Thursday, December 17, 2009

Keep a cool head, and take it a day at time.

Posted by Jeffrey Huang at Thursday, December 17, 2009

I would have to agree with Shannon – November was an absolutely hectic, stressful, but very rewarding month for me. And though I was really pleased with how the month turned out, it was also the first time I have ever seen bags and dark circles under my eyes.

Let’s start off with the rotation: Detroit Medical Center Receiving Hospital – Inpatient Internal Medicine. For those pharmacy classmates who are not quite sure what internal medicine is, just combine all of P2 and P3 therapeutic notes, and that is basically what you will be responsible for the month. With the rotation also being my first inpatient rotation, I was definitely tested each day and stretched to my capabilities.

At first it was overwhelming. With 0800 morning rounds with the medical team, it required waking up around 0500 to 0530 in order to have enough time to drive to the hospital and work-up our patients. After rounds, Justin Julian and I would normally meet with our preceptor to discuss our patients, visit patients on the other team, attend grand rounds, or present a topic discussion. It was pretty normal to leave the hospital around 1700 to 1800 on some days.

What I found most rewarding was the progression I saw in my capabilities. It takes a while to get used to a new computer system, collect and assimilate data efficiently, and finally be able to present the data or really apply it in new situations. And the patients we saw at DMC ranged from simple asthma exacerbation, to a patient with multiple end-stage chronic diseases, no insurance, drug abuser, and homeless, all of which one has to take into account for their treatment and discharge medications.

Dr. Terry Dunn was a very knowledgeable preceptor who challenged us each day but also provided us the tools to progress and learn from our mistakes. I appreciated the time she spent with us as well as her flexibility when it came to scheduling our PharmD seminar practice times – that’s the other half of the very hectic November rotation.

Both Justin and I presented our PharmD seminars on the last day of the rotation. Though it was really difficult to balance the priorities between everyday rotation duties with the PharmD seminar, I was really happy with the final outcome of the month. By the end of the rotation, I felt comfortable with my daily tasks at the hospital, and I was also really pleased with the product of my months with the PharmD seminar. I guess when it seems you have too much on your plate, the best way approach is to let your supervisors know your exact situation, try to reprioritize certain duties, keep a cool head, and just take it a day at a time. It's funny how everything seems to work out in the end.

Wednesday, December 2, 2009

Why are you asking me stupid questions?

Posted by Shannon Hough at Wednesday, December 02, 2009

November really went by in a whirl! I finished up my rotation at the Ann Arbor VA the week before Thanksgiving. During the November rotation, I worked in a number of clinics. I really put my drug interaction knowledge to the test working with anti-coagulation patients on warfarin. I got to see patients on my own, write chart notes and educate patients on the proper use of injectable rheumatoid arthritis drugs. During my last day in the rheumatoid arthritis clinic, I provided teaching to three patients. I can say that the third patient certainly got the most organized information with the least amount of "ummm's". It was great to develop a method that worked for me to provide the information to the patients. My preceptor had given me a great model with which to start, and I could organize the information as I needed. And wouldn't you know it: I knew the answers to the questions the patients asked...

I had that revelation this month that "Umm, just a minute, let me get the pharmacist for you" is not a line that we'll be able to use very much longer. As interns, we are trained not to provide information without discussing it with our preceptor. As P4s, some of the questions we receive we HAVE discussed with our preceptors prior to the question, and we are able to confidently answer. It's a pretty great feeling when that happens. Kind of makes you feel like....a pharmacist?

I also had my first cantankerous patient in the anti-coagulation clinic. This older gentleman also had a cardiology appointment booked shortly after his anti-coag appointment, and our clinic was running behind by a few minutes. After I called him back from the waiting room and greeted him with a smile, he informed me that I had "Five seconds" for our visit. I kept smiling, but this was no joke.

As I started asking him the usual monitoring questions for patients prescribed warfarin, he became impatient. I quickly had to decide which questions were the most important for this patient -- who had a history of stable
international normalized ratio (INR) readings for two years -- and was therapeutic that day. (INR is an international system for reporting the results of blood clotting tests.) I was trying to accommodate the patient and his appointment schedule and provide good pharmaceutical care, but I was not quick enough!


