Rotation 3: Meticulous Minds for Medication Error Prevention

Posted by Emily at Friday, August 28, 2015

Block three brought me to Silver Spring, Maryland (just outside of Washington DC) for a non-traditional rotation experience at the Food and Drug Administration.  This was my first rotation outside of UMHS and my first rotation where I didn’t have a classmate by my side for support.  That was a little nerve-wracking at first, but I’ve learned that putting yourself in slightly uncomfortable situations in unfamiliar environments and adapting as you go is a great way to grow personally and professionally.  The uncomfortable situation is rarely as uncomfortable the next time.

FDA Building 1

It was clear from day one that FDA loves acronyms even more than BMT.  My preceptor’s email signature read something like:

DMEPA|OMEPRM|OSE|CDER|FDA

Translated: I was working in the Division of Medication Error Prevention and Analysis, housed within the Office of Medication Error Prevention and Risk Management, which is part of the Office of Surveillance and Epidemiology within the Center for Drug Evaluation and Research at the Food and Drug Administration.  (Suffice it to say I quickly began referring to my division as DMEPA just like all the other employees.)

DMEPA is full of pharmacist safety evaluators who are responsible for conducting pre- and post-marketing safety reviews of proprietary names, labels, and labeling with the end goal of preventing medication errors.  For example, if a manufacturer proposes a carton design in which the drug strength “200 mg” is too close in proximity to the quantity “100 tablets”, the safety evaluator will recommend separating the numbers physically or graphically to minimize the possibility of a busy pharmacist mistaking “100 tablets” for “100 mg” and contributing to a potential overdose.  Safety evaluators also conduct safety reviews of proposed brand names.  Part of this process involves asking employees to interpret handwritten and verbal prescriptions to see if the name they see/hear could easily be confused with an existing drug name.  I have pretty good penmanship overall, so I struggled to make my handwriting physician-worthy when I was asked to contribute prescription samples for these studies.

I was my preceptor’s first student at FDA, and he explained on the first day that the rotation was going to be more observational and self-directed than my previous clinical experiences.  That was true, but between projects, meetings, field trips, and the extensive student lecture series, I kept busy.  To keep this post from becoming too unwieldy, here are some of the projects I did and meetings/talks I attended in list form:

Projects:

• Summarized the literature on the effect of calendarized blister packaging on adherence
• Created a chart of abuse deterrent formulation opioids
• Conducted a literature search on best practices for standardized chemotherapy order forms (my preceptor works specifically with oncology products
• Presented recent DMEPA interventions aimed at preventing errors with chemotherapy agents

Meetings:

• ISMP monthly conference
•  Human factors study meeting
• DMEPA and OSE “All Hands” staff meetings
• Advisory Committee practice meeting

Student Lecture Examples:

• Office of Prescription Drug Promotion overview
• Orphan Drug Product Development
• United States Public Health Service overview
• CDER Drug Shortage Program
• The Scientific Basis for Drug Control Under the Controlled Substances Act
• Unapproved Drugs
• President’s Emergency Plan for AIDS Relief
• Introduction to OTC Drug Regulation

 Field Trips:

• ASHP headquarters in Bethesda, MD
• Bureau of Prisons in Washington DC
• United States Pharmacopeial Convention in Rockville, MD
• Pentagon tour in Washington DC
• Consumer Product Safety Commission in Rockville, MD  (This experience was not part of the FDA “curriculum”; my awesome preceptor arranged for me to shadow the pharmacologists at the CPSC after I told him about my interest in poison control and prevention.  The CPSC tests all kinds of consumer products, everything from bike helmets to baby cribs, ATVs to mattresses, and everything in between.  The chemists do a lot of work testing products for lead and phthalates.  The coolest part of this experience was getting to tour CPSC’s testing laboratories.  I totally felt like I’d walked onto the set of MythBusters.  You can watch a video tour of the labs here: http://abcnews.go.com/GMA/video/consumer-product-safety-commissions-test-lab-13827984)

