Tuesday, January 24, 2017

Rotation 7: Lexicomp and Work From Home

Posted by Michael Harrison at Tuesday, January 24, 2017

I was very thankful that I received not only Lexicomp, but also with Steven Stout, someone with a technical background and someone immersed in the database management aspect of keeping this enormous drug information resource online.

Unlike most rotations, Lexicomp is a work-from-home. Typically, I met with my preceptor 2-3 times per week in various coffee shops in the Ann Arbor area for discussion of the work done so far, where to go from here, and do mini "topic-discussions" on topics related to the collection and organization of drug information resources. This includes statistics, study design, database design, information sources, how to vet information sources, searching (search terms, structure, narrowing results), and many, many more.

Work centers around the searching, collection, organization, and drafting of drug interaction monographs for inclusion in the Lexicomp Interactions database, as well as taking part in a number of longitudinal projects that his team is involved with. This includes migration to a new content management system and the thousands of tasks involved in that process, developing a tool that creates graphical summaries of queries to the OpenFDA API, among others.

This has been a very flexible rotation--work does not need to be done in an eight hour block so long as it gets done and during interview season (onsites for fellowships) this has been an incredible benefit as I can do work on the plane or in an airport or in a hotel in Seattle. That said, you will be tested on your time management skills as there is no external forces making you do anything! Self-motivation is a big plus!

One of the biggest benefits (as pointed out by other commentators) is the incredibly refinement of your literature search abilities. I had been doing this in a managed care setting for two years and still made leaps and bounds in my ability to careful craft queries (MeSH terms are the best) and iteratively refine my searches to maximize my relevant results. There have been many "mind-blown" moments when using PubMed, EMBASE, and other databases with these techniques, particularly when comparing how I used to construct a term versus my current method.

What has been incredibly cool is seeing the nuts and bolts of Lexicomp Interactions—how everything fits together and the methods that they use to keep their enormous quantity of data organized and maintained. My preceptor is truly a master of the craft and he has been an incredible mentor in developing some of my own skills in this area as well.

A typical day is what you make it, and there is tremendous flexibility in pursuing projects relevant to your interests! Highly recommended!

Michael Harrison (mhar)



Rotation 6: the Fellowship Search, MidYear, and PPS

Posted by Michael Harrison at Tuesday, January 24, 2017

Rotation 6: Off

Fresh off my experience at Eli Lilly, I had planned for Rotation 6 to give me time to get my life in order to prepare for the coming eight weeks (and hopefully not longer) of fellowship search and planning. I had been set on the non-traditional track for a long time: with nearly two years of Blue Cross Blue Shield of Michigan under my belt, an industry rotation, and three years of heavy involvement in the College of Pharmacy and beyond I felt well prepared to take on the challenge.

Fellowships are hard to get. Traditionally, less than 15% of fellowship applicants land a position. I had a plan B (and C) in case this did not work out.

I will not waste your time here reiterating excellent advice that can be found elsewhere about this process. I recommend this book: Pursue the Fellowship, (link to sample) that covers just about everything you could ever want to know. The author, Kimberly Gittings, is a current fellow at Xcenda who I had the chance to meet and interview with! She knows her stuff. Additional information can be found on program specific pages and many, many other sources. Dr. Kraft's class P3 year is invaluable, as are most tips about interviews relevant to residency applications.

I will instead tell you what I did and what the process was like from my perspective, to provide that insight.

Asking Important Questions

Specifically: what makes me stand out as an applicant?

For me those answers were approximately: my programming and computer science background, marrying clinical and technical expertise to fill gaps.

How can I apply that specifically to an industry career?

Thankfully I already had specific examples of using this in practice in my PDI and at Blue Cross Blue Shield of Michigan. Big data is a big thing, tying my experience here into business and clinically relevant outcomes was fairly straightforward.

What does my ideal program look like?

Somewhere that allows me to exercise these strengths but also provides ample opportunity for horizontal development. I am a big picture person and work best when I have a holistic understanding of the system I am working within, tailoring my output to the needs of the next step in the chain. The program should be open to innovation and new ideas and be forward thinking. Ideally, I would be working with or supporting oncology products, my area of interest given my family medical history.