Somehow, I was able to wrap up the interview, thanking the patient for the visit, and the importance of the visit and the questions, but a tiny part of me wanted to bop him on the nose! Earlier in November, I struggled with time management issues from the care-giver's perspective: how valuable clinic time is, how to be sure to see everyone, and how to provide good care as quickly and efficiently as possible. This time, I learned a companion lesson: How valuable the patient's time is.

Sunday, November 15, 2009

The Main Ingredient

Posted by Akin at Sunday, November 15, 2009

A Pharmacy Student Seminar course is a requirement of all fourth-year PharmD students. Each of us is assigned a topic related to pharmacy to present to our P-4 classmates. Alternately, we can choose to talk about our research project (the PharmD investigations project). A seminar adviser is assigned to each of us to provide guidance at every step of the way.The Seminar is an opportunity to help us build our communication skills and confidence. We learn how to thoroughly gather information from the literature and then assemble this information into a professional looking, 50-minute PowerPoint presentation. This is a skill many, if not all, of us will need in the future.

Out of my class, I’ve noticed that relatively few of us have a natural ability to speak in front of a large audience with utter fearlessness. In fact, many of us are deathly afraid of public speaking. I think I am somewhere in the middle-to-comfortable range of the spectrum. It’s just the five minutes right before, and the first five minutes into, any presentation that tend to be the most nerve-racking for me. The fact that I’ve known my fellow classmates for over three years doesn’t make it any easier.

The situation was no different at 1:05 p.m.November 6, approximately five minutes before starting my PharmD project presentation. My adviser, Dr. Barry Bleske, must have noticed my anxiety because he took this opportunity to tease me. After the course coordinator, Dr. Sally Guthrie, told me: “You know more about this topic than anyone in the crowd, so don’t be worried;" Dr. Bleske added: "Actually there are at least seven more students [my PharmD project partners] in the crowd who know just as much as you do!" (The implication: So you'd better be good.)

Dr. Bleske had been emphasizing simplicity during our practice sessions and wanted to make sure I had overcome my natural tendency to be verbose. This was in the back of my mind throughout the presentation and when I first began: “Welcome to my presentation, I will be talking about my senior project… uhhhh, [I mean] my PharmD project.” Shoot, I thought to myself, I already messed up. But I continued without too many other blunders and 50 minutes came and went before I knew it.

Overall, I think I was successful in communicating the most important points to the audience, sticking to the main topic, if you will. The presentation was also video recorded so I was able to see my mannerisms -- such as my propensity to sway back and forth as I talk. I will certainly improve on my weaknesses and strengths and I’ll have a chance to do this most immediately at the ASHP Clinical Midyear Meeting where five of us will be presenting the PharmD project in the form of a poster presentation. I think this will go smoothly as long as I have someone else talk for the first five minutes!

Friday, November 13, 2009

Lessons from my community pharmacy rotation

Posted by Kendra Yum at Friday, November 13, 2009

It’s about developing customer relationships. When customers come into the pharmacy and address the pharmacist and technician on a first-name basis, you know the pharmacist is providing service that keeps customers coming back time after time. The community pharmacy that I now work at has many long-term loyal customers. The pharmacists and technicians are well acquainted with the customers, their families, and their personal stories. No wonder pharmacists continue to rank among the most trusted and accessible health care professionals!

OTC, OTC, OTC. If you have gazed upon the mind-boggling shelves of over-the-counter (OTC) products at a pharmacy, you may have experienced the challenges (or confusion) in finding the right OTC product. Often times, customers will come up to the counter with a question starting with: “What can I take for…?” Or “My 9 month- old son has a fever. Is there anything he can take?” Or “I started getting acid reflux (heartburn) at night. What can I take to alleviate the symptoms?” Or “My wife has a burn on her arm, what can she use to help take away the pain?” This opens up the opportunity for us to ask the patients to describe the symptoms (onset, frequency, trigger, etc.) and to determine whether the condition requires a doctor’s visit, OTC remedy, or non-pharmacological treatments. This rotation has been one of the best refresher course on the appropriate use of over-the-counter products!

The most expensive medications are those that are taken incorrectly… or not at all. Taking medications incorrectly can lead to harmful reactions; and skipping prescribed medications can lead to unnecessary disease progression and complications. I have found that something as simple as going over the directions for taking a new medication (show-and-tell) and explaining a few of the notable side effects is greatly appreciated by patients.