ASHP Headquarters

USP Headquarters

Pentagon

Overall, my FDA experience was positive and unique.  It was great to see pharmacists from diverse backgrounds filling these non-traditional roles, and there are TONS of pharmacists at FDA!  Most of the employees seem to enjoy their work and the work environment, and even as a student I felt like I was part of significant work and something important.  I also felt proud to introduce myself as a University of Michigan student.  It’s true that the name demands a certain degree of respect, and I was grateful to be able to represent the COP outside of Michigan.  It also turned out to be a great networking tool.  I met two other Michigan alums on my second day, and that’s not including my preceptor!  One of the alums was a resident at one of the programs I’m considering, and he was more than happy to sit down with me to discuss his experience.  I was also able to network with the other students.  There were about thirty of us in total, representing over 20 different colleges of pharmacy!

While I learned a lot on this rotation about the drug approval process (and got to see firsthand that package inserts don’t just rain down from the heavens), the most important thing I learned is that I am not interested in working at FDA.  I love direct patient care too much to be happy in a job that involves no direct patient care whatsoever.  Perhaps in the future I’ll find myself in a position where taking on a desk job is the right move for me at that time, but for now I am excited at the prospect of pursuing residency and, more immediately, starting another clinical rotation next block at the Michigan Regional Poison Control Center!  Stay tuned.

PS – If you find yourself in the DC metro area for a rotation, be sure to take advantage!  I did all kinds of touristy things in DC on the weekends, and even caught a Tigers/Orioles game at Camden Yards in Baltimore one Friday.

Salk's polio vaccine at the National Museum of American History

Tigers vs. Orioles at Camden Yards

Rotation 3- Community: Still Going Strong

Posted by E. Caliman at Tuesday, August 25, 2015

I'm doing my Community Rotation at a local compounding pharmacy. I enjoyed compounding during P1 year and was interested in it even before starting pharmacy school. After the fungal meningitis outbreak from the New England Compounding Center in 2012, I thought that a community compounding pharmacy would be a nice, slower-paced rotation as compared to a chain community pharmacy.

I was wrong. I was so very wrong.

Compounding pharmacies are very much alive and well, even with piles of restrictions and new regulation. It's likely due to the fact that compounding pharmacies provide patients with medications they can't find at a regular community pharmacy and the personal level of service because many of them have fewer patients.

Slow days here are few and far between. I started off on a week where almost 100 scripts were filled each day. It's always busy. If you're not filling, you're probably tackling the pile of drug information questions patients and doctors call you about, from drug stability of compounded medications, to drug interactions, to helping them navigate insurance issues, since many insurance companies no longer pay for compounded medications.

Naturally, I got to spend time in the compounding lab. The pharmacy can compound capsules, suspensions, topical creams, ointments, lotions, suppositories, as well as sterile products. I got to try a little bit of each. The experience was more automated than I expected (there's a machine that mixes the topicals and you don't fill capsules by hand), but a little more labor intensive than P1 year would have you believe. Even so, I still enjoy compounding and it's still a career option.

Some of my other projects include updating policies and forms, as well as doing research into regulation and new business opportunities. I researched how a pharmacy in the partnership could provide a new service for the county and updated a privacy practice form to reflect that the pharmacy could now text patients with their permission. Overall I had a great experience and am looking forward to the next rotation.

Rotation 2: I'll Take a General Kit, Please

Posted by Unknown at Saturday, August 01, 2015

My entire life I've been terrified of blood, so imagine my shock and horror when I found out I was assigned to the operating room pharmacy for my health system/hospital rotation!  In the first hour of my first day I was handed a syringe of morphine mixed with blood to empty, and thus began my 5-week journey of desensitization.

