Wednesday, August 28, 2013

From Clinical Pharmacy Generalist to HIV Community Specialist

Posted by Rachel Lebovic at Wednesday, August 28, 2013

Rotation 1: Clinical Pharmacy Generalist
                  Entering the hospital for the first day of P4 rotations was energizing. I have walked through the University of Michigan hospital’s doors countless times as an undergraduate volunteer and P1-P3 student for shadow experiences and IPPEs, but this time was different. I knew that I would be playing an important role in caring for patients. No more watching other practitioners, this time it was my turn. Plus, I knew that I would be returning every day for five weeks instead of my previous once weekly routine.
After orientation the first day I was asked to work up eight patients. It took me several hours. I was motivated and tried to complete a thorough work-up for each patient. It was extremely rewarding when I was able to see these patients on rounds with the team the next morning. My preceptor joined me on rounds for the first few days, then I progressed to rounding by myself. Over time, I began to feel more comfortable and increased my patient load from eight patients to as many as 16.
Throughout most of the rotation my schedule usually involved arriving to the student computers in the basement pharmacy by 6:30am, working up the patients on my service until 7:40am, running upstairs to the fifth floor pharmacy to discuss any recommendations I wanted to make while on rounds, then meeting the healthcare team for rounds at 8am. Rounds lasted anywhere from 1.5-3 hours depending on the number of patients and the complexity of the cases. Then, I would return to the fifth floor pharmacy and discuss each patient with my preceptor in more detail. If there was more time, I would then work up patients on one of the non-rounding services (an attending only), discuss those patients with my preceptor, then discuss my recommendations with the attending from 1:30-2pm. Other afternoon activities included counseling any patient on my service who was on a blood thinner and looking up any patient-specific questions.
In my opinion, having the clinical pharmacy generalist rotation for block one was excellent scheduling. This rotation was a great review of pharmacokinetics and dosing for antibiotics including vancomycin and aminoglycosides, and I reviewed/learned a lot about several different anticoagulants. Furthermore, this rotation was a great balance of boosting my confidence and reminding me that there will always be more to learn.

Rotation 2: HIV/AIDS Community Pharmacy
                  Fortunate to have a great internship experience in Henry Ford Health System’s outpatient pharmacies, I found myself looking for something different for my P4 community rotation. I definitely found that “something different” with my HIV/AIDS community pharmacy rotation in Chicago! Considering we only had about three lectures on HIV in the P1-P3 curriculum, I had a lot to learn to be able to optimally treat patients with HIV. To prepare for the first day, Caitlin (the other U of M P4 on rotation with me) and I were told to learn all of the brand names, generic names, and abbreviations for the HIV medications currently on the market. It seemed like just memorizing the drug names was a lot to learn at the time, but little did we know that we would understand and apply most of the 240 pages of HIV treatment guidelines over the course of the next five weeks.
Most of the time we were in a miniature Walgreens pharmacy inside the Howard Brown Health Center on the north side of Chicago. This health center is focused on treating lesbian, gay, bisexual, transgender, and queer patients. Additionally, two afternoons per week we were in a multidisciplinary HIV primary care clinic at Mercy Hospital on the south side of Chicago.
A typical day in the Walgreens pharmacy consisted of:
1.     New to therapy calls – calling patients who recently picked up a new medication to see how it was going
2.     ADAP (AIDS Drug Assistance Program) calls – contacting patients whose HIV medications are shipped from a CVS-Caremark specialty pharmacy in Pennsylvania to let them know their medications arrived
3.     Typing, filling, and verifying prescriptions (with the pharmacist’s oversight, of course), along with patient counseling at the pick-up window
4.     “The Queue” – the list of patients whose HIV medications are due to be refilled or patients who are nonadherent to their HIV therapy. We filled these patients’ HIV medications, accessed their HIV regimens for appropriateness, and contacted patients to ask if they wanted their medications delivered to their home
5.     Discussions with our preceptor, Mr. Halbur RPh (Drew) – Drew would often say something to the effect of “let’s discuss nucs” or “tomorrow we’re discussing child pugh scoring.” What this really meant was review everything we knew about anything related to the subject and be prepared to discuss it in great detail! While preparing for these discussions was often a lot of work, they were a tremendous tool for learning about the HIV medications (side effects, drug interactions, patient counseling, etc.) and reviewing other topics.
A typical clinic day at Mercy Hospital consisted mostly of performing readiness counseling and adherence counseling with patients. Readiness counseling sessions are used to explore if a patient wants to start taking HIV medications. This is important because patients who do not take their medications reliably are subject to medication resistance, and their treatment options can become incredibly limited. Adherence counseling sessions try to determine the barriers causing patients to miss doses of their medications and help them figure out strategies to overcome those barriers. Often, we would set up pillboxes for patients to aid them in adhering to their medication regimens. Although more rare, one of my favorite types of counseling sessions was initiation counseling during which we would discuss the four first-line HIV regimens with a patient, discuss the patient’s lifestyle, disease state, comorbid conditions, and other medications, then work with the patient to determine which of the four regimens would be best for the patient to start.
Other projects we worked on during this rotation included:
1.     Teaching a transgender patient how to administer his own intramuscular testosterone injections
2.     Writing a newsletter article for the Howard Brown Health Center
3.     Giving a presentation titled “HIV 101” to the new PsyD (Doctor of Psychology) externs at Mercy Hospital
Even though this blog is mostly about my rotation experience, I have to mention that exploring Chicago with Caitlin was definitely an added bonus on this rotation! In the free time we scrounged up, we managed to check out some local eateries, go the Art Institute, hang out with Sue the T-rex at the Field Museum, and see lots of fun critters and creatures at the Lincoln Park Zoo (which is free, by the way).
Overall, my experience in Chicago was a whirlwind. I’m happy to say that I learned a TON about HIV, enjoyed working with unique patient populations at both clinics, and had fun exploring Chicago in the process!

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