From Clinical Pharmacy Generalist to HIV Community Specialist

Posted by Rachel Lebovic at Wednesday, August 28, 2013

Rotation 1: Clinical Pharmacy Generalist

                  Entering the hospital for the first day of P4 rotations was energizing. I have walked through the University of Michigan hospital’s doors countless times as an undergraduate volunteer and P1-P3 student for shadow experiences and IPPEs, but this time was different. I knew that I would be playing an important role in caring for patients. No more watching other practitioners, this time it was my turn. Plus, I knew that I would be returning every day for five weeks instead of my previous once weekly routine.

After orientation the first day I was asked to work up eight patients. It took me several hours. I was motivated and tried to complete a thorough work-up for each patient. It was extremely rewarding when I was able to see these patients on rounds with the team the next morning. My preceptor joined me on rounds for the first few days, then I progressed to rounding by myself. Over time, I began to feel more comfortable and increased my patient load from eight patients to as many as 16.

Throughout most of the rotation my schedule usually involved arriving to the student computers in the basement pharmacy by 6:30am, working up the patients on my service until 7:40am, running upstairs to the fifth floor pharmacy to discuss any recommendations I wanted to make while on rounds, then meeting the healthcare team for rounds at 8am. Rounds lasted anywhere from 1.5-3 hours depending on the number of patients and the complexity of the cases. Then, I would return to the fifth floor pharmacy and discuss each patient with my preceptor in more detail. If there was more time, I would then work up patients on one of the non-rounding services (an attending only), discuss those patients with my preceptor, then discuss my recommendations with the attending from 1:30-2pm. Other afternoon activities included counseling any patient on my service who was on a blood thinner and looking up any patient-specific questions.

In my opinion, having the clinical pharmacy generalist rotation for block one was excellent scheduling. This rotation was a great review of pharmacokinetics and dosing for antibiotics including vancomycin and aminoglycosides, and I reviewed/learned a lot about several different anticoagulants. Furthermore, this rotation was a great balance of boosting my confidence and reminding me that there will always be more to learn.

Rotation 2: HIV/AIDS Community Pharmacy

                  Fortunate to have a great internship experience in Henry Ford Health System’s outpatient pharmacies, I found myself looking for something different for my P4 community rotation. I definitely found that “something different” with my HIV/AIDS community pharmacy rotation in Chicago! Considering we only had about three lectures on HIV in the P1-P3 curriculum, I had a lot to learn to be able to optimally treat patients with HIV. To prepare for the first day, Caitlin (the other U of M P4 on rotation with me) and I were told to learn all of the brand names, generic names, and abbreviations for the HIV medications currently on the market. It seemed like just memorizing the drug names was a lot to learn at the time, but little did we know that we would understand and apply most of the 240 pages of HIV treatment guidelines over the course of the next five weeks.

Most of the time we were in a miniature Walgreens pharmacy inside the Howard Brown Health Center on the north side of Chicago. This health center is focused on treating lesbian, gay, bisexual, transgender, and queer patients. Additionally, two afternoons per week we were in a multidisciplinary HIV primary care clinic at Mercy Hospital on the south side of Chicago.

A typical day in the Walgreens pharmacy consisted of:

1.     New to therapy calls – calling patients who recently picked up a new medication to see how it was going

2.     ADAP (AIDS Drug Assistance Program) calls – contacting patients whose HIV medications are shipped from a CVS-Caremark specialty pharmacy in Pennsylvania to let them know their medications arrived

3.     Typing, filling, and verifying prescriptions (with the pharmacist’s oversight, of course), along with patient counseling at the pick-up window

4.     “The Queue” – the list of patients whose HIV medications are due to be refilled or patients who are nonadherent to their HIV therapy. We filled these patients’ HIV medications, accessed their HIV regimens for appropriateness, and contacted patients to ask if they wanted their medications delivered to their home

5.     Discussions with our preceptor, Mr. Halbur RPh (Drew) – Drew would often say something to the effect of “let’s discuss nucs” or “tomorrow we’re discussing child pugh scoring.” What this really meant was review everything we knew about anything related to the subject and be prepared to discuss it in great detail! While preparing for these discussions was often a lot of work, they were a tremendous tool for learning about the HIV medications (side effects, drug interactions, patient counseling, etc.) and reviewing other topics.

