Sunday, September 1, 2013

3-for-1 Special: Internal Medicine, Hospital/Health System, and Ambulatory Care

Posted by Silu at Sunday, September 01, 2013

Hello everyone! Silu here, blogging from the café at Plum Market in Ann Arbor. Like 95-100% of my fellow P4s will tell you, I cannot believe how fast this year is going by. In the spirit of Labor Day Weekend sales, this 3-for-1 special post includes my first 3 rotations. Please scroll to the headings you want to read if you don’t intent to read this lengthy post in one sitting. My apologies in advanced to the other bloggers whose posts I have probably displaced onto the next page x_x.

Rotation 1: Internal Medicine (Inpatient A), Mercy Memorial Health System
Preceptor: Dr. Tina Melanokos

Having only had experience in a large academic hospital so far, I was glad to have this opportunity to work in a Mercy Memorial Hospital, a small 200-some-bed community hospital in Monroe, MI. This was a unique opportunity to experience pharmaceutical care in different type of institution. Being a much smaller hospital, Mercy Memorial had a close-knit pharmacy staff, all of whom work together in order verification and clinical responsibilities including renal dosing, pharmacokinetic/antibiotic dosing, anticoagulation, TPNs, patient discharge counseling, and attending care coordination rounds. As students, my rotation partner Matt Allsbrook and I were responsible for these clinical duties on a daily basis. A typical day would include working up patients for any one of the clinical services offered and discussing recommendations with our preceptor in the morning, then project time in the afternoon. Beyond our clinical duties, we had special projects and additional responsibilities, including:
  • Drug information consults – our preceptor had a strong relationship with many providers, and several would ask drug-related questions. We researched and prepared write-ups to answer the more in-depth queries.
  •  IV Administration Guidelines – edited the hospital’s unit-specific IV push and IV infusion guidelines, compiling information about IV administration from several drug information sources. This was a huge undertaking, but was very much appreciated the nurse managers, who had been looking forward to a document like this to implement in their units.
  • Drug use evaluations

In addition to our daily responsibilities and projects, we also were able to spend one week in the adult ICU, where we monitored all medication therapy for the patients in the main medical/surgical ICU.  We also attended weekly safety meetings and any administrative interdisciplinary meetings of any committee our preceptor was a part of.

Overall, this was a great rotation to start with. We able to learn about these basic clinical duties offered common to many hospital pharmacy departments at a comfortable pace and low-pressure environment. Tina was an excellent preceptor and provided teaching opportunities from our everyday duties. The best aspect of Mercy Memorial was the family environment of not only the pharmacy, but the whole health system. Located in a small town, nearly all staff were from local area, and patients were often familiar to those participating in their care, giving a true meaning to taking care of their own community.


Rotation 2: Hospital/ Health System, William Beaumont Hospital (Troy Campus)
Preceptor: Dr. Scott DuFour

My second rotation was at Beaumont Hospital in Troy, MI. Slightly smaller than its main hospital campus counterpart at Royal Oak, Troy Beaumont is nonetheless a state-of the-art hospital with comprehensive inpatient and outpatient services. In addition, it’s one of the most beautiful facilities I have seen!

My rotation started off on an interesting note, where my preceptor, Dr. Scott Dufor, Director of Pharmacy, was on vacation the first week and half. Assistant Director, Dr. Dena Stout, and Clinical Coordinator, Dr. Jennifer Priziola, kindly adopted me and became my surrogate preceptors throughout this rotation.  I spent each day working with a different staff pharmacist on clinical services similar to those described in the previous rotation at Mercy Memorial. This was an interesting opportunity to see the differences in how similar duties were performed by different health systems. Besides working with the staff pharmacists, I was able to have a broad array of experiences in different areas of pharmacy operations, leadership, and clinical development, including:
  • Working with specialist pharmacists in OR, emergency, oncology, and intensive care
  • Weekly Family Medicine Rounds – an interdisciplinary group (nurses, pharmacist(s), attending physicians, residents, medical students, physical and occupational therapists, social workers, and case managers) lead by the family medicine team would gather weekly and discuss one patient, and use the expertise of each discipline to discuss treatment for the patient as a whole, even beyond the main concern for which they were hospitalized
    • **This was my favorite part of the rotation. The family medicine team truly respected the internal medicine pharmacist and valued all of the input, even eliciting further information and asking additional questions as a teaching tool for the residents and students!
  • Webinar series on pulmonary hypertension, a serious life-threatening disease requiring specialized intensive care
  • Leadership meetings/seminars with leaders of the hospital
  • Reporting adverse drug reactions and medication errors

