Rotation 4: Drug Information

Posted by Unknown at Friday, October 05, 2018

During the last 5 weeks, I had the opportunity to work with a well known drug information company and had a great experience!

Before the rotation started, I talked to multiple people who had this rotation in the past and came in with some specific expectations. While my expectations pretty much held up (time requirement, workload, preceptor style), I learned it is important to continue keeping an open mind going into any rotation no matter what you were told by others.

First, I'll let you know that this is one of the only rotations where you get to work from home!! It was amazing and I really enjoyed setting my own schedule and working at my pace! That being said, you have to manage your time well and hold yourself accountable to getting all the work done. I met with my preceptor (and fellow classmate on rotation with me) three times a week. These meetings were between 20 minutes and 1 hour and were helpful in keeping me on track with the rotation work. My preceptor was a great resource and was very receptive to questions and suggestions. She also gave great feedback and really helped refine my skills.

My preceptor worked in the drug interaction section of the company, so we worked on updating and creating drug interaction monographs. After this rotation, I feel a lot more comfortable doing PubMed searches because of all the searching I did for this rotation! I know I will take the skills I learned in this rotation and bring them with me wherever I go! I also learned how to write concise, one sentence summaries of clinical studies for the monographs. This is a very specific kind of writing and I think it will be helpful in the future when I am writing papers and in residency. I also got to explore topics I didn't know much about during three longitudinal projects (drugs that prolong QTc, possible UGT1A1 inducers/inhibitors and interactions with smoking).

I feel really proud of the work I did this rotation. There are people all over the world who will use the monographs I created to help patients! I can go and lookup the drug interaction (e.g., omeprazole and ginkgo biloba) and see one of the monographs I created! I feel so excited thinking that I contributed something so practical and widely used to the field of pharmacy and medicine!

Two things to remember:
-Keep an open mind going into any experience and put your best foot forward!
-Make sure you take time and enjoy this beautiful life, no matter how busy it gets!

Exploring Maine: Acadia National Park (top) and Baxter State Park (bottom)

Rotations 4-6: Working from Home, the MICU, and the Off-Rotation/Midyear

Posted by Jared at Thursday, December 29, 2016

Hello everyone! Apologies for the delayed post, but the last couple months have been quite a busy time! I'll summarize my last few rotation experiences below. Heads up, it's quite long!

Rotation 4: Drug Information

My fourth rotation was actually a work-from-home rotation! I worked for a drug company database alongside a fellow P4 student. The projects we were typically responsible for involved various inquiries from customers of the database (typically healthcare professionals) or drug companies asking us to clarify a statement about their drug that was listed in the database. Other times, we would have to look into evidence because a drug company was trying to prove that what we had in the database was false. We also typically looked into drug interactions that might not be present in the database, and wrote up drug monographs for these based on the research we found.

A typical day involved us meeting our preceptor a few times a week at an off-site location to discuss our assignments, what we found, and to discuss new things that came up. Afterwards, we were free to do as we pleased with our schedule, as long as we finished up the tasks given to us and e-mailed our preceptor with updates. This rotation really tests your time-management skills, as you really could slack off given the lack of normal structure. I tended to do many of my projects at night, as it's easier for me to work on projects like that at that time frame due to years of undergrad and pharmacy school studying. However, I really enjoyed this rotation as it helped to beef up my research skills and further interpretation of drug literature and drug labels. I got better experience understanding pharmacokinetic (PK) data and using PubMed, as often my preceptor would find things that neither me or the other student on rotation would find about our respective assignments. We also got the chance to read through foreign drug labels to help write our monographs, and they're quite different in the data that they provide compared to those here in the US!

I also appreciated this rotation, as it gave me time to finish up my PDI. If you're interested in seeing a different side of pharmacy and believe you can handle managing the time on your own, I would highly recommend this rotation! I really learned a lot more about searching strategies and drug interactions. 

Rotation 5: Critical Care - MICU

My fifth rotation brought me back to the hospital for another inpatient rotation, this time in the medical ICU at UMHS. This was actually my first rotation at UMHS, so I was both nervous and excited at the same time. However, this time I had another student with me on rotation, which was a welcome change from my infectious diseases rotation where I was the lone student.

Typical Day:

6 AM: arrive at the hospital to work-up patients.

7:30 AM: table rounds. This is when the night team would typically hand over new admits to the day teams. Also at this time, the attending doctors would typically go over various topics for the residents (i.e. sepsis, sedatives, etc.)