It's about being the patient's advocate. Not long ago, a young gentleman came into the community pharmacy with a Tamiflu prescription for his pregnant wife. He wasn’t sure if he should fill the Tamiflu prescription out of concern of possible side effect on the pregnancy and asked for the pharmacist’s advice. We carefully discussed with him about the pros and cons of taking Tamiflu. We informed him that Tamiflu has a pregnancy category C, but that pregnant women can get sicker than other people who get H1N1 flu. After our talk and a long conversation on the phone with his wife, he told us that felt much better about getting the prescription.

One of the overarching lessons I have learned at my community rotation is that pharmacists are uniquely positioned to provide patients with information on medication use. Our patients look to us to serve as their advocates. It is both a privilege and a responsibility. We are reminded each year during the Oath of a Pharmacist recitation in pharmacy school,
"I promise to devote myself to a lifetime of service to others through the profession of pharmacy… with the full realization of the responsibility with which I am entrusted by the public.”

Monday, November 2, 2009

From Inpatient to Outpatient

Posted by Shannon Hough at Monday, November 02, 2009

I've made the jump from inpatient care at Botsford General Hospital to working in an outpatient clinic area at the Ann Arbor VA. I spent my final weeks at Botsford working on a number of projects that are very representative of what a clinical pharmacist might do, outside of patient care.

One project I tackled was a drug utilization evaluation (DUE) for erythropoiesis-stimulating agents (ESAs). A DUE is a "system of ongoing, systematic, criteria-based drug evaluation that ensures the appropriate use of drugs"1. At Botsford, this entailed printing a daily report of all patients who had been prescribed an ESA, checking the paper medication administration record (MAR) to see if/when it had been administered, and checking a few laboratory parameters (hemoglobin, etc.). Health care institutions frequently conduct a DUE to investigate how a drug is being used to properly make decisions related to formulary considerations, outcomes and economics research, or to ensure that the institution is meeting current standards of care. While searching for numerous paper charts, MARs, and even patients can be tedious, the results are valuable to the institution.
My final project was to give a lecture to patients who had prior cardiac surgery. In the lecture, I gave a brief overview of each of the medication classes that the patients were likely to be using. The overview contained important safety information, expected side effects and specific instructions related to certain agents such as nitrates and warfarin. AND I SURVIVED! As a student and pharmacist intern, I felt very prepared to talk to other healthcare professionals regarding medication topics. However, I was pretty nervous to face a class of patients taking notes and asking questions. And would you believe I actually knew the answers to their questions too? A great way to end rotation 3.

I started my fourth rotation at the Ann Arbor VA last Monday
in ambulatory care. My preceptor and main clinic area is anti-coagulation, however I also attend geriatrics, primary care, and arthritis clinics. Most of the patients I have seen served in World War II. I had the opportunity to see a patient in clinic for a medication reconciliation appointment after he had confused his medication instructions.

Mr. G is 86 and on a fairly complex medication regimen with at least 9 drugs and 3 different medication administration times throughout the day. While reviewing his medications with him (and having to remove and rearrange many medications in his pillbox, and confiscate a number of expired medications), it became clear to me that he was very overwhelmed with his medication list, and was not able to understand the chart that the clinic provided to him. He jokingly told me that I could go ahead, but he wasn't going to understand how to read the chart
to fill his pillbox. At that moment, I was determined to help Mr. G, aside handing him a
chart he couldn't read and filling his pillbox correctly for a single week.
My first step was to put the medication list into his hands. I then asked him to read it to me. When he was having difficulty, I offered him a blank piece of paper, to cover up most of the chart and just read one drug at a time. This was helpful. Then, through a number of open-ended questions, I was able to understand that Mr. G knows when to take his medications by what they look like and what they are for. So it was important to list the indication for each drug on his chart. He also was not able to remember to take his medications at 3 different times, so I was able to change when he took certain medications so that he only had to take his medicines twice a day and not miss any doses. He also told me that it would be easier to read his medication list if the drugs were organized chronologically, with the morning doses listed first. By the end of the appointment, Mr. G was able to tell me when he took each of his drugs by name, reading off of the chart, and match them with the appropriate prescription bottle.
This whole encounter lasted about an hour, and Mr. G was a walk-in patient. Luckily, we had a low patient load that day and were able to spend the time with him. I have no doubt that pharmacists do not always have enough time to spend with their patients. I think that working in an ambulatory care clinic is a place where this can be especially trying. If a patient needs more time than they were scheduled for, what do I do? Spend the extra time with him and fall behind schedule, making later patients wait? Quickly update his medication sheet, throw away the expired medications and give him an encouraging pep-talk to get it together and stay on schedule? Hopefully there is a medium somewhere!