A mission and vision that I can support: this is critical--the mission and vision of a company drives everything that it does from a high level. If this is not something I can get behind it will be difficult to highly engage in my work. This was a deal breaker for several programs.

Professional development opportunities in conference travel, tuition support, leadership opportunities, mentorship, or other.

No geographic restrictions; location agnostic, as programs few and far between, especially given these other requirements. My girlfriend, pursuing managed care residencies (another relative rarity) will have even less control over where she ends up. 

One year over two years, wherever possible: I would like to avoid being away from my girlfriend for longer than I can avoid. Possibly excepting the case where the program is degree-granting or offers a significant benefit for the increased length (not just a teaching certificate).

Compensation: student loans are a real consideration. While I have spent the last four years making significant sacrifices to keep my balance down, avoiding a resident-level salary where possible would be appreciated (but not required of) a one year program. Two-year programs at this salary level would get a significant bias against unless there was a compelling reason otherwise (see above).

Targeting My Applications

After registering for PPS in September, it was not until October 24th that PPS opened up and I could actually see the programs available. I had my profile set up and CV uploaded and ready to go.

I decided early on that Rutgers was not a good fit for me given my interactions with current fellows and their staff, which ruled out the majority of positions. Ample information about the Rutgers application process exists online, I will focus on what I've done.

After filtering Rutgers out about 100 fellowship programs remained. After weighing them against my requirements above, I chose six to apply through PPS over the following two weeks by reviewing their PPS posting, any information available online, and reaching out through my network to ask a few questions when possible. I sent a short paragraph about why I was interested in their program specifically in my interview request.

It should be noted that I was a strong candidate and I did not realize until afterwards that programs are selective about offering interviews at PPS. Xcenda, for instance, gets hundreds of applications but only interviews 40 or so at PPS. While I was lucky to receive an interview at every place I was interested in, others I spoke with were not. Whenever I received a new interview from a company I made a point to block off the 30 minute blocks prior and following that interview so I would never have interviews back-to-back. This worked very well but may need adjustment based on your interview volume.

Two weeks before PPS I re-reviewed all available programs as new ones occasionally appear. None of the new ones interested me so I stuck with the six:
  • Two I was very, very interested in and hit all of my requirements (one year programs)
  • Two that were a good fit, hitting most of my requirements (one one year, one two-year)
  • One that I would be happy with (two-year)
  • One "backup" that I would do well at if I received an offer and felt confident about my ability to make it to the onsite phase (two-year)
This was a risky approach, but calculated given my strength as a candidate and the availability of strong plan B and C options.

MidYear

I was at MidYear solely for PPS and no other reason. While I did go to some residency showcases just to chat, see Peyton Manning, and go to various CE sessions, my focus was entirely on PPS and my interviews. After checking in to the conference your name badge will have a symbol indicating that you are registered for PPS that people at the door will check (which caught me off guard). There is a small waiting area inside the hall but outside the interview area with tables to rest, recoup, and wait in-between interviews. Food nearby is expensive (it was Vegas + conference hall after all) so I brought snacks (peanuts, protein bars, etc.).

Prior to the meeting I frequently heard the advice that you are there to get a fellowship and screw everyone else. Personally, I enjoyed many conversations and stories with fellow candidates in the waiting area which I felt helped me be conversational and relaxed in the interview setting. I made a point to stop by the UM booth every day and just walked around a bit to get a lay of the land and located each of my booths before my interviews started each day.

The Interviews

All of my interviews were far more relaxed and conversational than I had anticipated. I got a handful of situational/STAR questions but the vast majority started with "tell me about yourself" or "why us" or "why industry" and branched from there. I was careful to emphasize my experiences and what made me stand out (all of those important questions above!) in each of those initial questions and tried to have fun with it. People reflect your energy and enthusiasm in the vast majority of cases and if you know yourself and what you have done things generally flow pretty well. Try to enjoy yourself! Show off a little! I developed software that generates clinical trial abstracts so I brought copies to show my interviewers. Moves like this helped me not only set myself apart, but take control of the interview by talking about something I knew well and was comfortable with. Plus it guided follow-up questions!