A typical day kept me constantly moving and looked something like this:

0600 - 0730: Pass out kits
The OR pharmacy had pre-made drug packs containing various narcotics that the CRNAs and doctors could sign out for their patients.  There were kits for ECT, codes, PACU, the medical procedures unit (MPU), and, most popular, kits for general surgery.  Doctors and CRNAs could ask for additional add-ons, such as ketamine or Dilaudid, as well as pick up non-controlled medications, such as Tylenol, Neurontin, and Precedex, and request infusions.  This time was particularly busy, as all 30 ORs had a shotgun start at 7:30.  During this time, we also received several kits that were used overnight, and had to reconcile those with the provider while he or she was standing there.

0730 - 1000: Verify, topic discussions, and LOTS of paperwork
The next 2.5 hours were spent talking about various topics related to anesthesia, opioids, or other OR drugs, verifying the pre-op medications for the next day, and reconciling and completing the returned kit paperwork.  The paperwork could be very tedious at times, as we could have as few as 2 kits returned or as many as 20 or more if there was a weekend or holiday! The paperwork had to be double checked against what was actually returned and against the Omnicell.  Anything returned in syringes had to be refracted to ensure that what was documented to be in the syringe was actually in there.

1030 - 1430: Pharmacy adventure!
Every day I went to a new place to learn about a new area of pharmacy.  On Mondays, I went to the main pharmacy in the children's hospital, where I was able to check prescriptions, participate in cart fill, learn about dosing children, and chemotherapy dosing.  On Tuesdays, I went to the OR in the children's hospital, where I performed very similar tasks to my responsibilities in the adult hospital.  On Wednesdays, I worked with the medication safety officer on a medication use project.  On Thursdays, I went to the Investigational Drug Service and learned how to verify a prescription for a study, how to read a protocol, and how to write guidelines for pharmacists dispensing based on the protocol.  On Fridays, I stayed in the OR and filled pre-op orders for the next day.

One of my favorite days in the OR was a day I never thought would happen: I spent four hours walking in and out of various surgeries and intently watching the procedures.  I walked around with an amazing anesthesiologist, who showed me how she uses all the drugs I had seen coming in and out of the pharmacy every day, which was fascinating.  I was also able to watch a kidney transplant, brain tumor biopsy, ear canal tumor removal, and a prostatectomy using the da Vinci robot.  Watching those surgeries showed me that I had come a long way in those five weeks with regards to my blood sensitivity!

Overall, this was a fantastic rotation and nothing like I expected it to be.  It was a lot of work, but well worth the effort!

Meetings, Meds, and Monographs: Drug Information Rotation

Posted by Stephanie Burke at Friday, July 24, 2015


Already done with rotation 2 – time flies! I had my Drug Information (DI) rotation these past 5 weeks, and I learned a ton! I’ve got a pretty good grasp on where to find information for different types of DI questions. The questions I received ranged anywhere from ‘what are the clinical manifestations that could result following accidental injection of a nasal solution of drug A’ to ‘can drug X be crushed and flushed through a G-tube’ to ‘we have a patient who is allergic to sulfites – can you review the ingredients of the attached list of medications for presence/absence of sulfites?’ Not your typical, everyday stuff, but now I have some familiarity with the types of clinical questions that could arise and where I could look to find information. I consider it a great skill to have acquired early on in my rotation schedule.

In addition to answering phone calls and emails from the inquiring minds of our UM providers and researchers, the DI folk also attend a number of different committee meetings. On this rotation, I went to committee meetings for anesthesia, cancer, pain, inventory, and glycemic control. It’s great having our DI pharmacists present because they bring a solid understanding of the available literature, and the meetings help the DI staff stay up-to-date on new information. My personal favorite was the Glycemic Committee meeting given my interest in diabetes mellitus. There was a monograph presentation on Afrezza, the newer inhaled insulin product, and also a discussion on the concentrated insulins that have been surfacing in recent years. Lots of cool stuff in my opinion!!! My hope is to continue attending these monthly meetings in future rotations when I am back in Ann Arbor (out of area rotation 3). If that is the case, I’m sure you’ll see more fun stuff on that in future posts J

