Wednesday, July 27, 2016

Two Professions at Once: Surgery Generalist

Posted by Michael Harrison 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!

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