Rotation 2: Health Systems, Day +25

Posted by Millie at Saturday, July 30, 2016

Hi again! 

My second rotation was health systems/hospital at a cancer research and treatment center affiliated with a medical campus full of other hospitals. I came into this rotation not really knowing what to expect, and I’m leaving it with such a good understanding of pharmacy operations, pharmacy services, and more about bone marrow transplant and hematology/oncology than I could have ever thought possible from only 5 weeks!

My first two weeks were spent in pharmacy operations, where I observed and participated in unit dose, narcotic control, order verification, and making IVs for non-chemotherapy and chemotherapy products. I learned about the inventory process, which was especially interesting considering the pharmacy at this site is responsible for ordering and managing thousands of dollars’ worth of oncology products. I also spent some time with the Investigational Drug Services and was able to witness pharmacists’ role in managing medications for patients participating in a drug study. Being one of the largest sites for phase 1 studies, you can imagine the IDS pharmacists were very busy.

Starting with week 3, I transitioned from pharmacy operations to participating in our pharmacy clinical services. I was so excited that this site was a mix of both inpatient (floor) and outpatient services (clinics) because I wanted to get exposure to a variety of patients. I spent some days with the pharmacist in the bone marrow transplant clinic, where I was able to see a few patient education or “chemotherapy teach” sessions. Before patients begin their transplants, they come to the clinic and are counseled by a pharmacist who goes over the medications, the transplant process, and answer any questions they may have. It’s a very collaborative process between everyone in the room, and it was so great to see how the patients really appreciated a pharmacist spending the time to go over each step with them. I also watched how pharmacists, physicians, and nurse practitioners work together to write and review chemotherapy orders. I was also able to round with the infusion center nurses, watch how they administered chemotherapy, and ask them questions. I gained a good appreciation for how nurses manage to juggle everything, and the importance of effective and constant communication between all staff on the floor. I even got the chance to sit down with a patient and explain to her how her pain regimen worked!

I spent a few days with each of the inpatient pharmacy clinical specialists in bone marrow transplant, oncology, and critical care. During these days, I was given some patients to work up, create an assessment and plan, and present the case to the pharmacist. The pharmacists would ask me questions and we would discuss things to consider when assessing patients. We went on rounds together, where I had the opportunity to interact with medical and nursing staff. I was impressed at the collaboration between all of the members on the team, and it was fascinating to see the thought process behind clinical decisions.

Towards the end of my rotation I gave an in-service presentation to the pharmacy staff on Graft-versus-Host Disease in Hematopoietic Stem Cell Transplant. GVHD is a very complex topic, and I spent a lot of time diving into the immunology and pathology of the condition, as well as reading about the background of HSCT and how it pertained to my site. From this presentation, I was able to gain more experience in ways to effectively present complex topics and scientific data. Over the 5 weeks, I even got to participate in some important events, including a pharmacy and therapeutics meeting, medication safety meeting, and an emergency preparedness exercise. 

Overall, I was fortunate to learn from patients with such complicated cases and understand the pharmacy department’s role in the hospital, and it was a great way to get ready for my future inpatient rotations! 

Rotation 1: You get a CMR, and You get a CMR!

Posted by Millie at Saturday, July 30, 2016

Hi everyone!

My name’s Millie and I’m one of our P4 rotation bloggers for this year. My rotations schedule has me alternating back and forth between outpatient and inpatient settings – an exciting thing as I’m currently making up my mind over this next year about post-graduate plans. Stay tuned to hear about my experiences, and I hope they help you out too!

My first rotation was back in mid-May and June, where I spent 5 weeks with an insurance company specifically working on the Medicare Part D (pharmacy benefit) of the managed care pharmacy world. I was able to work with the Medication Therapy Management team and perform Comprehensive Medication Reviews (CMR) with members who qualified for the service under Medicare criteria. I called patients over the phone, went through their medications with them, and counseled on their health conditions or answered any questions they had about their medications. After our interaction, I put together some documents for the patient, including a Medication Action Plan that summarized our conversation and provided educational pointers for what actions patients should take now to optimize their health and medications. 

Since our patient population was generally outpatient and 50+ years old, this was a great review on many of the chronic disease states, such as hypertension, diabetes, hyperlipidemia, asthma, COPD, and osteoporosis, and their associated medications. By performing these CMRs, I really strengthened my confidence and skills in speaking with patients about their conditions and medications, and I learned a great deal on how to approach sensitive topics or probe for more information. It was always really rewarding when a patient expressed their gratitude for pharmacy taking the time to make sure the patient understood their medications and health. 