8:30 AM - 11 AM : Rounds. The MICU at UMHS is divided into two teams: Maize and Blue. For students on this rotation, typically one P4 will take each service and pick up all the patients for that service. There's about 20 beds or so (forgot the exact number) on the unit, so typically you'll have 8-12 patients at a time that you have to follow. For most of the time, we would each round with a pharmacist (either my preceptor or the resident on our rotation at the time). 

11 AM - 1 PM: lunch/preparation. Usually after rounds, we would have lunch, prepare for discussing our patients with our preceptor, or look up questions we were asked.

1 PM - 3 PM: At this point, we would meet with our preceptor and the resident to discuss our patients. We would typically go over our patients, discuss their status, and the changes the team made to their drug therapy. Often here, or during rounds, we would get asked what we thought about their changes. We would also discuss a certain topic that was relevant to critical care, such as sedatives, electrolytes/fluids, sepsis, etc. 

In terms of drug therapy, antibiotics were huge in terms of the pharmacist role. In the MICU, the general trend is to just throw a very broad-spectrum regimen as the patients are extremely sick (vancomycin and Zosyn are huge workhorses). We often had to remind the residents or the team that after 3 days, they needed to get ID approval to continue using vancomycin. Also, we would often recommend adjusting the antibiotics based on culture data and whether the patient was getting better/worse. The other big thing we looked for was renal dosing. Often, many of these patients developed AKIs that sometimes required them to go on dialysis or CRRT temporarily. I would always get asked if drugs were adjusted correctly given the renal function, along with when would be best to order levels for vancomycin or aminoglycosides if they were on one.

  

The MICU was challenging to me because the most common problems we saw were of a respiratory nature (i.e. respiratory failure, ARDS, etc). Beyond pneumonia, the presentation and therapies to treat these type of patients were completely foreign. Often, ventilator settings would be the common route for the team to adjust, and I generally had no idea what it meant. After the rotation, I have a better understanding of it, but I would definitely need more exposure to that and another review of the basic concepts. I also got a great refresher of topics we had learned in therapeutics that I personally wasn't great at, such as electrolytes, metabolic acidosis/alkalosis, vasopressors, and sedatives. Sedation strategy was another thing that often came up in the ICU, and I never really thought to think about it until this rotation.

Ultimately, I think a critical care rotation is a terrific experience, and one I would highly recommend. While it's not my favorite area of practice, I think it offers valuable lessons that would be useful in any setting of practice. You really get exposed to a lot of different clinical areas as these patients present as very complex cases, and you learn to prioritize what really needs to be solved now vs. what could be dealt with at a later time. Finally, it also really hits a number of gaps that our curriculum is unable to cover, particularly on the respiratory side of things.

Rotation 6: Off-Rotation / Midyear

Initially, I chose rotation 6 as my off rotation as I wanted to have time to attend Midyear and work on residency applications/letters of intent, as well as go on one last trip before graduation. However, this worked out for me really well for another reason. 

I had the opportunity to represent the College of Pharmacy at the 2016 International Forum of Pharmacy Students in Nanjing, China. This conference was sponsored and held by China Pharmaceutical University, which is one of the schools in China our College of Pharmacy has a partnership with. Here, I was asked to present a project that provided some insight into clinical pharmacy practice in the United States. In this case, I presented my PDI project as a glimpse into the roles of an infectious disease pharmacist in the US. I thought I was only going to be presenting my project in a small sub-forum, but I ended up being selected to present during the opening session in front of the entire conference, which had hundreds of attendees. Undoubtedly, I was nervous as I had just flown in from the US a couple days prior, but it ended up being a really great experience! I also got to meet other great student pharmacists from around the world, many of whom were there due to their connections with the International Pharmaceutical Student Federation (IPSF). Learning the differences in education and pharmacy practice between our respective countries was really interesting. After graduation, I'd like to get involved with the International Pharmaceutical Federation (FIP). After the conference, I had a chance to visit New Zealand, Australia, and Singapore. Needless to say, it was awesome and a perfect way to relax and clear my head before Midyear. Pictures below:

Some of the great student pharmacists I met at the conference in China

Skydiving in Queenstown, New Zealand

 Hiking the Ben Lomond Track: Queenstown, New Zealand

Mrs. Macquarie's Point at Sunset: Sydney, NSW, Australia

The famous Merlion in Singapore

Midyear

For those that don't know, the ASHP Midyear Clinical Meeting is the largest gathering of pharmacists and pharmacy students worldwide each year. It typically happens around the first weekend of December. This year, it happened in Las Vegas. I will quickly mention that I'd recommend not getting back from a trip on the other side of the world and then flying to Vegas a couple days later. I had the worst jetlag I have ever experienced, which caused me to not to sleep well during my time in Vegas, and also took me quite a while to recover from.

