Thursday, November 5, 2015

Rotation 5: Compounding Community Pharmacy

Posted by Emily at Thursday, November 05, 2015

I was fortunate to complete my community pharmacy APPE experience in a unique setting: a local, independently owned compounding pharmacy. I wasn't sure what to expect going into this rotation, but what I got was five weeks packed with variety and new experiences.

This rotation site was certainly not your average community pharmacy. According to my preceptor, about 80% of the prescriptions filled here are compounds, while the other 20% are "traditional", commercially available prescription medications. The front of the pharmacy has a small corner for normal OTCs, while the rest of the space is devoted to professional-grade, made in the USA dietary supplements. I had shadowed at this pharmacy as a P1 and ranked it for APPEs knowing that the pharmacy had a complementary and alternative medicine (CAM) leaning. My preceptor was very knowledgeable and walked an interesting line between the world of pharmaceuticals and nutraceuticals. As someone interested in CAM and traditional pharmaceuticals, I found this balance fascinating. It was clear on day one that this unique pharmacy attracts clientele who run the gamut from being heavily skeptical of alternative medicine, to being 100% against pharmaceuticals just because they're pharmaceuticals. My preceptor did an excellent job of presenting balanced information to a patient who was proud to no longer be taking her beta-blocker and was seeking a "natural" alternative for her heart condition. The pharmacist showed that he understood the patient's reticence to use prescription drugs, but explained that beta-blockers are often life-saving and that there was no good nutraceutical alternative. I tried to take this balanced approach in the consults I conducted independently throughout the rotation. I understand being hesitant to take drugs, and I think many people are over-medicated or unnecessarily medicated. But many medications are necessary, and it's the pharmacist's job to help patients make the distinction.

Each day was busy with small projects and tasks that included patient counseling, supplementation consultations, verifying lab calculations, helping to pack compounds into their dispensing receptacles, receiving, transferring, and filling prescriptions, making capsules, working in the sterile lab, fielding drug information requests from patients and practitioners, and administering (preservative free) flu shots.

It was clear from week one that pharmacists in this setting have to do a ton of multi-tasking. I was constantly making mental (and hard copy) to-do lists and shuffling my priorities as new requests, assignments, projects, and tasks arose. Since my preceptor was always running around putting out fires, or on the phone, or checking scripts, or attending to patients, it could be hard to get him to sit still long enough to ask for project guidance. Consequently, the ability to work independently and be self-motivated was huge. I felt more autonomous on this rotation than I have on any other, and since one of my primary P4 year goals is to build autonomy and confidence, this was a satisfying feeling. In fact, I had my most rewarding pharmacy experience to date during this rotation, which came as a result of the pharmacist trusting me (and me feeling confident enough in my abilities) to counsel a patient independently.

During my first week, my preceptor asked if I could stay late (typical rotation hours were 9AM - 5PM) as he'd just gotten off the phone with a patient who was planning to come in at 5:30 and needed to be counseled. She was in her thirties, but had just been diagnosed with type I diabetes that day. No one at the hospital or the chain pharmacy where she picked up her insulin pens and glucometer had shown her how to use them. In fact, she was coming to our pharmacy because the chain pharmacy had failed to dispense the needles that she needed for her insulin pen. My preceptor asked if I felt comfortable counseling her, and I said yes. Finally, a rotation challenge on something I felt well qualified to do! After all, how many times have I had to teach an SPI how to use an insulin pen? (Many times.)

I spent almost an hour with the patient and her dad reviewing and practicing how to use the insulin pens and glucometer. This was easily one of the most positive and rewarding pharmacy experiences I’ve ever had. I felt knowledgeable and confident, and it was clear that the patient truly valued my help. It was so gratifying to see the positive impact I could make as a pharmacist, especially for someone who was probably not having a very good day. When they left, the patient and her dad were very gracious, saying how much they appreciated me taking the time to step through everything slowly and that I was clearly passionate about and good at what I do! I didn’t even mind staying late because it was a great learning opportunity and more importantly, an opportunity to help a patient in need.

Despite this excellent encounter, I don't think community pharmacy is for me. If 80% of the job was encounters like the one I just described, I might feel differently. But from what I've observed, so much of the community pharmacist's energy is consumed with smaller tasks and the daily grind of checking prescriptions, answering phones, and in the case of an independent pharmacy like this one, managing the business and the bottom line. There were certainly aspects of this rotation that I enjoyed, but I'm looking forward to stepping back in to the world of hospital pharmacy with my next rotation in emergency medicine! Stay tuned.

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