation to end with!

Ambulatory Oncology -- A Different Perspective

Posted by Anna at Thursday, April 25, 2013

Before drafting this blog entry, I checked out Maria's post regarding this rotation. I was surprised to see how some aspects of the rotation stayed consistent with my experience while others were completely different! It does show how a given rotation will evolve as each student moves through it, as well as how the time of year may affect the tasks performed. Due to these differences, I’ve decided to share my experience, which is best broken down into two main categories: clinic days and project days.

Multidisciplinary Clinic Day:
7:30am: Present to specialty cancer clinic. Make a copy of the patient schedule for the day, work-up patients based on existing medications and disease states and determine any specific questions I want to make sure to touch on when I chat with them.
8:00-11am: Verify medication histories, answer patient medication-related questions, and make any recommendations. Document the information in the patient electronic medical record.
Afternoon: Repeat above if afternoon clinic day, otherwise work on independent projects.

The pharmacy role in the clinic flow was well established by the time my rotation started, and everyone was pretty used to seeing a student involved. I had the opportunity to chat with head and neck cancer (Monday AM), lung cancer (Tuesday AM), gastrointestinal cancer (Tuesday PM), and breast cancer (Friday AM) patients to get a thorough medication history and assess for any medication-related issues or concerns.

Project Day:
When not in clinic I would work on independent projects. This included preparing for topic discussion (five total), updating the febrile/afebrile neutropenia guidelines for the institution, and answering drug information questions presented to my preceptor. Additionally, I had the chance to shadow the Chaplain (provides spiritual care to oncology patients) and chat with the genetic counselor on staff, which provided a better understanding of the comprehensive care a cancer patient receives.

Pros:

• Beautiful hospital with a welcoming environment (and free parking ON SITE!!!)
• Good review of major cancer types and chemotherapy used
• Exposure to counseling on alternative therapy options
• Opportunities to interact with patients and support them in their fight against cancer
• A lot of autonomy and independence

Cons:

• Only a few days of clinic per week with variable volume—this meant there weren't many interventions made in a given day
• Not traditional ambulatory practice focusing on chronic disease states or delegated prescribing rights for the pharmacist
• Patients do not have appointments with the pharmacist, which can make finding time to speak with patients challenging
• Little one-on-one time with preceptor (maybe pro depending on the person!)
• Senioritis (I was very aware that this was my last rotation... this presents its own set of challenges)

Coming from someone with little interest in pursuing an ambulatory care position, I specifically chose an oncology-focused rotation for something a little more unique in the ambulatory setting. Additionally, my plan to pursue a residency post-graduation ensured I would gain exposure to chronic disease-focused ambulatory care if I so desired. However, I would say that if you are seriously considering a more traditional ambulatory care practice setting or a setting with delegated prescribing rights to the pharmacist this is not the rotation for you. Additionally, if you are the type who needs a lot of one-on-one attention, you may prefer a different rotation. Although my preceptor was always available by phone, email, page, or stopping by her office, she was much more hands off than other preceptors I had in the past. Case in point: my first day of clinic (day 2 of rotation) I was shown to the clinic, logged into the system, and then left to my own devices. I was comfortable with that, but it meant I had to be open to asking for help from the nurses and other clinic staff (all AWESOME, by the way). Overall, it was a nice way to end my final year. Due to the ample amount of project time, I only rarely had to bring work home with me and for the most part could enjoy my last few weeks as a P4 student.

This ends my P4 blogging adventure! I appreciated having the space to write about my rotation experiences, and I hope many others continue to take advantage of this opportunity. Good luck to the next P4 bloggers as you start your rotations in a few short weeks, and a HUGE congratulations to the PharmD Class of 2013!!

Another post about residency?!

Posted by Anna at Sunday, April 14, 2013

Yes, this is another post about residency. If you are so over it already, I completely understand—feel free to move on to the next post. I will say that Kristen posted a recent entry with a lot of great information and tips based on her experiences, and I highly recommend checking it out for a complete overview and residency how-to. Instead of rehashing that information, I wanted to reflect on just a few points that may be relevant to those who find themselves in my shoes.

Specifically, this could be meaningful to you if you are….

• A P4 student seeking PGY-1 hospital-based residency
• Planning to enter practice as generalist after completion of a residency, but open to further specialization via PGY-2 if you happen to find something that truly grabs you
• Restricting your search to Southeast Michigan based on a significant other or for other equally valid reasons

For the benefit of this post (and just for funsies), I have decided to interview myself:

Q: Why complete a residency if you want to pursue a generalist position? Do you even need a residency for that?!