Anyway, this meeting is very important for those of you that are pursuing fellowships or residencies. As I plan to go the residency direction after graduation, I don't know too much about the process with pursuing fellowships. All I can say is that it requires scheduling interviews ahead of time through the Personnel Placement Service (PPS) with the companies/fellowships you're interested in. In terms of residencies, Midyear is great because every residency in the country is present in one location for you to ask questions to their residents, preceptors, or program directors, and determine whether or not you want to apply to a program. So, for those of you that are looking for residencies all across the country (like myself), this helps to put faces to programs and answer some questions that weren't possible via simply e-mailing them. However, if you're only interested in Michigan residencies, Midyear might not be necessary for you. The SMSHP Residency Showcase that occurs in October has all of the Michigan residency programs present and allows you to meet the residents / program directors and ask questions there. Anyway, here's some tips from my experiences:

• BE PREPARED. This really can't be overstated. You will hear this all the time in Dr. Kraft's Opportunities class and from anyone you ask about Midyear. Have updated CVs, business cards, etc. While you won't be handing out CVs to most programs, they sometimes will ask for it or provide a place for you to drop it off. I often heard that if they ask for a CV, it's typically a bad thing as there's so many people at Midyear most programs likely won't remember who you are. But, in my case, I went to a couple programs that did take them to help remember who stopped by their booth, and even got asked for one from a residency program director that I had a good conversation with. Also, many programs took business cards as well, possibly another way for them to keep track of who stopped by. 
• Do your program research ahead of time. Prior to Midyear, go to the ASHP Residency Directory. It lists all the accredited ASHP programs by location and program type, along with giving a summary of the program and the links to the program's website for more information. Prior to Midyear, ASHP provides a schedule of when each program is available during the Residency Showcase, along with a map of where their booth is. The Residency Showcase is divided into three sessions: Monday, Tuesday AM, and Tuesday PM. Each program is only present during one of these times, so it's imperative you know which programs you want to talk to, where they're located, and when they're available.
• Prepare questions for each program you want to talk to. From my experience, it didn't seem like you could just walk up to a program and ask them to give you a general overview of the residency. The residency showcase is like a zoo, with a bunch of frantic P4s trying to figure out their futures and many residents would be talking with multiple P4s at a time. With the limited time frame, you really want to get the questions that will make or break a program for you asked and answered. You could certainly listen to other people's questions and then ask something if you think of it on the fly, but it's easier to be prepared. I personally created a general list of questions I could ask most programs, along with specific questions that pertained to the programs I was visiting. 
• Reach out to preceptors, professors, and alumni! Prior to Midyear, I reached out to a lot of people with help in terms of editing my CV, looking at my program list, asking questions about residencies, etc. Everyone at Michigan or those who have graduated from the program are extremely helpful and really want you to succeed. Your preceptors as well can give useful insight, especially if they're at a system you're interested in possibly obtaining a residency at. 

Finally, my last tip in terms of the application process: Ask for transcripts and letters of recommendation ahead of time. Fall grades will come out way too late for them to be sent to programs on time, so I would recommend immediately sending your transcript to PhORCAS once it comes out in November. Also, I would ask for letters of recommendation ahead of Midyear as well. Many preceptors and professors will understand that you may not have your program list finalized until after Midyear. However, it is good to ask them how they would like the references generated. With PhORCAS, you generate a request to your letter writers and can provide extra directions. For most programs, one general reference will suffice. But, if your writer knows someone at the program, sending another request that's more personalized to that program can be beneficial. When submitting the app, you can designate which specific request you want to assign to a program. This might not make much sense now, but it will when you go through the process.

Wow, sorry again for the long post! Hopefully there's helpful advice in there for you, and enjoy the rest of the holidays!

A DI Rotation: Drug interactions? No, Drug Information!

Posted by H. Tran at Tuesday, July 21, 2015

We are in our last week of our second rotation. I’m currently on my Drug Information rotation in Ann Arbor and it’s been a great experience. My daily tasks have revolved around sharing phone duties with another P4 student, which entails answering drug information questions that come in. These questions could come from anyone -- nurses, physicians, pharmacists, psychiatrists, etc., and could be about anything.  Some of the more interesting ones I’ve received were questions regarding appropriateness of using medications off-label (not FDA-indicated). For starters, a psychiatrist inquired about using N-acetylcysteine (NAC) for an autistic patient’s aggressive behavior who had experienced tardive dyskinesia (adverse effect) from their risperidone.  Specifically, they were asking if NAC would cause problems for this patient.  Another interesting request I had was to find a recipe to compound a topical cream of paromomycin for cutaneous leishmaniasis.  You are probably thinking, “Paramo—leishmani—what?!” That was exactly my reaction.