One of my other favorite components of this rotation was the monograph project (or in my case, 3 total monographs!). The monographs I prepared will be presented at future Pharmacy and Therapeutics Committee meetings for consideration for formulary addition. The first drug assigned to me was mifepristone. This is a very interesting (and controversial) medication. Used as an investigational drug since 1985, mifepristone was FDA-approved in 2000 for termination of pregnancy through 49 days gestation. The drug had already been adopted in a number of European and Scandinavian countries prior to its approval in the United States. The brand name for this indication was Mifeprex^TM, produced by Danco Laboratories. Twelve years later, mifepristone was approved for another indication – management of hyperglycemia in patients with impaired glucose tolerance or type 2 diabetes secondary to endogenous Cushing’s syndrome. This brand, Korlym^TM, was produced by Corcept Therapeutics. Same active ingredient, two different brands, indications, and manufacturers. Take a look at the pharmacology of mifepristone to see how it could work for two very different conditions!

The third monograph I wrote was for U-300 glargine (Toujeo^TM). Again related to diabetes, it was of significant interest to me. The clinical trials that Sanofi-Aventis completed showed, overall, that U-300 glargine was non-inferior to Lantus in blood glucose control, and in some cases, produced less nocturnal hypoglycemia. There were no significant differences in adverse effect profiles between the two. The primary concern we see with adding U-300 glargine to formulary is safety. There have absolutely been medical errors when someone draws up the concentrated product thinking it’s the unconcentrated, or a provider fails to correctly calculate the volume needed given the number of units of insulin. Many things could go wrong here when used in the inpatient setting. For those unaware, insulin is a high alert medication, and there must be effective and appropriate protocols in place to ensure safe use of insulin products.

Drug Information was an excellent experience. It challenges you to dig deep into the inquiries that come in, and also to consider all the data you’ve gathered and make a clinical recommendation. The rotation also better familiarizes you with drug information resources which will be invaluable to any type of work that you do.

 

Rotation 2: Prednisone Tastes like Rancid Mints and Other Pearls from Pediatric Generalist

Posted by Emily at Thursday, July 23, 2015

What does a generalist do?  The short answer: everything!

Here's what a typical day looked like on rotation as a pediatric generalist-in-training:

0730-0930 - work up patients at the hospital

On the first day of rotation, my classmate and I were both assigned to a specific pediatric general medicine service that we would continue to follow for the rest of the month.  These services see kids with all different kinds of chief complaints ranging from intractable vomiting to osteomyelitis to febrile seizures to premature babies who are simply admitted for feeding and growth monitoring; basically patients who are too sick to go home but not sick enough to be sent to the PICU or assigned to a specialty service like heme/onc.  Patient duration of stays also varied greatly, so our patient lists changed every morning as our old patients were discharged and new ones were admitted.  This kind of variety is the hallmark of a general service and because of it I gained exposure to an array of disease states and medications that I hadn't previously seen.  We reviewed our patients and recommendations with our preceptor before starting rounds.

0930-1100 - rounding with the medical team

My favorite part of the day!  Pediatric generalist is a teaching service, so my team consisted of an attending physician, medical residents, medical interns, med students, and a dietitian.  I benefited from the attendings' teaching points just as much as the medical students did, and sometimes I was even able to answer the attendings' questions when the medical students couldn't.  (What do we want to monitor with linezolid?  Weekly CBC!)  Rounds was also my opportunity to make recommendations, though because of the fact that these patients tended to be less complicated than, say, my BMT patients last month, and because the medical students and interns were all working to develop their own autonomy, I feel like the generalist pharmacist wasn't as valued/utilized as the specialists pharmacists are during rounds.  Nonetheless, the team DID turn to me with questions from time to time, and I was also able to recommend a few therapeutic interventions of my own. :D

1100-1500 - review patients, do med recs/med histories, do medication teaching, review TPN orders, work on projects, eat lunch