A: You do not need a residency for a generalist position, and many people start in a generalist position immediately after graduation. Residency is a very personal decision and is not the right path for everyone—do not feel like you have to do one! For me, I wanted the extra year of hospital-based rotations, intensive study, and freedom to learn underneath an experienced pharmacist to either become a stronger and more confident generalist or to determine if further specialization is the path I want to pursue. I was also very open with my reasons for residency through my letter of intent and during my interviews.

Q: If I want to stay in Southeast Michigan, do I have to go to Midyear?

A: Absolutely not. The SE Michigan Residency Showcase and Career Gateway events both occur in mid-October to early-November, and are great venues to learn about the local residency programs. Unfortunately, I was not able to attend these events due to being out of the area on rotation. I did go to Midyear primarily to present a poster on my PharmD research, and I was able to chat with Michigan programs at the residency showcase there. If you do end up attending Midyear, do not feel bad speaking to Michigan programs! The only one I would stay away from is UofM, strictly because if you are a UofM student you will have easy access to resources regarding the program back in Ann Arbor.

Q: How many programs did you apply to and how did you choose?

A: I ended up applying to seven programs. Knowing you want a SE Michigan residency really helps narrow down the initial list of possible programs, but still leaves you with a considerable list. With my personal goals, I wanted a program that had teaching opportunities, diverse rotation opportunities, a bigger residency class, and a large health system. I was able to narrow down my list to seven programs—which is still sort of a lot until you realize that Detroit Medical Center requires separate applications for each site—through information on websites as well as what I gathered at Midyear. I accepted interviews at all seven sites, as I wanted to physically visit the hospitals and experience the learning environment. I do believe that you get a definite feel for each residency once you actually interview, and this feeling played a big role when I ranked my programs. Additionally, since I was within a 40-50 minute drive from each interview, it was feasible for me to go to many interviews without spending money on flights, hotels, and other travel expenses.

Initially I was jealous of my classmates who had the freedom to apply to any program in the nation, with no geographic limitations. However, I found that Michigan has many amazing residency opportunities, and I did not have to compromise any of my “must haves” in a program in order to stay in the area. Hopefully these few points will be helpful to those who find themselves in similar situations, and good luck!

Residency Bound?

Posted by Kristen Gardner at Saturday, April 06, 2013

As fourth-year student pharmacists, my classmates and I who pursued residency training are constantly asked about our experiences going through the process- and for good reasons! It can seem overwhelming, it is competitive (but you can do it if that is what you want!), and I definitely believe there are tips/tricks to success. I decided it would be best to place the details on a google doc instead of taking up oodles of space on the blog website.

In general…

• I encourage students to start exploring the residency path early if you think you may be interested. Speak to many different people because everyone offers their own perspective. It also allows you to see the commonalities in the opinions to help you know what you really need to do.
• Use our faculty to learn about programs, make contacts, improve interviewing skills (have additional mock interviews), and proof your CV or cover letter! This requires initiative on your part.
• Know yourself- self reflection and self-awareness are powerful tools/traits
• Be strategic with program applications/interviews. Do not apply only to top programs regardless of being in Rho Chi, holding national leadership positions, having posters, manuscript, etc. I had several amazing pharmacy friends with the above criteria who did not match this year. Be smart but at the same time do not apply/rank a program you would not be happy being a resident; however, there are many programs

Programs to which I applied/interviewed; feel free to ask me questions if you are looking into any of these programs! I matched to UNC PGY-1 program!

• University of Michigan
• University of Minnesota Ambulatory Care Residency Program
• University of Pittsburgh- St. Margaret
• Saint Mary’s Health Care (Grand Rapids, MI)
• Virginia Commonwealth University Health System (Richmond, VA)
• University of North Carolina Health Care (Chapel Hill, NC)

UPMC St. Margaret (a community teaching hospital with an amazing physician-pharmacy relationship particularly if you like outpatient/family medicine practice) and University of Minnesota had very interesting/unique programs. I encourage you to look into these programs which may be less known among our student body. University of Minnesota also has a 2-year Pharmaceutical Care Leadership Program (ambulatory care focused) which is very unique as well.