To address these questions, the first thing I did was review the patient’s charts to assess appropriateness of the requested therapy given the patient’s medication list and medical diagnoses. The review includes side effects, kidney/liver function, drug interactions, and any other precautionary measures that would ensure safe and efficacious use of the therapy. I then referred to the literature to support any responses I would provide the requester. Because these therapies were off-label uses, the literature would be the most appropriate resource to support my response. NAC is FDA-indicated and routinely used in case of acetaminophen overdoses, but luckily, NAC has been recently studied for neurologic disorders. I pulled the evidence from the literature and provided the articles to the requester for him to make his own clinical decision based off the outcomes from these studies. From a pharmacy standpoint, I acknowledge whether or not a therapy is appropriate given a medication and problem list. Once I’m ready to make my response/recommendation, I bring it to my preceptor to sign off on, and away it goes!

The request for a recipe was a little more difficult.  Paromomycin is an antibiotic that isn’t on formulary where the requester is situated.  It comes only as a capsule formulation, so finding a recipe was a challenge. Through a literature search, I found a military-based recipe that I provided the requester.  Topical paromomycin is so uncommonly used that it came down to utilizing a recipe that one doctor created for military use. Some of the other drug information questions I received were related to drug stability, drug interactions, if a drug would be safe for a given patient, and alternative therapy options.

When I’m not on phone duty, I work on various projects.  My main project is to create monographs of new drugs that are/may be considered for formulary. I give a rundown of the drug (general description, indication, mechanism of action, side effects, costs, clinical studies, etc.) and compile it all into a monograph.  The drugs I’m working on are ivabradine and combination product sacubitril/valsartan, which are new heart failure medications. The ivabradine monograph will be presented at the Pharmacy and Therapeutics Committee meeting for review of approval and addition to formulary, while sacubitril/valsartan has a novel mechanism of action that will likely be considered for addition to formulary as well. Separately, I also looked into revising guidelines on ketamine use in the emergency department. I surveyed policies and guidelines from various institutions across the nation and compiled the data for the pain management committee to review.

All in all, I never thought drug information was like this. It’s something new every day with different questions for you to problem-solve through. Whether or not you’re interested in drug information, the skills you develop in efficient navigation of references (and knowing what references to use!) would help pharmacists in any setting. I’m glad I had this as my second rotation as it has already made feel more comfortable and efficient in searching through references and studies for answers during my future rotations.

Rotation 1: The Infamous Stay-At-Home Rotation

Posted by Unknown at Thursday, June 18, 2015

My first rotation was drug information.  I’d heard a lot about this rotation, so I was very excited to begin!  I was at a company that provides clinical information for users, and my focus was primarily on drug-drug interactions.

A Typical Day

I started the rotation mostly editing existing monographs and performing quality assurance on monographs that had not updated recently, but I gradually took on more responsibility and began writing more new monographs.  Requests for new monographs generally came from internal (other departments) or external questions, updated product labeling with new interactions, or articles that my preceptor or I happened to stumble across when researching another topic.  Two or three times a week, my preceptor, the other P4 on my rotation, and I would meet at a coffee shop (yum!) to talk about our work, discuss therapeutic topics and the drugs we were working on, research and writing strategies, and talk about life as a pharmacist.

I Didn't Just Write for 25 Days Straight

I didn’t just sit at home writing all day.  We had a Journal Club midway through the rotation, which was my first JC experience.  I also had the opportunity to poke around a little in the informatics side of the company and see where my monographs went once I finished writing them.  I was also able to work on a few pharmacogenomics projects and give recommendations based on my research, which I eventually wrote into a very different type of monograph.  In addition, I worked on a rotation-long project categorizing drugs based on levels of evidence.

Dusting off the MedChem

I unexpectedly found myself constantly challenged finding mechanisms of action, drug metabolic routes, and using this information to figure out how two drugs interacted with each other.  Some interactions were fairly obvious or were spelled out in a study or drug label, but others were not as clear and needed to be deciphered based on studies with other drugs or in vitro studies.  A few interactions had no evidence whatsoever, and the mechanism was left as “unclear, but the following mechanisms have been ruled out.”  I learned a lot about how drugs could interact, even in the strangest, most roundabout ways.

