Wednesday, September 11, 2013

Catching up: Cardiology and Managed Care

Posted by Patrick at Wednesday, September 11, 2013

Diving into Cardiology – University Hospital

       My P-4 year began in earnest in the cardiology department at UM Hospital, ably managed by a team of three preceptors (Dr. Dorsch, Dr. Pogue, and Dr. Hanigan). So much of this rotation was defined by the structure these three preceptors had built for our experiences. On day one, myself and my three colleagues all received a list of expectations for the coming five weeks. The cardiac pharmacy team has a variety of services to provide and several of those services were strictly the within the purview of the pharmacy students. These services include counseling patients on anti-coagulation medication, obtaining an accurate medication history, counseling patients on all new medications at discharge, and conducting daily medication reviews electronically to seek out discrepancies. Should I find any, and as the weeks proceeded I got better and better and catching potential medication problems, we would (depending on our interpretations of the time-importance of the intervention) mention it to the medical team directly during rounds or bring it up for discussion during our daily meetings with our preceptors (generally in the afternoon).

       It soon became apparent that this rotation was going to be teaching me three primary skills: cardiac pharmacy and therapeutics, how to appropriately interact with the medical team, and most critically, moment-by-moment time management during a hectic day. We received tremendous support from our preceptors (in my case Dr. Hanigan for the first week and a half, with Dr. Pogue working with me for the remainder of the time). We students would conduct weekly topic discussions, reviewing and discussing a slew of key cardiology papers. During the week leading up to my presentation of stable vascular disease, I learned more about the history of statin therapy and the evidence supporting their use than I had ever known before. Our afternoon discussions would often include impromptu mini-lectures on medication issues encountered on rounds regarding individual patients. I never stopped being amazed at the time and dedication all three preceptors showed helping us to master the topics critical to proper practice of cardiac pharmacy.

       The second important teaching point was how to interact with the medical team. It was important to build a relationship with the resident physicians and help them to know that you (the pharmacy student) could be relied on in a pinch. When a minute could be spared, I found it helpful to spend more time on the floors, participating in their discussions about patient care; sometimes I was able to offer helpful input, especially when it came to medication decisions. For example, when one patient had an issue with a statin drug interaction, I (having done my patient-specific research early in the morning) had an appropriate substitution at the ready. It was moments like that which helped me to find my niche in the team.

       Time management was by far the biggest challenge (in my humble opinion) faced by students on this rotation. Patients were seldom in their room when you expected (hoped, prayed) that they would be. Every day was unique and full of surprises. Some tasks would take far longer than expected, others would pop up in the form of a page and quickly become priority number one, pushing all other tasks back up to an hour. Becoming efficient in the all important tasks of “working up” patients in the morning as well as typing up notes in the afternoon were the critical pieces required to make everything fit into the day.

       Week by week I found myself more comfortable with my role in the hospital and on the health care team. I needed less and less immediate support from my preceptor. As my skills improved, she developed trust me in and my judgment, and as she developed trust in me, I developed trust in myself. Half-way through week five, I found myself feeling truly capable of pharmacy practice at a relatively high level; it was an immensely satisfying feeling. As the summer solstice approached, my cardiac rotation came to an end and I was off to Seattle to explore the world of managed care. My first five weeks were a wonderful, challenging, and exciting introduction to the life of a fourth year pharmacy student.

Managed Care in Tukwila, WA

       For rotation block 2, I made the long, long drive from Livonia, MI to Renton, WA (25 minutes southeast of Seattle) to the home of a kind couple, with whom I had made arrangements to spend the next five weeks via A small, possibly helpful side-note: Airbnb is a great housing alternative for these stays of intermediate length (five weeks). There are options with affordable prices and none of the hassle of a short term lease.

       Arriving at my rotation for the first day, I was immediately surprised at the variety of the workload. On the very first day, I had three separate projects with varying approaches and methods. One project was a long-term assignment concerning a clinical review of injectable anti-psychotics. The second project was a response to a physician who had a question about a potential side effect of gabapentin, and the third project was an inquiry into dosing options for citalopram in patients at a variety of weights. The upside of this diversity was that I could mix and match over the course of the day. If I got stuck on one project, for one reason or another, I would always have something else I could work on productively. As a result, I’m proud to report, I accomplished a great deal.

       As I accomplished one project, my preceptor, Dr. Arnold, was always prepared with a new question or direction for me to explore. There were always a few plates to be spun at once, but never more than I could handle. I felt extremely lucky to have a preceptor who so ably helped me to balance my workload.
With the bulk of my major projects completed, the last week gave me the chance to branch off into new dimensions, taking on assignments that were more often the domain of the pharmacy residents, rather than students. I conducted a few dozen “Targeted Medication Reviews,” or TMRs as they are ubiquitously referred to. TMRs are interventions by a pharmacist in response to a “flag” identified by automated computer searches, indicating potential sub-optimal patient care. For example, a patient may be taking a brand name medication when a more affordable generic is available. Another common example would be medications flagged as potentially unsafe in the elderly population. In either case, the role of the pharmacist (my role on this particular week) would be to use clinical judgment to decide if an intervention is warranted and if so, to propose a change to the physician and the patient. I also had the chance to conduct a CMR (Comprehensive Medication Review), which are available to specific sub-groups of Medicare Part D patients. These reviews involved 15 to 30 minute phone calls with patients involving complete reviews of their medications and disease state, addressing any problems found.

       My five weeks in Managed Care surpassed my expectations. It was empowering to take charge of a major project and see it through to completion, knowing that in the future, it may have an impact on patient care for hundreds of patients. Managed Care and Drug Information are both paths that I’ll be considering as I move forward toward residency and beyond.

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