I made a point to get the business card for each of my interviewers.

It goes without saying that you should have a baseline familiarity with the company, their pipeline, recent events that affect them (subscribe to FiercePharma), not because they will necessarily ask questions about these things (though I have heard that) but because incorporating these into your responses to questions or just in conversation is a big plus! I included mission and vision statements in my responses whenever I was asked "why us" or similar questions (remember that this was a critical part of targeting these programs in the first place!).

All of the STAR/other questions I can remember getting (paraphrased):
  • You have made a mistake on a project that you delivered to a client. It would be embarrassing to you and the company to bring it up but could affect their work. What do you do?
  • Walk me through the timeline you would use for developing a big presentation due in one month.
  • What are your time management strategies?
  • What are you proud of that is not listed on your CV?
  • What do you do to relax/for fun?
  • Are you open to relocating?
  • Where do you want to be/what do you want to be doing in 5 years? 10 years?
  • Tell me about a time where you
    • struggled to balance short and long term goals
    • improved the efficiency of a process
    • dealt with conflict on a team
    • worked well with a team
    • managed a big project
    • made a mistake/failed
  • What was the best team you've ever been on?
  • Why not managed care or informatics? (specific to my interests, what I was talking about with computer science as these are plausible alternative careers)
  • What are you looking for in a program (and why do you think we have those qualities)?
  • Tell me what you know about medical affairs.
Invitations for second round interviews were either by phone, text, or email (always have your phone on you and not on silent EXCEPT WHEN IN AN INTERVIEW for this reason.

All programs that did second round interviews invited me to one. In each case they were more of the same with different members of their team and generally were more relaxed/conversational than the initial round (about 50% of people get cut at this stage). Usually, about 50% of the interview was time for me to ask questions. This conveniently brings us to:

Asking Questions

While my first round interviewers usually made 3-5 minutes for asking questions, my second rounds were much more focused on my receipt of information about their program (it really is a two-way street). It goes without saying that logistic and compensation questions (how long, where, how much, benefits etc.) are off the table. These are either basic or answered in the PPS listing, online, or are simply off the table as appropriate questions. Focus on questions that let you learn about quality of life, where past fellows have ended up, mentorship and leadership opportunities, and subjective questions that each interviewer can respond to, including:
  • Who makes up the team I would be working with?
  • What kinds of cross-functional work might I be doing?
  • What are some stand out qualities of past fellows?
  • Tell me about a time someone in your program blew you away.
  • Will I have the opportunity to precept students?
  • What would my relationships with leadership and management look like?
  • Does this program aim to retain fellows? If not, where do they go?
  • What appeals to you most about the work that you do?
And the list goes on and on. Ask follow-up questions. Honestly not thinking too hard about this helped me a great deal. My goals were to assess the openness of the company to new ideas, its innovative spirit, the opportunities for horizontal development, and what cross-functional work looks like. Reading between the lines on the answers to any question will tell you more than what the response is--it is pretty easy to tell when someone is simply stating the party line and when someone is genuinely excited about what they do. Think about what is important to you and come up with half a dozen questions that will help you assess that (go back to the qualities of your ideal program!); the rest will work itself out!

Thank You Cards

I did not send thank you cards after PPS. I went back and greeted whoever was around the booth and chatted very briefly thanking them for the great interview (with specific things that we talked about) and how excited I was to hear from them again. Some people deliver cards onsite, others mail them following PPS. Considering how fast the turnaround is for getting onsite interviews it seemed more sensible to me to go chat in person wherever possible. I specifically avoided emails at this stage on the advice of friends who had successfully navigated this process and interviewers who said that these generally get deleted immediately.

Hearing About Onsites

Generally, you will hear about onsite invitations within 24-48 hours of PPS ending, earlier if a program stops interviewing earlier or you are stand out candidate. Of the six programs I applied to, I received five onsite invitations, three of which were by phone before I got on the plane to come home. One was by email the next week; the last was by phone the following week. Many programs will email you to let you know that you were not selected to continue, but this is not common. I did my best to not hold my breath too hard (though it is hard not to be nervous!).