A lot of what this rotation boiled down to was writing, research, and coffee, which are three things I’m very fond of.  However, there were also many non-writing opportunities, and I was challenged in ways I didn’t expect to be challenged, most notably utilizing all of the medicinal chemistry I had tucked away in my brain a few years back.  If you like to write, I would highly recommend this rotation! 

Drug Information: Lexi-Comp

Posted by Eric Zhao at Sunday, November 13, 2011

This month, I'm excited to help write for a drug information program known for both its online and mobile platforms:

I'm looking at you, Lexi-Comp

Working with a previous University of Michigan College of Pharmacy alumnus as my preceptor, I help write and update drug-drug interactions for the program. Some examples of the interactions are those between carbamazepine/non-dihydropyridine calcium channel blockers, levodopa/iron salts, and oxcarbazepine/phenytoin, among others.

The Process
1. Initial Search: The initial search involves a very broad query in PubMed for the interacting drugs, and if there are a reasonable number of hits (around 200 or less), we begin screening abstracts for possibly pertinent articles. Sometimes the query produces over several thousand results, so we employ alternative search strategies (e.g., using limits, excluding "review" articles, etc.).

Some sort of national database

2. Screening: After combing the abstracts, I can usually narrow the article list down to about a quarter of the original number. Here's where I access and skim the articles to see if they will be useful for the write-up. This narrows the list down even further.

3. Write-up/Update: Once I determine which articles will be useful for an evidence-based write-up, I determine a strategy. Ideally, my final list involves articles that provide many different viewpoints of the drug interaction, which include primary literature and case reports. After thoroughly analyzing the articles, I begin writing the drug interaction monograph.

4. Upload: Prior to uploading, I review my drafted monograph with my preceptor for his opinion and expertise. If all goes well, my preceptor will remotely log-in to the database and upload our monograph. It's pretty neat to see the immediate changes on my phone's Lexi-Comp application after uploading.

This rotation allows me to practice my literature searching skills while providing a lot of autonomy. My preceptor gave me several projects that he wants finished before the end of rotation and it's up to me to prioritize and deliver (i.e., I set my own schedule). During our meetings, I inform him of what I have been working on, and he lets me know my progress. That said, I'm going to get back to my projects.

-Eric Zhao

It's Not Boring, I Swear.

Posted by Matthew Lewis at Tuesday, October 25, 2011

Hello Readers.

I'm already in the groove for my newest rotation, which is drug info. This is my second rotation in the Veteran's Affair group of hospitals, but there is a huge difference between the hospitals, and I think that is because of financial support. For example, the Detroit VA does not have a residency program but Ann Arbor (and Battle Creek) do.

[As a side note on residencies, several students from my class hope to be placed in the VA system, but I've been told that there aren't any residencies available at the Ann Arbor VA site this year. This situation isn't unique to VA as the demand for pharmacy residencies continues to outpace the supply nationwide. That means increasingly intense competition for limited slots. Michigan has one of the highest pharmacy residency placement rates in the country, but being a Michigan PharmD does not automatically make you the preferred candidate for a residency. Landing a residency still comes down to polished interviewing skills and an ability to package your talents in ways that make you stand out from the crowd.]

Back to the story at hand. As I mentioned, my current rotation is drug info. My preceptor, Dr. Ed Lehaie is a great guy and was recognized as preceptor of the year for 1999. The first day was all about getting paperwork in and computer access. I even answered some questions. Today, I answered a few more questions, particularly on replacements for the pain medication fentanyl because there is a drug shortage looming on the horizon. First, I did not even realize there were other drugs in the fentanyl family, so learning about those was interesting. I compared onsets and found appropriate doses through literature searches for sufentanil, remifentanil, and alfentanil. Finally, I did a little cost analysis.

You may have heard about drug shortages in the news, since they have gotten so bad people are dying from not getting proper medications on time. Part of drug information's job is to figure out how to work around these shortages. The other major part of drug information's job is to ... well, dispense drug information. This is usually in the form of approving medication requests that are off-label or extremely costly, such as cancer medications. We will also present new drugs and new research to our pharmacy and therapeutics (P&T) committee, where they can discuss what additional restrictions they want to place on drugs. VA P&T committees are quite different from normal P&Ts, in that each hospital has to follow the nationally mandated formulary decided upon by the national P&T. The local hospitals can only further restrict use.

That's the nuts and bolts of this rotation. I'm definitely going to be getting some weird questions, so I'll keep in touch to share them all.