Friday, October 23, 2009

Beauty Is Only "Skin" Deep

Posted by Mary Liu at Friday, October 23, 2009

The term "beauty is only skin deep" is taken literally here at Kythera Biopharmaceuticals, Inc. in Calabasas, California. Throughout my 4 weeks here, I delved into the fascinating (not exaggerating) world of dermatologic drug products. I learned very quickly that the rules and regulations that apply to dermatologic products are quite different than those that apply to other medications.

My main project was to develop a formulation model that would not only be commercially viable, but also enhance the intellectual property (IP) of this product. I initially performed multiple literature searches, digging through articles to uncover clues and formulate educated hypotheses on a drug candidate Kythera is studying in disorders of pigmentation.

Formulation of a novel topical drug candidate, however, is no easy feat. Once I investigated possible formulation options, I realized that there is an entire set of related issues I had to address: IP, competition, manufacturing, pharmaceutics, and toxicology.

Thus, my wild adventure into the world of dermatologic products began...

The key question every dermatologic drug candidate needs to resolve prior to formulation development is: Can this drug molecule get into the skin? To answer this, two issues must be addressed: (1) size and (2) lipophilicity.

(1) 500 Daltons tends to be the upper limit of the size of a molecule that can penetrate through the stratum corneum. (A Dalton is a measure of molecular weight or mass equal to the mass of one hydrogen atom.) But that does not stop molecules like Protopic (Tacrolimus), which is over 800 Daltons, from being made into an ointment and applied directly to the skin. Recently, an article was published on topically applied cosmeceutical creams containing growth factors and cytokines. Growth factors range anywhere from 20 to 150 kDa (Kilodaltons), so how were they penetrating the skin? The answer may lie in the hair follicle, which has been studied for years by such experts as University of Michigan College of Pharmacy Pharmaceutics Professors Emeritus, Drs. Norm Weiner and Gordon Flynn. Their research, and that of other experts, studied how large molecules could penetrate the skin, and they discovered that transfollicular delivery, along with sebaceous glands, appeared to be most likely the route.

(2) A non-lipophilic drug molecule is not likely to penetrate through the stratum corneum layer of skin. (Lipophilic refers to the ability of a chemical compound to dissolve in fats, oils, lipids, and non-polar solvents such as hexane or toluene. Stratum corneum is the outermost layer of the epidermis.) During my research, I found that various penetration enhancers can be added to the drug vehicle as well as novel drug delivery systems to encapsulate or surround the drug, such as liposomal delivery and molecular umbrellas.

Getting the drug molecule into the skin is just the first hurdle. If we create a formulation that successfully penetrates the skin and reaches the target site of action, then we have to start considering the possibility and consequences of systemic absorption and active metabolites. Based on discussions with a toxicology consultant, preliminary ADME (absorption, penetration, metabolism, elimination) studies could answer these concerns as well as provide a clue to the length of our toxicology study program.

The current commercial landscape is also another issue that we have to consider. Who are our potential competitors? What competing products are already in the marketplace? And from these questions, IP questions will inevitably follow. If other products are already in the marketplace, how will ours be better? What can we do to obtain IP protection and exclusivity in the market?

The majority of my time at Kythera was devoted to piecing together the answers to these questions, as well as to develop potential formulation pathways based on my own research and discussions with various experts in the fields of toxicology, IP, formulation, and penetration/absorption.

I spent the balance of my time at Kythera speaking with various functional leaders of the company (in regulatory, marketing, operations, quality assurance, etc.) to obtain a better understanding of the daily and long term operations of a pharmaceutical company. One valuable concept that I learned was that all roles are interconnected. One decision cannot be made without affecting another department within the company. Kythera grasped this concept from the beginning, reflected in the interior design of their office: glass walls on which people jot ideas, as well as open doors, which welcome a free flow of communication between people.