Throughout this rotation I was able to learn so much about managed care pharmacy, a topic I had previously had little knowledge about. I learned about Medicare Part D, MTM, HEDIS measures, immunization benefits, coverage gaps (most notably, the “Donut Hole”), and much more! It was awesome to see how many different roles there are for pharmacists in managed care, and I definitely left with a good understanding of how managed care pharmacists can make an impact on patients. 

Two Professions at Once: Surgery Generalist

Posted by Unknown at Wednesday, July 27, 2016

After my first rotation at a local community pharmacy I was finally due for my first clinical rotation--generalist. This rotation is required for all University of Michigan pharmacy students and (looking back) a great way to kick off my clinical experiences. A few weeks prior to my assigned block we got a survey asking us to rank which generalist sub-specialty we were most interested in. We could choose between Internal Medicine (pediatric and adult), Surgery, Cardiology, and the pediatric intensive care unit (PICU). Before long, I was assigned to Surgery.

I had no idea what to expect. Surgery (of any type) is not exactly something that we cover in school and while I find it fascinating I had zero practical knowledge about how to manage these people. To be honest, I knew very little about how to manage a 'regular' patient, let alone one that we've gone in to and moved a whole bunch of things around.

Due to the way that preceptor schedules worked out, I spent three weeks with a general surgery unit and the remaining two weeks with a urology surgery unit. The units work a little differently:

A Day In the Life on General Surgery

Arrive at 7 AM to begin working up patients. I live on the south side of campus but the buses come every 10 minutes and there is virtually no traffic. For the general unit there are no formal rounds that pharmacy is a part of (they happen at 5 AM!). As a consequence, we meet with the Physician's Assistants that are doing most of the day-to-day clinical management around 11 AM to discuss our interventions. This meant that I would work up my patients until about 9 or 9:30 AM, then meet with my preceptor. We made a point of staying out in the conference room where the medical team worked to be accessible for drug related questions. We would walk through each patient, each problem, and discuss what information we needed (usually the people who knew were right behind us!) and why, then make recommendations accordingly.

Surgery patients are challenging in that every third word is a strange surgical term or acronym. Down the literature rabbit hole I would go to find out what is going on and determine how their medications might be affected. Regardless of the procedure, the four main areas we focus above and beyond the typical dosing, safety, and interactions are home medications, nutrition (pharmacy owns IV nutrition like TPN and PPN), anti-infectives, and anti-coagulation.

By the time that process was finished it would be 11 AM or so and I would have a dozen things to follow-up with patients and nurses, disease states to look up and apply guidelines or literature to, drug-information questions to research, as well as counseling and education to complete.

Somewhere in there, I would take 20 minutes for lunch before meeting back in the pharmacy for a quick follow-up with my preceptor and discuss our plans before jumping into a one-on-one topic discussions with one of the surgery pharmacists. We covered a wide range of topics from toxicology to common procedures for X, Y, or Z disease state, infectious disease and much, much more.

This would be immediately followed by a student led topic discussion, case presentation, or journal club (we each had an assigned afternoon for each of those three things spread out over the five weeks) that wrapped up the day around 3:30 PM.

A Day in the Life of Urology

Urology works a little differently. They also have general rounds that pharmacy does not participate in directly, but instead have interdisciplinary rounds led by the urology intern/fellow around 8 to 8:30 AM. I would quickly look over my patients beforehand (not a full workup) to see if there were any major, urgent issues to review before briefly meeting with my preceptor to discuss things before heading upstairs to rounds. These are primarily an information gathering session--notes in the electronic medical record can often be a day behind so these allowed us to get up-to-date on the plan and goings-on for each patient in our service. Any major questions we have are answered (and we get a fair number of questions ourselves!) before heading back down to report out. A full workup of each patient follows, along with the same walk-through-each-patient as before, go talk to the team as before, and a dozen things to look up and follow-up on as before.

There is still room for lunch before the afternoon progresses just like before with topic discussions, case presentations, and journal clubs.

In each case, there are usually a handful of things to finish during the evening hours, but never so many that you can't hit the gym, relax a little, get some other work done, and make dinner before getting some rest and doing it again the next day!

--

Now on my last few days, I can safely say that I have learned an enormous amount and that this is a fantastic springboard for my next rotation: infectious disease! See you again soon!

