Sunday, July 19, 2015

Rotation 1: The Art of Pimping

Posted by Alena Wu at Sunday, July 19, 2015

What is ambulatory care like in Ann Arbor?
My first rotation started off in your local doctor’s office with nurse practitioners and physician assistants called ambulatory care pharmacy. Here pharmacy acts as a consult service for the physicians. Since my preceptor, Dr. Anne Yoo, specializes in chronic conditions of diabetes mellitus, hypertension, and hyperlipidemia, our pharmacy service was consulted when patients has uncontrolled diabetes (Hemoglobin A1C >9%), uncontrolled blood pressure (BP>140/90 for diabetic and chronic kidney disease patients or BP >150/90 for adults over the age of 60 years old without diabetes or chronic kidney disease). Hyperlipidemia are usually accompanied in patients with diabetes or hypertension. Additionally, in recent year, the guidelines have changed and there is no longer a goal target range for lipoproteins (i.e. LDL, HDL).
Ambulatory pharmacist have full autonomy under a specific collaborative practice agreement with the physicians in the office. With regards to our specific practice agreement, we can start, discontinue, or adjust dosages of patient’s diabetic, hypertensive, or hyperlipidemia medications and order any relevant labs. Additionally, there is a new program that was recently started called comprehensive medication review, where patients are recruited if they have 5 or more chronic medications. This service allows patients to meet with clinical pharmacist one-on-one to go over their medications, safety concerns, appropriate indications for each medications, and/or cost issues. The main aim is to catch any medications errors, duplication in therapy, and/or address any concerns the patients had. Additionally, it increases awareness to the broad service pharmacy can provide to the public and to the clinic.

What is the learning curve on this rotation?
As my first one, I had a lot to learn. Our classes prepare us for majority of the real life as a P4, specifically our P1 year communication class, our P2 year community IPPE, and P3 year chronic diseases management course. The biggest gap I had to make up was my ability to manage time and stay efficient. First hill I had to overcome was my data collection skills. Our University of Michigan system is fortunate to have an electronic medical record synch with inpatient and outpatient setting, allowing us to easily access past documentations and lab results. But it was challenging for me to quickly seek out pertinent information. Second hill goes hand-in-hand with my first, creating your own monitoring form. You will have practice during P3 disease management class, but the key is to tailor it specifically to our clinic’s need and present to your preceptor the most relevant information. For instance, if we are only have 15 minutes to see this patient for his or her blood pressure management, it is important to present on factors that may increase blood pressure. Your own monitoring form will prevent you from missing any relevant information and help you build a foundation within your own mind crucial labs or information to look out for when treating each condition. Overall, this rotation should be a refresher for your chronic diseases, but it should push you to perfect your time management skills and efficiently delivering patient presentations.

What makes this rotation difficult?
There are two main reasons. First, patient work load gradually increases over the course of 5 weeks. It would go up from 4 patients ---> 6 ---> 8-10 ---> 16-18. Typical full day involves 17-18 patients. Work for each patient involves initial work-up, patient specific questions/concerns, and post- note writing. Initial work-up is when you collect pertinent data about the past medical history of patient, current medications and dosing, and labs for your patient presentation to your preceptor. Patient specific questions is researching about a concern a patient may have brought up during the last visit that needs to be addressed during this one. This could range from herbals supplements to alternative drug therapy. Finally, post-note writing is exactly what it sounds, the note you write documenting the recommendations made at the visit.  Second, the art of pimping. This is a phrase used by Dr. Yoo when she fires off questions. Questions usually involve what evidence was used in your recommendation, what are the common side effects of a medication, what is your plan B and plan C if plan A does not work, what are the trends on this lab result etc. I struggled each time I received pimping; however, I felt those were the times I learned the most and recall it quickly at a later time.

Final thoughts?
This rotation is highly recommended for those that wish to pursue more direct patient communication and have a passion for preventive care. Even though you will become the treatment expert, majority of the time will be spent on you coaching your patient through their chronic conditions and being their support and encouragement. I enjoyed this rotation a lot as it made me realize to always look up the evidence that supports each recommendation and not rely on the words of your preceptor. It was a mistake I made which probably left a weak impression on the patient. So don’t shy away from these pimping questions when put to the test. Be glad you are getting pimped now rather than when you become a pharmacist. 

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