And although beauty may be skin deep, there's nothing else about this industry that is. The dermatologic drug industry is an increasingly crowded and competitive field. I learned from Kythera, however, that if you are driven, business-savvy, highly knowledgeable about your field, and think outside-the-box, you have great potential to be successful in this industry. This rotation has certainly opened my eyes to the plethora of job opportunities for PharmDs in the pharmaceutical industry — and possibly, a career in drug development for me.

Wednesday, October 21, 2009

Pharma: Sanofi-Aventis with a Global Perspective

Posted by Jeffrey Huang at Wednesday, October 21, 2009

Fellowship or residency: this is the question I have been struggling with so far this P4 year. Both post-doc programs are motivating in different ways and both hit different areas of my academic curiosity. At the University of Michigan College of Pharmacy, we are groomed for a clinical path. We have excellent professors who specialize in different areas of clinical pharmacy and we have experiential training that exposes us to many of these different areas. The curriculum is mostly patient-case based, and we have the opportunity to choose almost half of our P4 rotations in diverse inpatient settings.

These are tough odds for any student thinking about a different path, but here is my train of thought: I hope for a career in pharmacy that goes beyond the counters of a pharmacy and the walls of a hospital. International influences have just fallen into place for me so far in the pharmacy program, including International Society of Pharmacoeconomics and Outcomes Research (ISPOR), International Pharmaceutical Students’ Federation (IPSF) and the newly established Center for Global Health (CGH). And from speaking to different professors and faculty, the route to a pharmacy career that spans international borders is through the pharmaceutical industry.

In industry, the path for a pharmacist can span medical to commercial, research to advocacy. Today, I spoke with a director in the Pharmaco-economics and Reimbursement Department at Sanofi-Aventis. She was originally from the UK, had lived in France for the past four years, and has just recently moved back to the US. She loved the fact that she could move abroad in industry and integrate cultural differences and viewpoints within her work. I also had dinner with a Michigan alumna, now a second-year Rutgers Fellow. She described the various international sites and vendors she works with in her firm's global clinical operations department, and the opportunities she has to travel to these sites to help meet their needs. She’s expanded her reach beyond the US borders, and the opportunities that lay ahead for her are really exciting.

I remember my mother telling me the Chinese idiom 井底之蛙 (Frog in the Well) in sixth grade when she dropped the news that we were leaving Seattle to move to Taiwan. It is a story of a frog in a well whose only vision of the world is the circle of sky it sees from the bottom of the well. It is not until the frog finds the courage to climb out of the well that he realizes how vast the world is, and how much there is to discover outside of his small circle of comfort.

My advice to my classmates, other students at the College, and prospective PharmD students is to explore things outside of your comfort zone and keep your options open. Throw yourself into the unfamiliar and the unknown. I guarantee you will discover things about yourself that you would never have otherwise known. There are so many options for pharmacists beyond institutional and community settings, and even in these settings you can create a unique niche that fits your own aspirations and motivations.

I am quite certain now as I finish my last few days at Sanofi-Aventis that I will be pursuing a path in the pharmaceutical industry through the Rutgers Fellowship. I can easily see myself living abroad and practicing pharmacy on a global scale, and I hope my experience with ISPOR, IPSF, and the CGH will help create opportunities to explore this area.

Sunday, October 18, 2009

Connections of past reflections with new perspectives

Posted by Akin at Sunday, October 18, 2009

My current institutional pharmacy rotation at the Karmanos Cancer Center in Detroit has been meaningful. I was able to do a clinical inpatient rotation in August that was also in cancer, so this present rotation provides reinforcement of some of the major cancer topics that I have learned before, but now from the perspective of the dispensing side.

During my clinical rotation, I was able to work-up patients who were taking chemotherapy regimens and got to see how patients responded to the medication and how they generally appeared and felt during treatment. From this new perspective at Karmanos, I get to see the entire behind-the-scenes process starting from after an order is first written by a physician all the way to the finished medication being sent to either the outpatient infusion clinic or to the inpatient floors. The process involves prudent verification including triple and quadruple checks of dosing calculations, proper documentation, and preparation of drugs in the IV room.

I was given the chance to go under the hood and prepare some IV chemo myself. I was trained to use an interesting device called a Phaseal to prevent accidental spilling of the hazardous chemo. One of the days when I was in the IV room, a chemo vial was accidentally dropped and spilled on the floor. After the chemo spill was cleaned, a demarcated line on the laminated floor remained from where the medication had been even though the medication was cleaned within a few minutes of the spill. These agents are pretty powerful! I certainly wouldn’t want to get any on my skin.