Rotation 1: All is fair in Lovenox and Warfarin

Posted by Dana at Sunday, July 24, 2016

Hi, I’m Dana, and I’ll be telling you all about my life this year as I make my way through P4 rotations! Before I get started on talking about my actual rotations, I'd like to share with you some of my goals and interests so you can determine how much you'll get out of my blog posts. During the P1-P3 years of pharmacy school, the topics I most enjoyed learning about were infectious disease and oncology. Then, when I did my intermediate pharmacy practice experience (IPPE) at the VA in Ann Arbor, I saw first-hand the amazing impact that ambulatory care pharmacists have on their patients, and I was really inspired by that, too. At the moment, I’m still working out exactly what I want to do after graduation. I’d love to pursue any and all of the interests I just mentioned, but I’m also trying to keep an open mind and learn as much as I can this year. At this point in time, I'm planning on applying for a general PGY1 residency. 

Whether you're a prospective pharmacy student trying to get a glimpse into life at U of M, or a P1-P3 doing your homework for ranking, I look forward to sharing my journey with you, and I hope I can give you some good insight. J

I completed my first rotation in Ambulatory Care back in June, which was in the Anticoagulation Service at Domino’s Farms here at U of M. The pharmacists and nurses in the Anticoag Service regularly monitor and adjust patients’ anticoagulation therapy. Medications I regularly worked with included warfarin, DOACs (direct oral anticoagulants such as Xarelto and Eliquis), and lovenox.

The pharmacists at this clinic manage a special population of patients who have Left Ventricular Assistant Devices, or LVADs. An LVAD is an implanted device that serves as a pump from the left ventricle to the aorta for patients with late-stage heart failure. They’re pretty cool to learn about, so I’ll link you here and here to some videos if you’re curious. Having an LVAD device puts patients at an especially increased risk for blood clots compared to other patients, and warfarin is the only anticoagulation medication that has been studied in patients with LVADs. Therefore, these patients must be monitored more closely than most. 

Additionally, several of these patients take antiarrhythmic medications such as amiodarone, and must be put on antibiotics fairly frequently for device-associated infections. As we know, several drugs interact with warfarin, so this is another great opportunity for pharmacists!

Typical Day: 

I got into the office every morning at 8AM. I’d usually start out my day working up patients who were recently discharged from the hospital. After working the patients up and evaluating their anticoagulation therapy, I would talk to my preceptor to discuss and change the plan I devised, and call the patient to talk about their medications and inform them of any special changes or instructions. 

After discharges were done, I would work up patients whose INR levels had come back to the clinic. If the INR level was out of range, I would adjust the patient's warfarin dose appropriately, then determine when I wanted to get their next INR. Doing this on a daily basis not only gave me a solid foundation in warfarin therapy adjustment, but really enhanced my patient communication skills and gave me confidence when speaking with patients. Occasionally, I got the opportunity to evaluate DOAC therapy and develop bridging calendars for patients with upcoming procedures. One day, I even got to communicate to a patient through a translator, which was a very cool experience!

Other Projects & Activities: 

During the first half of this rotation, my preceptor and I would have regular topic discussions on frequently seen medications, frequently seen drug interactions, general indications for anticoagulation, certain disease states, and more. Preparing for these topic discussions was sometimes time-consuming, but they really helped me build a solid foundation in therapeutic knowledge, and I know that I'll be glad for it on my upcoming rotations. During the second half of the rotation, I got to work on various projects and presentations in the clinic. I did some chart review for all the patients who were admitted to the anticoag service during the month of May in order to evaluate the appropriateness of their therapy. I also had the opportunity to present on crash cart medications to the cardiac rehab team.

Tips:

For anyone who gets a rotation that involves regularly speaking to patients on the phone, something that really helped me was making a script to read off of so I didn’t get flustered or forget what to say. Warfarin is typically discussed with patients in tablet size – for example “2 tablets on Mondays, Wednesdays, and Fridays, and 1 tablet on all other days.” This can be pretty easy to get backwards when you’re first starting out, so having a script with blank spaces to fill out helped me keep everything straight and remember to get all of the important questions and points into every conversation.

     Final Thoughts:

      This was a good rotation to start with, because it gave me a lot of confidence in interacting with patients, and I also got to really "master" one subset of disease states and medications. If you have a huge interest in ambulatory disease states such as diabetes, hypertension, and hyperlipidemia, this may not be the rotation for you, but I thought it was a great experience. 

     Next Up:

      I'm actually already on my LAST WEEK of rotation 2 right now! I also have my seminar presentation coming up in 2 weeks, so I'll update you guys on both of those things soon.

     Until then, I hope everyone is having a good July!