As an aside, I do not believe residency is the right path for everyone. Do not feel pressured to pursue this pathway- do want is right for you depending on your career goals and personal situation! This can be a difficult decision; however, know that our College will be proud of you for pursuing your dreams and being an awesome clinical pharmacist regardless of the setting in which you practice (e.g. community, managed care, industry, hospital, ambulatory care/clinics, etc.). Regardless of where you want to practice, FIND A MENTOR that fits your career goals. You will have to search for one within our College or ask faculty for an alumni contact which may be able to help you. Read and be informed of how to be a great mentee and cultivate a mentor-mentee relationship. This is not something to take for granted. You should also spend time appropriately approaching a potential mentor and articulate why them, what you hope to gain, and thank them for their consideration.

If you have any questions contact me! My favorite things are peer mentorship and professional development. Mentors and upper classman have helped me and I want to pay it forward. I would be happy to give comments on CVs or example cover letters you may have from P550 (although I expect these to strengthen when you actually apply because you will have more insight at that time)….prior to starting residency on June 17^th. J

Email: gardner.750@gmail.com or kngard@umich.edu (while I am still a UM student)

GOOD LUCK! The final year is so exciting. Time time to be proud of your accomplishments and soak in every minute. It goes by fast!

UMHS Drug Information

Posted by Kristen Gardner at Saturday, April 06, 2013

I completed my drug information rotation at UMHS with Dr. Abraham Bazzi as my preceptor of record (BTW He is awesome!). 

This rotation was really fun! The environment was more relaxed with an energetic primary preceptor and very knowledge and well-respected secondary preceptors.

The drug information service is a student run service with 2 students at the site per rotation block. You split the phone shift (9am-4pm) between the two of you such that one student answers the phone from 9am-12:30pm and the second student fields requests from 12:30pm-4pm. When the resident is on site, you run the question and response by the resident and only go to the preceptor as needed. When the resident is not there you will run the question/response by the preceptor of the day (the staff rotate this role through the rotation).

Responsibilities

• Complete a pharmacy & therapeutics (P&T) manuscript (my topic= antithrombin III)
• Complete an external review of a compounding pharmacy
• Answer drug information requests by phone, page, and email
• Prepare an article for the UM Newsletter (my topic= tolvaptan associated liver enzyme elevations)
• Complete 2 medwatch reports
• Attend meetings with the preceptors (drug shortage conference calls, pre P&T meeting, P&T meeting, product vendor selection committee meeting, etc.)
• Attend (per availability) the resident research proposals, final report, and CE sessions at the hospital

I like this rotation because you get to know the residents more and interact with all the preceptors. Each of them approach things differently and it is great to gain this perspective. They are all very friendly and knowledgeable.

At the end of the rotation, I came away with much more confidence answering drug information requests. Additionally, I no longer have a fear of, “Oh my, what am I going to be asked when I pick up this phone?” We are very lucky at UMHS to have extensive resources available at our fingertips. Several calls we get are from other institutions wanting to know our practices or protocols. It is quite remarkable.

A sample of the types of questions I was asked

• Can we compound or obtain any quinacrine product?
• What is the conversion from tablet to suspension formulation of megestrol acetate?
• How to adjust carbamazepine dosage using serum levels
• Can a patient taking Trileptal consume pomelo fruit? (FYI= research indicates that pomelo fruit (some varieties) inhibit CYP3A4 to an extent similar to grapefruit juice!); however, Trileptal is not primarily metabolized via this route…..
• Drug interaction questions (LOTS OF THEM)
• Alternative antidepressant for a patient who experience QT prolongation with fluoxetine
• Recipes and whether or not tablets can be crushed/given via tubes somehow (LOTS OF THEM)
• Options for administering selenium as a result of the never ending shortage of this trace element (Thank you Dr. Kraft)
• Is a medication still good after being stored outside package insert parameters

Tips

• Be cautious assuming everyone understands pharmacokinetic drug interactions related to CYP450 enzymes. In my experience, it is best to communicate using the both languages about 1) Drug A is a CYP2C9 substrate and Drug B is a CYP2C9 inhibitor; therefore 2) Drug B would be expected to inhibit the metabolism of Drug A resulting in increased levels of Drug A vs. expecting the other person to make the connection. I found this to be true more so among the nurses vs. physicians.
• Always remember to consider alternatives/back-up plans when responding to drug information requests
• When assessing whether medications can be administered down tubes, consider the formulation of the drug product. For example, when assessing this for dronabinol, the medication is formulated in sesame oil and is not soluble in water; therefore, in the absence of data we could not recommend for it to be given via this route as it would likely adhere to the tube and you could not rinse it down with an aliquot of water. 
• Micromedex has some helpful therapeutic resources!!! Just search and try it out!