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!

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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!

What day is it?

Posted by Matthew Lewis at Wednesday, August 31, 2011

It is hard to believe it's Wednesday already and the first half of the first week of the second rotation is done. As I suspected, I am very familiar with lung transplant issues due to my PharmD project, which is finding out if an anti T-cell drug (antithymoglobulin) has a good risk vs. benefit ratio. I am loving this rotation! It feels great to actually know something about the medications and the patient population, instead of neonatal patients and issues.

However, this rotation started off with lots of work and patients. The expected learning curve is shorter, since we are now all rotation pros, having been on the scene for the lengthy time of four weeks at a previous site. I have already gotten assigned an in-service presentation, did a medication class overview, with another one on the way, got assigned a larger topic on infection protocols, and had four patients. Okay, you might not think four is a lot, but when you consider most of these patients are going home on 20+ medications,multilayered comorbidities, and need extreme education, it becomes a lot. In fact, transplant pharmacists educate everybody because anti-rejection medications like Prograf and Cellcept have severe side effects like nephrotoxicity and debilitating diarrhea which must be managed with appropriate dosing and therapeutic choices. I'm happy here though despite the work load. This is going to be great, but it's going to fly by.

Well, that was fun.

Posted by Matthew Lewis at Wednesday, August 24, 2011

My NICU rotation is all but wrapped up, and I learned a great deal about being a clinical pharmacist. Yes, there was drug information learned like pharmacokinetics of caffeine or proper medication selection with neonatal abstinence syndrome (that's when mothers have to go through methadone withdrawal or a child was exposed to illicit drugs). More so on this rotation, I learned process. How to go about researching, writing, and organizing a topic presentation. How to figure out what to expect when you initiate drug therapy and which of those results have a clinically significant meaning. My preceptor is incredibly knowledgeable about her specialty, especially since she has been with neonatal medicine close to when it really became its own branch of medicine. To fully appreciate that fact, consider that now we just give a baby caffeine to help it remember to breathe. My preceptor started her career shortly after they abandoned mechanical bed shakers.

However, this is all drawing to a close. By Friday night, the first rotation will be done and gone. Due to my desired career path, it will be a very long time before I need to drudge up the medication lessons I learned here. The process lessons I learned, like how to investigate and build the patient's story, I will take with me to my next rotation, which is transplant pharmacy.

Transplant pharmacy rotation is one of fields of pharmacy I am highly interested in going into,and I ranked this rotation very highly. Where I knew next to nothing about neonatal intensive care medications, I come into this rotation with a decent background. Although we were hardly taught about transplant medications in class, my pharmD research project is in this area and my summer workplace supplies transplant meds to patients, so I have a better knowledge on these than my average classmate. I am also glad to be back into working with adults, since I can talk to them and my classwork applies to this population more.

In other news around pharmacy school, we had our first seminar session where we learned a little bit about the P1-P4 mentoring program and then had an info session on the APhA pharmacy convention, commonly called Midyear. I can't wait for both of these things to start. The mentoring will allow me to help somebody have an easier time in pharmacy and really get their new career going. Midyear will help me get my own career going. It's scary and exciting at the same time.

P.S. Sorry about the lack of pictures. It turned out to not be an option after all. Have to respect patient and family privacy!