Monday, October 31, 2016

Rotation 4: Ambulatory Care Like You've Never Seen Before

Posted by Unknown at Monday, October 31, 2016

I spent block four at the Cancer Center at St. Joseph Mercy Hospital (SJMHS).

My preceptor is piloting a new program at SJMHS where each person that is receiving any oral medication to treat cancer is required to speak to a pharmacist about that medication. Oral chemotherapies—while often much more tolerable than the usual intravenous option—are not benign by any stretch of the imagination. More importantly, unlike the IV chemotherapy where the patient is surrounded by healthcare professionals for the duration of their infusion, the pills go home with them. For many of them, there are very real risks associated with exposing other people to the drug and other considerations like what you should/not eat or drink, warning signs for side effects and other complications, and drug-drug interactions that could compromise their treatment.

All of the same items apply for patients new to IV chemotherapy, but the majority of the side effects and management have significant overlap so that is done in a classroom setting. However, there are always little things that a nurse practitioner and I would team up to address afterwards.

These sessions would typically take about an hour (and sometimes much longer!) and after three or four in a day I would try to avoid talking for a while so I wouldn’t lose my voice!

Typical Day

I would typically arrive at SJMHS between 7 and 8 AM. First things first: check in ARIA (the infusion center electronic medical record system) to see if there were any new patients for the day. While most of these were scheduled days or weeks in advance which would give us plenty of time to prepare, there was the occasional last minute addition. The morning was usually project work or counseling, depending on the day, and afternoons were the same dependent on the IV chemotherapy teaching class schedule. Generally, I would be in my car headed home between 4 and 5PM with a smile on my face.

The Work

Working up a patient is less focused on their specific disease and more focused on the drug and the logistics of getting it to the patient on time. A lot of things need to click in to place before the drug is sent to them by the (usually specialty) pharmacy, and a big portion of what I was responsible for was, on top of the usual pharmacist duties, ensuring that our office had all of the information we needed and that all necessary testing was done or scheduled. Based on the drug or drugs they were receiving additional screening (such as hepatitis B, HIV viral load, or an echocardiogram) might be required.

Next would be actually going to meet the patient and their family. I often had groups as large as eight or nine people—and spend the hour or more discussing the information that I had, answering their questions, and if they wanted to continue, collecting their consent form. Most days these counseling sessions would take 3-5 hours on 2-3 days a week.

These sessions have been some of the most fulfilling work that I have done as a student pharmacist. Most of the people I was seeing have only known that they have had cancer for one or two weeks. There is a lot of apprehension and a lot of things are changing very fast—suddenly they need to reevaluate their entire life plan and here I am talking about all the bad things that could happen if they take this medication. I could relate to what this was like—my father was diagnosed with cancer when I was in high-school—and those experiences went a long way towards helping me understand what these people were going through. The relief that each person experienced when they were done speaking with me was something to behold. Many underestimate the power of knowledge and what that can do when you have been preoccupied with so many fear-filled unknowns. Pharmacists make this possible.


My preceptor more-or-less owns the responsibility for the back-end management of ARIA and as such, we had access to a ton of data and reporting tools for process improvement. I used my programming background to streamline several reporting processes for each of the five clinic sites that will probably save an analyst a full week of work each year (30-45 minutes per report à 10 seconds per report). This is on top of literature searches for various questions like “should we use cryotherapy with doxorubicin infusions” or “is glucarpidase over dialysis cost-effective in managing methotrexate-induced acute kidney injury?”

A major component of these counseling sessions is a set of informational packets built for each drug. The Michigan Oncology Quality Consortium (MOQC) has built a ton of these for the oral chemotherapies that we enhanced for use in our clinic. Part of my job was building these for new drugs and updating old drugs with new data.

Overall Thoughts

Year to date, this has been a blast of a rotation. I sincerely left each day with a smile on my face and an excitement about the next morning. I found the work fascinating, challenging (but manageable), and I made a sincere, visible difference in the lives of so many people. Not to mention, I got to program and use a bit of my technical background as well! You can peer in to the world of specialty pharmacy billing, learn a whole lot about various cancers and their treatments, and a ton of other interesting work besides. I highly recommend this rotation!

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