A typical clinic day at Mercy Hospital consisted mostly of performing readiness counseling and adherence counseling with patients. Readiness counseling sessions are used to explore if a patient wants to start taking HIV medications. This is important because patients who do not take their medications reliably are subject to medication resistance, and their treatment options can become incredibly limited. Adherence counseling sessions try to determine the barriers causing patients to miss doses of their medications and help them figure out strategies to overcome those barriers. Often, we would set up pillboxes for patients to aid them in adhering to their medication regimens. Although more rare, one of my favorite types of counseling sessions was initiation counseling during which we would discuss the four first-line HIV regimens with a patient, discuss the patient’s lifestyle, disease state, comorbid conditions, and other medications, then work with the patient to determine which of the four regimens would be best for the patient to start.

Other projects we worked on during this rotation included:

1.     Teaching a transgender patient how to administer his own intramuscular testosterone injections

2.     Writing a newsletter article for the Howard Brown Health Center

3.     Giving a presentation titled “HIV 101” to the new PsyD (Doctor of Psychology) externs at Mercy Hospital

Even though this blog is mostly about my rotation experience, I have to mention that exploring Chicago with Caitlin was definitely an added bonus on this rotation! In the free time we scrounged up, we managed to check out some local eateries, go the Art Institute, hang out with Sue the T-rex at the Field Museum, and see lots of fun critters and creatures at the Lincoln Park Zoo (which is free, by the way).

Overall, my experience in Chicago was a whirlwind. I’m happy to say that I learned a TON about HIV, enjoyed working with unique patient populations at both clinics, and had fun exploring Chicago in the process!

Not "Just" Community Pharmacy Rotation at Sam’s Club

Posted by Unknown at Friday, August 23, 2013

May 20, 2013. To some people it may have just been a normal Monday, but to me and my College of Pharmacy classmates, it was a day of transition as we went from mostly classroom-bound P3 students to almost-clinician P4s. They tell you when you start pharmacy school that “it’s going to fly by” and “before you know it, you’ll be all done,” but until you’re sitting in your car in a parking lot, staring at the entrance to your first P4 rotation site and hoping you’ve learned (or should I say, retained) enough throughout the past three years, it really doesn’t hit you. They were right – time FLIES!

Community pharmacy is generally a realm of pharmacy that most people are familiar with, as pharmacists who work in the community are the most accessible to the general population. I admittedly wasn’t the most excited to have to complete the community rotation as a requirement during P4 year, as I’d had several years of practice as a pharmacy technician at a couple of different community pharmacies as well as during my IPPE in P2 year. Luckily, this experience at Sam’s Club with my awesome preceptor, Dr. Sujal Patel, was definitely not what I was expecting! Walking through the doors to the giant warehouse and into the small but cozy pharmacy in the back of the store, I immediately felt welcomed by the staff. It wasn’t long before I was learning the system, filling the prescriptions, and putting my therapeutic knowledge to use through patient counseling.

My experience on this rotation was not the normal community pharmacy experience, however. Since Sam’s Club as a company was just starting the immunization program in their pharmacies, I had the opportunity to educate the staff not only in our pharmacy, but in several other pharmacies across the state during the roll-out of this program. I put together a binder of resources on the administration of vaccines and helped develop the protocol for their dispensing. This allowed me to not only brush up on my immunization knowledge, but to further develop my communication skills with other health care providers. Once our program went live, I was able to educate patients about their vaccinations too! This was probably one of my favorite parts of this rotation.

Another memorable aspect of this rotation was the health fair I was able to participate in. When I first started at Sam’s Club, all I knew about the health fair was that it was on a Saturday, which meant I’d be missing out on half of my weekend! Despite some initial complaints to my classmates about having to go in on a Saturday, I ended up having a great experience! June’s health fair focused on men’s health, and incorporated PSA testing, TSH testing, BMI evaluations as well as blood pressure assessments. The major niche for me in this setting was to interpret and counsel patients on their blood pressure screens and BMI calculations. I was surprised how many patients really wanted to talk to me about their screenings, and also about how much advice I was able to communicate about lifestyle changes, advocating for a healthy diet and exercise. I even had a couple urgent situations with patients that had less than optimal blood pressure screens, so that part kept me on my toes! Luckily, everyone left the health fair feeling okay and those who needed it were counseled to follow up with their physicians as soon as possible. You never know, I may have indirectly saved some lives that day!