I should note that none of my programs had selective receptions that I was waiting on invitations for, unlike most Rutgers programs. For those programs if you do not receive a reception invitation by the second or third day of PPS you are generally out of the running.

Completing Any Additional Applications

A handful of programs (not all), having made it to the onsite stage, requested a formal application, letters of recommendation, transcripts, or other documentation. These were all due the week following PPS and were not time consuming or stressful provided that you have your letters of recommendation ready to go. Most of them were online (either emailed or through an HR portal). Clear instructions were provided for all steps so no worries there!

Scheduling Onsites

Each program that I was invited to sent an email with additional details within a few days of the invitation, detailing available days, times, and other relevant information. You will generally have 2-3 days to choose from for scheduling interviews and things can get fairly cramped as there can be overlap between programs. In my experience, everyone was willing to work with me to fit everything in.

This brings up an important point: if you have made it to this stage of the process with a company they are very interested in you. You are one of their top 5-10% of candidates! Do not be afraid to ask if there is a scheduling conflict or other issues that arise. They understand that you are pursuing other opportunities! Everyone that I worked with was wonderful and bent over backwards to make sure everything worked out schedule wise!

All of my travel, hotel, rental cars (when needed), meals, and incidentals were paid for by the company I was visiting. Flights were arranged through an agency that I was instructed to call in each case (they already had my information!) that allowed me to select my preferred airline and provide my frequent flyer information. Hotels were prearranged and specific instructions for reimbursement for other expenses were provided in each case. Even though the company is paying for it, you are expected to provide a credit card when checking out a rental car or checking in to a hotel.

In each case I was given an itinerary for the day listing each person that I would be meeting, for how long, details on the presentation I was expected to give, and any other logistic information about the day.

Preparing for Onsites

Keeping in mind that anyone interviewing you onsite (and spending $1,500+ for the privilege) is interested in you, it is doubly important to show the same courtesy. I found any information I could about each interviewer listed on my itinerary, made sure I knew in depth about the company’s mission, vision, ongoing trials, products I would likely be supporting, and other details. I had enough thank you cards packed for each person (not prewritten!), copies of my CV, and plenty of mental preparation. I made sure I fully understood the logistic arrangement for the interview day (is there a shuttle? Am I driving? If so how long does it take to get there? Parking? Where am I getting breakfast in the morning?) and baked in extra time for potential problems.

I took the time to reach out to current fellows by email (remember those business cards?) to ask questions and get a better feel for the program overall. It is the holidays, so don't freak out too much if they do not respond or cannot set up a time to talk on the phone. This is an extra step.

Onsites generally happen either the week before Christmas (for some MCPHS programs) or the weeks following the holiday. Mine were from January 3rd through the end of the following week, with one "onsite" over the phone with the managing partners of one company. I had no issues with travel, lodging, or any other arrangements, but the HR representatives were all very responsive when I had questions (mostly about the rental vehicles!).

The Onsites

With preparation the onsite interviews were actually one of the easier parts of the process. Each company was a little different but all of them followed the itinerary to a tee and were largely focused on getting to know you as a person, what your goals are, and assessing your fit based on what the program has to offer. As one of my interviewers put it while I was there 
"The fact that you are here at all indicates that you can absolutely excel at this job. Everyone we have invited here today will no problems. This is a matter of learning about who you are, what you want, and how well it aligns with our goals and what we have to offer you."
As part of the process in each case I was meeting senior leadership (VP, Director level), the team I would be working with, current and past fellows, and sometimes just other interested parties. Since I knew a little about each of them going in it was much easier to get started on a strong foot. Time absolutely flies by--all 4-8 hours of interviews (lunch was provided when needed!).

With the exception of one interview at one onsite I felt like the team was genuinely interested in getting to know me and I actually had quite a bit of fun.

Remember, if you have made it to this stage: they want to hire you. Be yourself, have fun, and ask questions. This is about you finding a program that is right for you, not just a program! At this stage it is appropriate to ask more questions about living arrangements, the city, what they do for fun, logistic things like the commute and public transportation, etc. Compensation is still of the table.