If I could do my clinical cancer rotation again, knowing what I now know from this current institutional rotation, I think I would approach things a little differently. For example, seeing firsthand the power of some of the chemo, I think I would be a little more understanding of some of the patients who looked pretty miserable on the days that they were getting these agents. Another example is with dose recommendations. Now knowing how difficult it is for the techs to measure between the graduated lines on a syringe, I would probably be more likely to round doses to nice whole numbers.

I think I understand why pharmacy residents are required to staff on weekends at the hospital. It helps to understand the behind-the-scenes verification process when on rounding teams. Your contribution to the team can put into consideration things such as IV preparation, inventory, and Rx order travel time that physicians are unaware of. This rotation allows me to integrate past familiarity from previous rotations with current experiences. I’m enhancing my learning and fortifying knowledge so that I can remember key concepts for years to come.

Friday, October 16, 2009

Exploring a Different Side of Pharmacy

Posted by Kendra Yum at Friday, October 16, 2009

Last Friday, I listened to two physicians speak to pharmacists about reinventing health care in America. Their names? Howard Dean and Bill Frist.

They were the keynote speakers during Academy of Managed Care Pharmacy’s (AMCP) Educational Conference. I had the pleasure of attending the conference since I was presenting a poster project from my managed care summer internship in Seattle.

It was interesting to hear what these two well-known politician/physicians had to say about what may and should happen to America’s healthcare system. They presented various hot-topic questions: Would a public option introduce competition and efficiency into the healthcare market? Could it crowd out the private sector? Should there be a healthcare mandate? After a dynamic and lively presentation, an anonymous member of the audience posed a final question: “Would either of you be interested in joining the next season of Dancing with the Stars?”

In addition to hearing about the healthcare reform debate, the conference offered sessions related to emerging trends in the pharmaceutical pipeline, specialty products and managed care pharmacy. I had the privilege of meeting a number of student pharmacists from all across the nation. Many of them took part in AMCP’s Pharmacy & Therapeutics (P&T) competition, where students are charged with the task of analyzing a product dossier and preparing a P&T monograph and presentation.

To give you a glimpse of my managed care summer internship, I stayed in the beautiful city of Seattle and worked at Group Health Cooperative for nine weeks. I had the chance to contact prescribers and patients about the availability of a generic ophthalmic medication. I presented evidence-based information to clinicians which examined high-risk medications in the elderly. I also created and presented a drug monograph for Group Health Cooperative's P&T committee. I developed a project on medication safety, focusing on chemotherapy administration in the outpatient setting. Based upon reported medication errors, published recommendations, and discussions with clinical pharmacists, I helped identify opportunities for improvement and drafted a new policy on chemotherapy handling that included additional error-prevention safeguards.

A final remark about the AMCP conference: I had a GREAT time in San Antonio! I connected with many of the students and pharmacists at the conference on the riverboat tour, while visiting the historic Alamo, and over Tex Mex cuisine and some darn good margaritas!

Tuesday, October 13, 2009

Why Pharmacy?

Posted by Shannon Hough at Tuesday, October 13, 2009

When I was in high school, I babysat for my neighbors. The dad was a nephrologist, and they had two kids and a dog named Henle. Yep. As in the Loop of Henle. At about the same time, I started trying to figure out what I wanted to be "when I grew up". I knew I wanted to work in health care, but started thinking I might like to be a physician. So my neighbor gave me a summer job in his office. I did all sorts of wild and exciting things. I filed charts, picked up lunch, ran urinalysis and answered the phone ... with a lot of hand washing in between! Often times I also went through brown bags of patient medications, consolidating them onto a neat list for the physician to review. As I worked in the office longer, I found myself less interested in lab tests and how a physician determines a diagnosis, and more interested in how all of those drugs helped the patients. I chose pharmacy to impact how the use of medications can improve quality and/or quantity of life for a patient.

I am currently on an institutional rotation at Botsford General Hospital in Farmington Hills, Mich. Pharmacists at Botsford provide decentralized (read: they are not all in the basement) pharmacy services. I will have had the opportunity to rotate through four different weeks with different pharmacists and patient populations. At the halfway point, I have been doing a lot of pharmacokinetic and anticoagulation dosing services.