All in all I really enjoyed the rotation and had a great time getting to know my preceptor and the technicians. Besides all the great clinical knowledge I gained, I also learned not to judge a rotation by its classified requirement! I’m excited to start rotation 2 and see what it has in store!

End of Rotation 1/Start of Rotation 2

Posted by Unknown at Thursday, August 22, 2013

06/24/2013

Today was the first day of the second rotation. But first to close-out rotation #1....

Health System/Hospital aka "Institutional" will be very hard to beat in the "truly enjoyable experience" category. I must really thank Kathy Kinsey, RPh and Cathy Poirier, RPh for setting up such a great experience. The days were split into halves with the 6th Floor Pharmacy serving as a "home base". I learned so much about the operations of the pharmacy department at U of M and the dispensing tasks involved in providing medications for a 900 bed hospital. The pharmacists and technicians I met were so helpful and truly great people to be around. The OR pharmacy brings to mind a carefully and obsessively controlled drive-thru window at a fast food restaurant.  The surgery narcotic bags were being handed out to each surgeon/resident/CRNA and the pharmacy must account for every mL and mg of each and every controlled substance. There are 28 or 29 ORs at the University Hospital and I think we handed out almost 60 "general narcotic kits" on the mornings I was there. It was a great time and a good experience getting familiar with all the medications that aren't commonly seen anywhere else. There is nothing like someone approaching the window for some "iso" or "sevo".

I didn’t just learn about pharmacy on this rotation though, I had the opportunity to spend several hours shadowing a nurse and a med tech in the ICU.  I also met with a dietitian and learned about their day-to-day activities (did you know they sometimes manage 80 patients at a time?!  That’s a lot of TPN and dietary considerations!) One day I spent a couple hours with a social worker learning what they do and the different areas patients go for therapy while inpatient.  When would I have ever gotten these great experiences if it weren’t for this rotation?? 

I'll miss the Health System/Hospital rotation because it was a perfect balance of learning, fun, and companionship but I'm looking forward to the remainder of rotation 2.

Today was day 1 of Rotation #2. Manchester Pharmacy is a Hometown Pharmacy location and is the longest operating pharmacy in Michigan. It opened in the early-mid 1800’s. So far the pharmacist, Dr. Demski and the techs, Kelly, Rose and Melissa, have been very friendly and willing to teach me everything I'm interested in. I think this will be another great experience for me! I'll write more about it once I'm into the groove a little bit more. It is nice to start at 9 am vs. 6 or 7 am, although I don’t reach home until 7pm.

P4 Year Begins!

Posted by Unknown at Wednesday, August 21, 2013

05/23/2013

Orientation was a fun time to spend with friends. After 3 solid years of daily togetherness, having 2 weeks without seeing everyone seemed weird. It was nice to reunite. We were given lots of helpful advice and expectations for seminar were shared.  We also went through some therapeutic reviews like infectious diseases/the bug drug list and anticoagulation modules. It was actually really nice to go over some of the therapeutic topics again right before rotation actually started.

Rotation 1 week 1 is just about over. Today was day 4 of P4 (hahaha).  So far I'm loving it! The days are split into halves and each morning I'm in different locations with assigned tasks then in the afternoons I'm in the 6th floor pharmacy. Here's what I've done this week so far:

• re-stocked paramedic boxes and code boxes (and dealt with all the shortages involved....)
• attended some work flow meetings and drug shortages meetings
• mastered the pneumatic tube system (witnessed my first broken glass vial in the tube)
• learned how products are checked by the RPh (everyone has their own style)
• drawn up oral solutions aka the oral batch (TOO MANY!!! AHHHHH)
• verified orders in WORx (with lots of help, of course)
• triaged the phone calls in 6th floor pharmacy (where all 6 lines COULD actually be ringing at the same time!)