Remember how I said generalists do everything?  Our afternoons were left open for completing the myriad tasks that generalists are responsible for.  We'd review our patients again with our preceptor after rounds to let her know if there were any significant updates, and then we were free to complete medication histories and medication reconciliations for all the patients who had been newly admitted to the floors.  For patients being discharged with new prescriptions for Diastat (diazepam rectal gel for seizure emergencies), EpiPens, or enoxaparin, my classmate and I were available to review proper medication administration technique with parents and families.  We were also tasked with reviewing total parenteral nutrition (TPN) orders to make sure that all changes made to the TPN composition were appropriate based on that morning's labs, and that the changes made were appropriate for each patient's age and weight.  In addition to these patient care activities, we had a handful of projects to complete during our five week rotation block.  These included three informal topic discussions (I presented on perinatal HIV, preeclampsia/eclampsia, and pediatric acetaminophen toxicity), a journal club on a randomized controlled trial of aerosolized versus subcutaneous injection measles vaccine, and a formal patient case presentation on Kawasaki's disease.

1500-1600 - attend topic discussions, journal clubs, and case presentations

The last hour of the day was often devoted to topic discussions led by various pharmacy staff.  Topics included an introduction to pediatric pharmacy, how to properly conduct a medication reconciliation, pediatric emergency services, a pharmacokinetics review, how to verify TPNs, and a discussion of lines and tubes.  But our most fun (and most disgusting) afternoon activity by far was the infamous TASTE TEST.

Many pediatric patients are not able to swallow pills and thus are prescribed liquid medication formulations.  To gain a better understanding of what we're expecting our patients to endure when we recommend a liquid formulation, we participated in a taste test of over twenty different liquid medications.  Armed with bottles of pop and chocolate sauce to cleanse our palates in between each medication, we were given a drop or two of commonly prescribed pediatric drugs (everything from azithromycin to Zofran) on a plastic spoon to sample.  The results ranged from legitimately delicious (amoxicillin) to horrifyingly vile (metronidazole).  Knowing how these medications taste gave me a much greater appreciation of why it can be so difficult for parents to get children to take their medicine.  As a pharmacist, it's easy to say "take 15 mL twice a day" and to stress the importance of completing a full course of therapy, but if a medicine has a completely intolerable taste the kid isn't going to take it no matter how much ice cream she chases it with.  In fact, the day after the taste test, my attending prescribed Bactrim rather than clindamycin for a six month old patient because (aside from being less likely to cause C. diff) Bactrim is MUCH more palatable.  Bactrim tastes like medicinal Kool Aid.  Clinda tastes like sadness.  This is the kind of practical knowledge you can only gain from being out on the front lines, and it’s such a refreshing change after three years of textbooks and lectures.

note sheet and snacks from the liquid medications taste test

Interestingly, three years ago I completed my first P1/P4 shadowing experience while my P4 was on this exact rotation.  In my post-shadowing write up, I said, "I feel connected to the pediatric patient population, but I worry that I lack the emotional fortitude to work within this specialty."  For the most part, this rotation has not been as emotionally demanding as I was expecting it to be.  Most of the kids on a general service are not too sick - not sick enough to be in the PICU, at least.  We also don't see hematology/oncology patients.  In short, most of our kids aren't dying.  That said, I still saw some difficult cases this month, the most striking of which was a seven week old baby boy who was admitted for "non-accidental trauma" (e.g. child abuse).  His x-rays showed more than twenty fractures in various states of healing.  While it was hard to know that such a cute little guy had had such a rough start, it was incredibly rewarding to be a member of the team that was ensuring he would be safe and responsibly cared for in the future.  In fact, I enjoyed working with the kiddos so much that I've added pediatric rotations and PGY2 offerings in pediatrics to my PGY1 residency search list.

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 Art of Pimping

Posted by Unknown at Sunday, July 19, 2015

What is ambulatory care like in Ann Arbor?