The Presentation

An object of dread by many fellowship and residency applicants, the presentation was unquestionably the most stressful part of each interview day. Each of my programs provided specific details about what they were looking for and they were conveniently very similar: 15 minute presentation on an industry relevant topic. PowerPoint was suggested and it was either emailed to a coordinator ahead of time or saved to a flash drive.

I developed a presentation specifically for this purpose, but many people have successfully used presentations that they have given before. I used a topic (the impact of fraudulent science on patient care and clinical development) that was more relevant for companies in the oncology space, but still applicable elsewhere. This was a topic that I have been interested in for a long time and a side project that allowed me to highlight some of my computer science skills, as well as tie them in directly with the business and patient-care interests of the company. Most importantly, it was something I was comfortable in discussing outside the scope of my presentation and answering questions about. I steered away from therapeutic topics for this reason and with a consideration of the audience I would likely be presenting to.

Speaking of the audience, in each case it was between 10 and 20 people, usually all of my interviewers plus a handful of other individuals. They were always a good audience, attentive, and asked thoughtful (but not overly difficult) questions afterwards. After about 5-10 minutes of answering questions I was shuttled to my next interview. In one case I was provided a rubric, stating that I would be graded on the quality and organization on content, speaking style and delivery, as well as ability to answer questions. Based on what I have heard elsewhere, I infer that it is likely similar at other programs.

Waiting

Following each onsite interview I either sent thank you emails to each of my interviewers or mailed them a personalized thank you card based on the decision timeline. Sooner: email; later: letter.

This waiting period is the absolute worst part. After you've completed onsites (though you may have some stragglers) and your hand is down it is only a matter of keeping your phone on you at all times and waiting. I made a point of asking when I could expect to hear back at each onsite.

I will not lie: there was some intense self-reflection and considerable stress during this time. I cannot thank Emily and my family for being so supportive during the ten or so days I was waiting on bated breath and every phone call was potentially a great or terrible moment. This is normal. It is not fun. But you will get through it!

Each program called me with either a "no" (which I appreciated just the same) or a "yes."

Handling Offers

If you are lucky and receive an offer, congrats! Generally, you will have 3-5 business days to accept or decline the offer. If you happen to interview very early and receive an offer but have an interview very late, you might not have time to wait for an offer from the later program before time to accept the first offer runs out. Two things can happen here:
  • Early program is your first choice: accept immediately
  • Other program is your first choice: call your first choice and ask!
In the case of the latter, is important to handle these conversations carefully. Do not attempt to play offers off of each other. If you are calling your first choice, emphasize that you received an offer but still think of their company as a better fit and why you believe that this is the case. Ask them if it is possible to provide a decision on your candidacy more quickly. If yes they can accelerate their timeline, great that says a lot about them, if not, then this is a hard choice to make! Receiving an offer at all puts you in the 15% of people that ever get one at all. If you were focused on what programs you applied for, then they should all be good choice in the end!

I was lucky in that the timelines for my interviews and offers worked out very well: I heard within a week about all of the programs I applied to.

Accepting Offers

Thankfully, my first choice offered me a position and I could not be happier! I accepted on the phone and received the offer materials later the same day. Now it is just a matter of signing on the dotted line and telling everyone the good news!

Wrap Up

Phew, that is a lot. Hopefully my journey helps you navigate your own! If you know yourself, have engaged in your work in pharmacy school, and can get excited about the work you will be doing in a non-traditional role, I have every confidence that you will get through these stressful few months a better, gainfully employed pharmacist!

Other things to consider: all the programs I applied for did not require becoming licensed, only that you hold a PharmD. I will still become licensed (because student loans) but others may find this interesting!

Be sure to thank your friends in the Advancement Office and Career Connections for all of their help over the years! I know I will be!

Michael Harrison (mhar)

Five Weeks at Eli Lilly: A Non-Traditional Experience

Posted by Michael Harrison at Tuesday, January 24, 2017

With the majority of my clinical experiences under my belt, come October it was time to drive the four hours to Indianapolis to begin my rotation at one of the world’s largest pharmaceutical companies.