I was also given
 several small projects, from writing an article about drug shortages for the hospital newsletter to developing a department procedure for splitting tablets to creating a comparison chart of antiplatelet drugs for nurses (and those of you who know me know my predilection for making tables/charts…).

Despite driving over 1 hour daily drive to and from Troy, I truly enjoyed this rotation. Some of the pharmacists I worked with were great teachers, and most allowed me the autonomy to perform tasks independently under their supervision (inputting orders, adjusting antibiotic doses, and suggesting changes for optimizing therapy). Other perks of Troy Beaumont? They have
 amazing home-made peanut butter granola bars and potato chips. If you’re there in the summer/fall, they have a farmer’s market by the parking lot too =). Get the kettle corn.


Rotation 3: Ambulatory Care, UMHS Canton Health Center, Canton, MI
Preceptor: Dr. Stuart Rockafellow

Having been interested in ambulatory care pharmacy since P2 year, I was beyond excited for this rotation in U of M’s ambulatory care practice. I really hoped to sharpen my patient communication skills, gain a more in-depth understanding of chronic disease management, and decide if ambulatory care is the right career path for me.

My site was at the UMHS Canton Health Center in Canton, MI. Having spent the past 10 weeks driving 2 hours every day to and from rotation, I was thrilled this site was 4 miles away from my parent’s house, where I was staying at the time. This clinic was mostly composed of family/internal medicine physicians and pediatricians. Our patients are referred from the family medicine doctors for management of diabetes, hypertension, hyperlipidemia, and polypharmacy. Dr. Rockafellow has clinic 3 half days and 1 full day per week. Patients could be called for a phone visit for 15 minutes, or be seen in clinic for 30 minutes. New patients would always have a clinic visit first, then can be followed up by phone depending on their/the pharmacist’s comfort level.

On the first day, Dr. Rockafellow and I discussed my responsibilities and goals for this rotation. I imagined he might have standard expectations of how a student should progress in terms of autonomy in patient visits, but he very much individualizes the rotation to the skill and comfort level of the student. In the first few days, I  listened/sat in on phone/clinic visits and wrote SOAP notes for each in-clinic patient. I was surprised that by the end of the first week, I was taking medication histories by myself, and at the beginning of the second week, I was seeing patients independently.

The best (and perhaps most challenging aspect) of seeing patients is the holistic approach Dr. Rockafellow uses with his patients. Not only would we manage medication therapy, but discuss lifestyle factors that may contribute to disease management such as diet, exercise, stress, and sleep. I spent about as much time discussing medication changes and dose titrations as I did providing nutritional counseling and recommending exercise regimens.  (Yes, ask me about the sugar content of a Venti Caramel Frappuccino with whipped cream, I dare you).  The challenge was trying to fit all this into a 30 minute visit, especially with the more loquacious patients.  I also had some unique opportunities to discuss with a few physicians in the clinic about optimizing medication therapy for patients and answer drug information questions.

This was my favorite rotation so far, not only because I love the ambulatory care setting, but because of the impact of excellent patient care by a pharmacist. It was inspiring to see the trusting relationship patients had with Dr. Rockafellow, most of which see him as a provider similar to their doctor. Additionally, this rotation also challenged me to become more effective at balancing quality patient care with the constraints of time and patient volume. I self-titrated the number of patients I saw throughout the weeks, taking both phone and clinic patients, and met my personal goal of running an entire half-day of clinic on the last day. This site also had a diverse array of patients of different ethnic and socioeconomic backgrounds, offering opportunities in learning how to individualize therapy based on these factors.

That is all for now! I hope you’ve enjoyed this account of the past 15 weeks so far. Stay tuned for the next chapter: Pediatric Generalist at C&W Mott Children’s Hospital!


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