Monday, March 17, 2014

Ambulatory Care – Cardiology Clinic at the Ann Arbor, Veteran’s Affairs Hospital

Posted by Mindy Prasad at Monday, March 17, 2014

Rotation 7
Ambulatory Care – Cardiology Clinic at the Ann Arbor, Veteran’s Affairs Hospital

I was fortunate enough to get one of my top choices for the for the ambulatory care rotation. I had heard from students in previous years that this particular site and preceptor really challenged the student to perform at high levels, and would offer me an excellent experience in how a pharmacist can practice at the top of their license by essentially providing care autonomously in an outpatient setting. This rotation was also supposed to improve my cardiology therapeutic knowledge and force me to practice writing thorough SOAP notes. (SOAP notes are the main written communication tool used in patient care settings of all types and the level of detail varies with the type/scope of services provided). I can definitely say that this rotation lived up to all of my expectations!

Dr. Michael Brenner was my preceptor. He definitely had high standards for SOAP note quality and really helped me develop my writing by allowing me to make any corrections instead of just adjusting them himself. This was a really good way to get a lot of practice in writing. He also allowed me to see patients on my own for a large portion of the rotation. There was always the “staffing” component, of course (patient presenting) in which my recommendations were vetted and challenged by Dr. Brenner.

There are several types of clinics that Dr. Brenner runs and helps out with that provided me a variety of experiences. All are cardiology focused. On Thursdays was the post-discharge heart failure clinic, Monday mornings were the anticoagulation clinic, and the remaining days were general cardiology appointments in which patients were referred for Amiodarone monitoring, resistant hypertension, lipid management, or other cardiology related issues.

The beauty of cardiology is that much of the treatments are guideline driven. This is because there are LOTS (and lots!) of studies and clinical trials related to cardiology topics. There are also a very larger number of patients with cardiac issues. One of the most challenging aspects of this rotation was keeping the guidelines straight and remembering which drugs had evidence for mortality benefits and which drugs offered symptom reduction only. (Being able to cite a particular study when making a recommendation is particularly useful in defending a treatment recommendation to your preceptor.)

In addition to the clinics, Dr. Brenner provides medication education to cardiology patients who are signed up in a special program/class that offers exercise, dietitian care, and of course pharmacist provided medication education among other services. The veterans signed up for the group meet regularly over the course of five or six weeks and participate in a variety of sessions. The group is small and personal and I was fortunate to take part in two classes, the first time teaching about erectile dysfunction treatment options and the second time facilitating a question answer session. It was interesting, to say the least!

Dr. Brenner also provided the opportunity for me to spend a day in the heart catheterization laboratory (cath lab). I observed a left heart cath, a right heart cath, a trans-radial angiography, and the placement of 3 PCIs (percutaneous coronary interventions aka heart stents). This was amazing to see and I was surprised at how “awake” the patients were during the procedures. I also provided comfort to one patient before his cardioconversion and then I was able to actively participate in his conversion. It was impressive to see his heart rate drop from 105 to 83 instantly after 200 Joules of electric current went through him. One of my most memorable experiences of pharmacy school, for sure.  


Overall, this was a challenging yet rewarding experience. The patient population of this clinic was possibly my favorite part of the rotation. Everyone is a veteran and that is reason enough to instill a feeling of deep respect above and beyond the average respect for patients. Just walking down the hallways and saying hello is inspiring. It was really rewarding to be able to see changes in patients when they returned for follow-up appointments. This was a tough rotation but one that I am very grateful to have had. 

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