Lilly, like most large companies, specializes in a handful of therapeutic areas: oncology (gemcitabine, pemetrexed, cetuximab, among others), neuroscience (the largest Alzheimer's development program on Earth), diabetes (Humalog, Humalin), and bio-medicines. The Bio-medicines unit covers a handful of smaller focus areas, including men's health, cardiovascular, pain, and others. While they have a global presence, their headquarters in Indianapolis also houses most of their production facilities, which I will discuss more later. For more background on Lilly, here is their Wikipedia page.

I had no idea what to expect going in--my preceptor is a clinical research scientist in Early Phase Oncology Clinical Development. I would quickly discover what that means!

Day 1:

I stayed about 20 minutes from Lilly's technology campus (about a 10 minute drive from their headquarters) at a friend's house whose family generously offered to allow me to stay with them (great coincidence!). The day began with a few hours of onboarding (filling out paperwork, safety training, etc.) after which I drove to the main campus to meet my preceptor.

All of the buildings on the main campus are connected underground, including the parking garages! The campus is massive--with restaurants, dry cleaning, a bank, a gym, track, and soccer fields, and other amenities on-site. We spent most of the morning discussing my preceptor's role and where I would be fitting in. It breaks down like this:

My preceptor is a clinical research scientist. As a PharmD in this role, he is responsible for the day-to-day operations of his clinical trials. This could mean ensuring enrollment is on-track, monitoring incoming safety and efficacy data (blinded!), and importantly, answering clinical questions from the providers at the research sites regarding eligibility, enrollment, side-effects, clinical management, and anything and everything in between for any of the sites scattered around the world.

Outside of the Phase III trial he is responsible for, he is required to put on his early phase hat from time to time. This might mean working with the pre-clinical development group to identify promising leads or providing recommendations for unmet medical needs that could drive a new project, authoring study reports, protocol, or manuscripts, or designing trials. This is a role with an incredible diversity of responsibilities and work types--perfect for precepting a student!

Day 2 and Beyond:

Typical days worked like this: I could arrive anywhere between 6 and 9 AM, staying until 3 to 6 PM. I was issued a company laptop that allowed me to work from home provided I had no in-office responsibilities (though I always cleared these days with my preceptor). I opted to arrive early and leave early to avoid the minimal traffic that Indianapolis developed along my route.

The work environment is highly interdisciplinary and they use an open-office environment. With your laptop you can sit more-or-less wherever you would like, lock into a dock (with a large screen and peripherals) and work there all day or move around. Few people have permanent desks but there is tons of space to sit a group around a table, and space to work alone for a while if you need to as well. I was struck by walking down the halls and overhearing conversations by engineers, pharmacists, statisticians, physicians, PhDs of all flavors, and more!

My major projects could be summarized as follows:

Safety Monitoring or Other Reporting:

As I have a computer science background, I asked for data-centric projects where possible. I was routinely given blocks of data to crunch and provide recommendations. Usually, this was blinded adverse event data from a trial. With pivot tables and a little VBA these usually went quickly. Other reporting included analyzing concomitant medications and correlating those with outcomes, or doing demographic breakdowns for relevant groups. Notably, one project had me examine the different subtypes of cancers in these trials and examine the rates and locations of metastasis and correlate these with other relevant biomarkers--are there patterns? Are these in-line with literature, if it exists? Clinical trials are valuable sources of medical knowledge even outside the medication they are testing--we've learned a lot!

Medical Information and Writing

A major responsibility of the CRS is medical writing--whether that be trial manuscripts, clinical study reports (a data summary of a clinical trial), or communication with healthcare providers. I was tasked with authoring a manuscript for a Phase I dose-escalation trial that had not yet made it to publication. I had the opportunity to dig deep into a clinical study report, learn a disease-state inside and out, and work with the primary investigators (physicians and pharmacists) to report what they had found. When I left, the study was squarely in the hands of the medical writers who were polishing and editing the final draft!

As part of the CRS role, my preceptor received anywhere from 5-10 eligibility or clinical questions from the research sites worldwide. He passed many of them on to me, where I was responsible for evaluating their question, examining the protocol and literature where appropriate, providing a recommendation, and drafting a response.