 I found that I like the fast-paced nature/constant action of 6^th floor pharmacy - although as a pharmacist this would be very hard to deal with while ensuring 100% accuracy. Good thing they are professionals and they have a good team to work with!

Out-of-Here!

Posted by Tony Lin at Friday, April 26, 2013

September 8, 2009 seems like yesterday. In fact, this “overnight” event consists of 1,328 days of laughters, cramming, caffeinated beverages, friendship, and hard work. Many of us have grown while some have chosen to hide from reality for just a tad longer—either way, becoming a PharmD is imminent and hitting the stage at Rackham this Saturday will be bittersweet.

In case you are not familiar with the Class of 2013, here are some unofficial records that were set:

-         Highest occupancy for the first 5 rows in the classroom

-         Most married/engaged individuals

-         Most pledge amount at over $106k

-         Highest exam averages

-         Highest Rho Chi cutoff

-         Highest out-of-state students percentage

As I have been sitting here next to David (aka Dr. Plumley) and Anna (aka A+) for the past 5 weeks at St. Joe’s Ann Arbor, I realized how much I’m going to miss all of my classmates. Judging from all the Facebook activities, I don’t think even infliximab can treat our senioritis. It’s been a long time coming.

I will be honest—the past 4 years have not been the best years for me. However, it is the challenging times that will make the next 40 years even more worthwhile. I have met some of the best people in the MACE (Most Amazing Class Ever) and will be sad but happy (definitely more happy) to see everyone going their separate ways.

Enjoy the moment, live happily. Because when we take off “candidate” in our signature, the world will be ours.

To quote President Mary Sue Coleman: 

      For today, goodbye. For tomorrow, good luck. Forever, go blue!

Rapid-Fire Reviews...

Posted by Unknown at Thursday, April 25, 2013

As a result of a long-winded bout of writer’s block, I’m in debt several blogs! Here’s some rapid-fire reviews of my latest rotations.

Ambulatory Care at Briarwood Medical Group with Dr. Marcelino

After rolling off 3 clinical rotations at UMHS, my ambulatory care rotation was a huge shift in pace. At the hospital, my norm became working up patients the night before, catching up on any new information in the morning, and picking up new patients during the day. Often, I’d follow a patient for several days, and then they’d be gone – for good. Conversely, in an ambulatory care clinic, you know exactly which patients are on your schedule days or even weeks ahead of time. While patient volume was often high, reaching 15 patients a day at times, knowing schedules ahead of time allowed me to pace myself with work-ups. The thing I liked most about this rotation compared to some of my other ones was the rapport I got to build with the patients. Follow-up visits are often scheduled at two-week intervals, which mean that I got to follow a patient’s progress with controlling their diabetes and hypertension over 2-3 visits. The staff at BMG was phenomenal, and it is clear taht the physician-pharmacist relationship established in this practice is one of mutual respect and utility. Dr. Marcelino’s patients are very grateful for her involvement in their care. She has high standards for her P4 students, and it’s a great rotation for anyone looking for a good challenge. 

Drug Information (Lexi-Comp) with Dr. Streetman

This was an untraditional rotation if there ever was one! My weekly routine involved writing from home, and meeting with Dr. Streetman and my co-colleague twice a week to discuss progress on various projects. These projects included anything from researching and answering questions that Lexi-Comp received about drug interactions, updating old interaction monographs, or drafting new monographs from scratch for interactions that were never entered into the database. I had 3-5 projects “open” at any time. Some of them were longer-term projects that I chipped away at all rotation, and others were time-sensitive assignments that required fairly quick turnover because someone was waiting for an answer from us at the other end! The most satisfying aspect of this rotation was having my direct words published on a reputable database. My work on this rotation is forever immortalized! Until another P4 comes and updates it with hot-off-the-press research years from now, that is.

