Wednesday, September 25, 2013

Diabetes, High Blood Pressure, High Cholesterol, and More Diabetes!

Posted by Rachel Lebovic at Wednesday, September 25, 2013

Rotation 3: Ambulatory Care with Dr. Trisha Wells
While many ambulatory care pharmacists are only in clinic a few days each week, I was fortunate to spend my ambulatory care rotation with Dr. Trisha Wells who sees patients five days a week. The physicians at the University of Michigan Brighton Health Center are currently scheduling patients’ next appointments at least six months out, so they rely on Dr. Wells to see patients with chronic diseases in between their physician visits. Specifically, the chronic diseases I helped manage on Dr. Wells’ rotation were diabetes, high blood pressure (hypertension), and high cholesterol (hyperlipidemia).
A typical morning on rotation with Dr. Wells consisted of a combination of 30-minute in-clinic appointments and 15-minute phone appointments. For the in-clinic appointments, I would first present the patient case to Dr. Wells and we would discuss my plan for the patient, including whether I wanted to order any labs and how I would adjust the patient’s medications. Then, I would collect the patient from the lobby, get their weight, and bring them into Dr. Wells’ office. Next, I would ask the patient a set of routine questions about their diet, exercise, home blood sugar readings, caffeine intake, and medications. Then, I would take the patient’s blood pressure and perform a foot exam (if the patient was due for one). Lastly, Dr. Wells would discuss our plan with the patient. Sometimes, the plan involved adjusting the patient’s insulin doses, oral diabetes medications, or blood pressure medications. Other times the plan involved improving the patient’s diet or exercise. In the latter case, we used a technique called motivational interviewing by asking the patient what changes he or she wanted make for diet and exercise instead of telling the patient what to do. I really enjoyed individualizing a plan for each patient based on the patient’s lifestyle, daily routine, and values.
Some of the patients had multiple appointments with Dr. Wells during my five weeks in her clinic, and it was a great experience to build relationships with these patients over time and get to know each patient individually. For example, I loved it when one patient brought her dog to clinic. This was one of the best-behaved dogs I have ever met. He even carried the patient’s glucometer and test strips in a saddlebag! I also enjoyed building a relationship with a patient who was starting to use insulin for the first time. We taught her how to inject insulin, showed her how to use her glucometer, and answered all of her questions about diabetes. Building these relationships with patients made my time in clinic a rewarding experience.
After mornings full of clinic appointments, the afternoons were spent writing clinic notes to document each patient’s appointment and preparing presentations. Throughout the rotation, I presented topic discussions on diabetes, hypertension, and congestive heart failure. The other student on rotation with me, Haya, presented topic discussions on hyperlipidemia, diet and exercise, and asthma. Preparing these topic discussions often felt time-consuming and tedious, but after discussing each topic with Dr. Wells and listening to her clinical pearls, I definitely have a better understanding for how to optimally manage each of these disease states. I also presented two journal clubs on recent primary literature and gave a presentation on a patient case to other P4 students on rotation with U of M ambulatory care pharmacists.
Overall, I truly enjoyed the plethora of patient care experiences on my ambulatory care rotation. I was pleasantly surprised by the autonomy pharmacists have in this role. Ambulatory care pharmacists can order their own labs, take blood pressures, perform foot exams, schedule follow-up appointments, and adjust patients’ medications. However, I did not like limiting my patient care to three disease states. Diabetes, hypertension, and hyperlipidemia are complex chronic conditions to manage, but I missed managing all of the patient’s disease states like I did in the inpatient setting. I still think an inpatient clinical specialist position is a better career choice for me, but ambulatory care was a great experience because of all the patient interaction.

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