Protocol Authorship

My final major project was built around a handful of pre-clinical compounds that Lilly had been working on for some time. They targeted a genetic mutation that is believed to drive the growth of several cancers. It was left to me to examine the literature and define where the greatest unmet medical need existed; meaning which cancers lack available treatments and have high rates of mortality (e.g. pancreatic cancer) versus a cancer that the mutation might be less common in, or the cancer has powerful existing therapies available. This was much more complicated that I initially expected, given that even identifying people with the mutation consistently was a problem. What assays should we use and how do they work? There were over a dozen methods that were not correlated with each other, and then attempting to work out how they correlated with outcomes was another hurdle.

This culminated in authoring a protocol synopsis: taking everything I had learned and transforming that into a study summary including information like: what cancers, who are we targeting, how do we identify them? What inclusion and exclusion criteria should be used to that effect? What are the treatments we'll use? What study design? What endpoints will be used and how are they measured? And much, much more!

Other

Lastly, Lilly has a structured program for visiting P4 students where you will meet dozens of practicing pharmacists from roles all over the company. There were usually 2 or 3 weekly, plus any other one-on-one meetings that you could schedule anywhere you'd like. One of the pharmacists works in the manufacturing facility, so we got a tour and saw how many of their drugs are made! Incredible to see!

I had a wonderful time at Lilly, and now there are even more opportunities to go! I hope this gives you a good idea of what I did while I was there--I definitely learned that this is where I want to end up!

Michael Harrison (mhar)




Monday, January 9, 2017

Rotation 6 - General Medicine

Posted by Millie at Monday, January 09, 2017

Although rotation block 6 is six weeks rather than the traditional five, the time really flew by! For this rotation I was back at UMHS for my general medicine rotation on the adult internal medicine service. The largest difference from my last inpatient rotation (SICU) was that instead of a very large interdisciplinary rounding team (see SICU post from October), I rounded with 1-2 medical residents and 1 medical attending. I hadn’t realized previously how different the rounding structures could be, and I’m very grateful I was able to experience both types.

My service admitted patients every other evening. We would generally round at 8:30 AM. On post-call days (the morning after the medical resident had been admitting patients ALL night), we would typically round 30 min-60 min earlier than the regular rounding time (so 7:30 AM instead) so that the resident could go home and sleep after being awake for 30+ hours!

Below is a typical schedule for if we were to round at 8:30 AM:

6:30 AM: Arrive at hospital to work up patients. I followed 11 patients, the max number of patients for my service.
8:00 AM – 8:30 AM: Meet with preceptor to go over patients. I would give an abbreviated presentation and mention any VERY pertinent issues and run my planned recommendations by my preceptor for her feedback.
8:30 AM-11:30 AM/12:00 PM: Round with medical team. These were bedside rounds, and it was a different experience from my previous inpatient rotation because we actually went into the patient rooms and spoke with the patients.
12:00 PM-2:00 PM: Grab lunch, follow up on questions for medical team, document scoring tools, medication reconciliation, anticoagulation discharges
2:00-2:30 PM: Meet with preceptor to go over patients. I would present patients, fill my preceptor in with what happened on rounds that morning, and discuss any new recommendations I had for my patients.
2:30-3:30 PM: Meet with other rotation students for case presentations, topic discussions, journal club. We each had a number of rotation projects for this block and it was really interesting to learn about different topics from each student.

Since the medical residents and medical attending changed so frequently, I made sure to always introduce myself to anyone new and make sure they knew I was part of the pharmacy team and that they were able to page me and come to me with any questions. Over the rotation, I received quite a number of pages from my team asking for my opinion or if I could look into something for them, and it was always a nice feeling to see how much they appreciated my help and how much I was able to help my patients. On the flip side, I also sent quite a few pages to my team whenever I felt there was a problem or that we could make an improvement in therapy for a patient.

Overall, I was very fortunate to have such a great preceptor who gave me a lot of autonomy and responsibility early on in this rotation. After a couple of days, she had me round with the medical team by myself and continue rounding by myself for the rest of the rotation. After the first week of the rotation, she had me documenting on the pharmacist scoring tool and gaining experience writing patient notes. By the middle of the rotation, any pages from the medical team that were directed to the pharmacist pager went to my pager and I was responsible for 1) answering any questions from the team, or 2) looking up any questions I didn’t know and following up with the team.