Institutional

Last but not least was my experience down in UMHS’s very own B2 pharmacy. I spent a week each at Mott’s, the central B2 pharmacy, sterile lab, IDS and had an admin week in which we attended various meetings and prepared a CE presentation which my classmates and I presented to the pharmacy technicians in our final week. Throughout the rotation I found myself thinking, ‘Wow, I wish I had had this rotation first! I certainly would have appreciated having faces to go with all the people who are working hard to prepare the medications I was recommending on my various rotations at UMHS. It was a nice full-circle to finally be able to see some of the medications I had never physically seen. I never knew that tigecycline was bright yellow! Kathy Kinsey and all of the preceptors involved with the rotation did a great job of making sure we got a varied experience at all of our sites. It certainly was a great rotation to end with!

Ambulatory Oncology -- A Different Perspective

Posted by Anna at Thursday, April 25, 2013

Before drafting this blog entry, I checked out Maria's post regarding this rotation. I was surprised to see how some aspects of the rotation stayed consistent with my experience while others were completely different! It does show how a given rotation will evolve as each student moves through it, as well as how the time of year may affect the tasks performed. Due to these differences, I’ve decided to share my experience, which is best broken down into two main categories: clinic days and project days.

Multidisciplinary Clinic Day:
7:30am: Present to specialty cancer clinic. Make a copy of the patient schedule for the day, work-up patients based on existing medications and disease states and determine any specific questions I want to make sure to touch on when I chat with them.
8:00-11am: Verify medication histories, answer patient medication-related questions, and make any recommendations. Document the information in the patient electronic medical record.
Afternoon: Repeat above if afternoon clinic day, otherwise work on independent projects.

The pharmacy role in the clinic flow was well established by the time my rotation started, and everyone was pretty used to seeing a student involved. I had the opportunity to chat with head and neck cancer (Monday AM), lung cancer (Tuesday AM), gastrointestinal cancer (Tuesday PM), and breast cancer (Friday AM) patients to get a thorough medication history and assess for any medication-related issues or concerns.

Project Day:
When not in clinic I would work on independent projects. This included preparing for topic discussion (five total), updating the febrile/afebrile neutropenia guidelines for the institution, and answering drug information questions presented to my preceptor. Additionally, I had the chance to shadow the Chaplain (provides spiritual care to oncology patients) and chat with the genetic counselor on staff, which provided a better understanding of the comprehensive care a cancer patient receives.

Pros:

• Beautiful hospital with a welcoming environment (and free parking ON SITE!!!)
• Good review of major cancer types and chemotherapy used
• Exposure to counseling on alternative therapy options
• Opportunities to interact with patients and support them in their fight against cancer
• A lot of autonomy and independence

Cons:

• Only a few days of clinic per week with variable volume—this meant there weren't many interventions made in a given day
• Not traditional ambulatory practice focusing on chronic disease states or delegated prescribing rights for the pharmacist
• Patients do not have appointments with the pharmacist, which can make finding time to speak with patients challenging
• Little one-on-one time with preceptor (maybe pro depending on the person!)
• Senioritis (I was very aware that this was my last rotation... this presents its own set of challenges)

Coming from someone with little interest in pursuing an ambulatory care position, I specifically chose an oncology-focused rotation for something a little more unique in the ambulatory setting. Additionally, my plan to pursue a residency post-graduation ensured I would gain exposure to chronic disease-focused ambulatory care if I so desired. However, I would say that if you are seriously considering a more traditional ambulatory care practice setting or a setting with delegated prescribing rights to the pharmacist this is not the rotation for you. Additionally, if you are the type who needs a lot of one-on-one attention, you may prefer a different rotation. Although my preceptor was always available by phone, email, page, or stopping by her office, she was much more hands off than other preceptors I had in the past. Case in point: my first day of clinic (day 2 of rotation) I was shown to the clinic, logged into the system, and then left to my own devices. I was comfortable with that, but it meant I had to be open to asking for help from the nurses and other clinic staff (all AWESOME, by the way). Overall, it was a nice way to end my final year. Due to the ample amount of project time, I only rarely had to bring work home with me and for the most part could enjoy my last few weeks as a P4 student.

This ends my P4 blogging adventure! I appreciated having the space to write about my rotation experiences, and I hope many others continue to take advantage of this opportunity. Good luck to the next P4 bloggers as you start your rotations in a few short weeks, and a HUGE congratulations to the PharmD Class of 2013!!