My first rotation started off in your local doctor’s office with nurse practitioners and physician assistants called ambulatory care pharmacy. Here pharmacy acts as a consult service for the physicians. Since my preceptor, Dr. Anne Yoo, specializes in chronic conditions of diabetes mellitus, hypertension, and hyperlipidemia, our pharmacy service was consulted when patients has uncontrolled diabetes (Hemoglobin A1C >9%), uncontrolled blood pressure (BP>140/90 for diabetic and chronic kidney disease patients or BP >150/90 for adults over the age of 60 years old without diabetes or chronic kidney disease). Hyperlipidemia are usually accompanied in patients with diabetes or hypertension. Additionally, in recent year, the guidelines have changed and there is no longer a goal target range for lipoproteins (i.e. LDL, HDL).

Ambulatory pharmacist have full autonomy under a specific collaborative practice agreement with the physicians in the office. With regards to our specific practice agreement, we can start, discontinue, or adjust dosages of patient’s diabetic, hypertensive, or hyperlipidemia medications and order any relevant labs. Additionally, there is a new program that was recently started called comprehensive medication review, where patients are recruited if they have 5 or more chronic medications. This service allows patients to meet with clinical pharmacist one-on-one to go over their medications, safety concerns, appropriate indications for each medications, and/or cost issues. The main aim is to catch any medications errors, duplication in therapy, and/or address any concerns the patients had. Additionally, it increases awareness to the broad service pharmacy can provide to the public and to the clinic.

What is the learning curve on this rotation?

As my first one, I had a lot to learn. Our classes prepare us for majority of the real life as a P4, specifically our P1 year communication class, our P2 year community IPPE, and P3 year chronic diseases management course. The biggest gap I had to make up was my ability to manage time and stay efficient. First hill I had to overcome was my data collection skills. Our University of Michigan system is fortunate to have an electronic medical record synch with inpatient and outpatient setting, allowing us to easily access past documentations and lab results. But it was challenging for me to quickly seek out pertinent information. Second hill goes hand-in-hand with my first, creating your own monitoring form. You will have practice during P3 disease management class, but the key is to tailor it specifically to our clinic’s need and present to your preceptor the most relevant information. For instance, if we are only have 15 minutes to see this patient for his or her blood pressure management, it is important to present on factors that may increase blood pressure. Your own monitoring form will prevent you from missing any relevant information and help you build a foundation within your own mind crucial labs or information to look out for when treating each condition. Overall, this rotation should be a refresher for your chronic diseases, but it should push you to perfect your time management skills and efficiently delivering patient presentations.

What makes this rotation difficult?

There are two main reasons. First, patient work load gradually increases over the course of 5 weeks. It would go up from 4 patients ---> 6 ---> 8-10 ---> 16-18. Typical full day involves 17-18 patients. Work for each patient involves initial work-up, patient specific questions/concerns, and post- note writing. Initial work-up is when you collect pertinent data about the past medical history of patient, current medications and dosing, and labs for your patient presentation to your preceptor. Patient specific questions is researching about a concern a patient may have brought up during the last visit that needs to be addressed during this one. This could range from herbals supplements to alternative drug therapy. Finally, post-note writing is exactly what it sounds, the note you write documenting the recommendations made at the visit.  Second, the art of pimping. This is a phrase used by Dr. Yoo when she fires off questions. Questions usually involve what evidence was used in your recommendation, what are the common side effects of a medication, what is your plan B and plan C if plan A does not work, what are the trends on this lab result etc. I struggled each time I received pimping; however, I felt those were the times I learned the most and recall it quickly at a later time.

Final thoughts?

This rotation is highly recommended for those that wish to pursue more direct patient communication and have a passion for preventive care. Even though you will become the treatment expert, majority of the time will be spent on you coaching your patient through their chronic conditions and being their support and encouragement. I enjoyed this rotation a lot as it made me realize to always look up the evidence that supports each recommendation and not rely on the words of your preceptor. It was a mistake I made which probably left a weak impression on the patient. So don’t shy away from these pimping questions when put to the test. Be glad you are getting pimped now rather than when you become a pharmacist.