By the end of the rotation, I was working up patients, rounding alone, documenting on the scoring tool, writing and updating pharmacy notes, and was responsible for the pharmacist pager for my team. Although I had many responsibilities, I was still able to bounce ideas off of other students or my team and I was constantly learning new things from my preceptor, who was always there as a supportive mentor and teacher. I really grew a lot during this rotation and it was great to finally feel like a pharmacist. It was a great 6 weeks!

Apart from rotation, the other major event that happens during Block 6 is the Midyear Clinical Meeting. Jared has discussed this event at length in a blog post below so I won’t go into this too much, but I definitely will second how important it is to get your transcripts in EARLY and to ask for your letters of recommendation early as well. Although it was very busy to have rotation during the same time as Midyear, I was glad I ended up having my second inpatient rotation during block 6 because I gained much more patient care experience and I learned so much more about myself -- experiences I may not have otherwise gotten prior to the conference.

Monday, January 2, 2017

Ambulatory Care at the University of Michigan Canton Health Center (Rotation 6)

Posted by James Shen at Monday, January 02, 2017

My 6th rotation was at the University of Michigan Canton Health Center where I got to experience the day-to-day of an ambulatory care pharmacist. The University of Michigan is unique in that the structure of their ambulatory care model revolves around a patient-centered medical home (PCMH) model.  Essentially, clinical pharmacists are integrated throughout the various UMHS clinics, and are able to assist providers in managing chronic conditions, such as diabetes, hypertension, hyperlipidemia, or asthma through a collaborative practice agreement. 

There is always opportunity to improve patient care when it comes to chronic conditions, whether it is through medication related changes or lifestyle optimization. Typical services that I provided while I was at this clinic included medication reconciliations, medication adherence assessments, patient self-management and goal setting, medication initiation and dosage adjustments through the collaborative practice agreement, patient education on chronic conditions and medications, lab orders for diagnostic tests, and some physical assessments (blood pressure readings, pulse monitoring, diabetic foot exams). A large portion of my patient population was primarily diabetic, but many patients had concomitant hypertension and/or hyperlipidemia issues as well. Additionally, I also had a few pediatric asthma patients, which was an interesting change of pace from my typical patient base.

I saw approximately 5-10 patients each day, but the number could vary depending on who showed up to the clinic. We discussed everything from their lab values, their health goals, their diet and exercise, their medication adherence, their personal stress, etc. It was important to establish a strong rapport and relationship with each patient, because many of these patients would often be back within the next few weeks for follow-up visits. By the second week, I was seeing these patients independently without any preceptor backup, coming up with recommendations, and writing up full SOAP notes for each encounter. I finally felt like I was a real pharmacist – the patients truly respected my opinion and treated me as a healthcare professional, not just a student!

After meeting with each patient, it was up to me to come up with an assessment and plan for moving forward. How many episodes of hypoglycemia did they have in the past month? What is their average fasting blood sugar? Is the patient a smoker, and if so, how motivated are they to quit? Is there a major holiday coming up that may affect diet (ex: Thanksgiving)? How is the patient’s stress level at home and work? Is their A1C, blood pressure, or ASCVD risk score at goal? Do we need to order any new labs? These are just some of the many questions that I needed answers to before I could come up with a reasonable plan. Many times, patients just needed a little encouragement and reinforcement for sticking to healthy lifestyle goals. You would be surprised how far a little motivational interviewing can take you. However, we also frequently adjusted insulin regimens, started new medications, or discontinued current medications based on a patient’s status.  


Other projects during this rotation included comprehensive medication reviews, topic discussions, patient case presentations, and journal club presentations. Overall, this was an interesting rotation that provided me valuable insight into the role of an ambulatory care pharmacist. It was rewarding to establish a strong relationship with a patient, develop a plan of action, and then follow-up with the patient at the next visit to see if he or she improved. The patients were always very grateful, and enjoyed talking with us about their overall healthcare. For anyone interested in ambulatory care, the UMHS clinics and the PCMH model is definitely the way of the future. Not only do pharmacists partner with their patients and empower them to take an active role in managing their own health, but the pharmacists also have a lot of autonomy when it comes to making any medication related changes or recommendations.