This month's rotation takes me back to why I chose pharmacy. Other than seeing my neighbor nephrologist every day, I’ve had the opportunity to monitor drug therapy to improve patient outcomes. Possibly one of the most rewarding and petrifying things that this rotation includes is a Cardiac Rehab lecture. I will also be giving a lecture about cardiac medications to patients who have recently undergone heart surgery next Monday. Stay tuned!

Thursday, October 1, 2009

The many hats we wear

Posted by Akin at Thursday, October 01, 2009

As a fourth pharmacy student, my duties extend far beyond experiential rotations. I must also be thinking about completing my PharmD investigational research project, preparing for an hour-long seminar presentation, applications/interviews, and student organization obligations to name a few… just enough time-consuming requirements to make P-4 year anything but a vacation.

Another duty we P-4s have is to mentor first-year pharmacy students (P-1s) who are assigned to us. They shadow us on our rotations for a few days each semester. It is our responsibility to be a source of advice and support to them whenever they need. I have two P-1s assigned to me this year. Some might consider this as a double burden, as most students have just one P-1 student. But I see this as an opportunity not only to be a mentor, but also more importantly to “show-off”. (Smile.) Additionally, I can use this opportunity to reflect on my own P-1 year, and to see how far I’ve come in three years.

My P-1s came to Mott Children's Hospital to see me on my pediatric rotation service -- each on different days. As they asked me questions about my daily P-4 activities and my career goals, I began to realize that it wasn’t so long ago that I was in their shoes asking those same questions. When they asked me about my own aspirations after graduation, I told them what I wanted to do. But when I told them that there are many ways to get there and that I wasn’t 100 percent sure which route was best for me, I was reminded that I, too, need more guidance. I hope to get that at the ASHP Midyear Clinical Conference in December, and from my own mentors who are faculty and alumni.

It is good to have P-1 buddies to whom I can (hopefully) provide some wisdom that will last long after I graduate. I look forward to several more opportunities for them to shadow me as the year goes on. I want to give a shout-out to Courtney and Victor. You both are very enthusiastic students. But, just wait ‘til P-2 year!

Tuesday, September 29, 2009

The Hope for Change in Los Pajarillos

Posted by Mary Liu at Tuesday, September 29, 2009

It’s been a little over a month since I left Honduras. Now that I’m back to the fast-paced life of rotations and hopping from city to city, I immediately notice the blatant disparities between my current lifestyle and those people in Los Pajarillos, Honduras. #1, I drive a car to rotations, while they walk 2 hours down and up a mountain to go to and from work. #2, I went from DC to Ann Arbor to San Diego to Calabasas just this past weekend, while many of them have never left their village, let alone visited a metropolis. #3, I have dined out an inordinate amount this past month in DC, while they make their own food from scratch daily. #4, I constantly use my Blackberry to go on the Internet or connect with people, while the entire village lives without electricity. It’s disturbing witnessing myself slip right back into my old lifestyle even after I was exposed to something as eye-opening as this experience.

To go back to the beginning, I had decided to go on this trip with a friend of mine, Sheerali. We wanted to get out into the world to show what we were made of. After all, we were in school for so long and seeing only the four walls of a classroom or the library can make you a little antsy. Most importantly, we wanted to step out of our Ann Arbor bubble and challenge ourselves, using the tools we have gained from school and life experiences, in a completely foreign environment. We were aware of the Honduras Medical Brigade, which several pharmacy students always participate in every year. But we were seeking a more dynamic interaction with people in the community, where we would not be limited to the walls of a pharmacy dispensing medication. The Honduras Public Health Brigade had just started its first year here at Michigan, so Sheerali and I decided to join.

The Brigade seemed perfect for us, except for the fact that neither of us remembered any Spanish from our high school years. And speaking from experience, it’s not like riding a bike. The language doesn’t instantaneously come back to you once you’re in a country full of Spanish-speaking people. So I intended to borrow Spanish tapes, like Rosetta Stone, thinking I could go from non-speaking to fluent in a few weeks. I even brought my old Spanish notes from high school and my little English-Spanish translator. It turns out that what you learn from reading text on sheets of paper and electronic devices can only take you so far, especially when the electronic device stops working once you arrive in the country. I ultimately relearned Spanish while speaking with the children who attended the 1-classroom school in Los Pajarillos.

At first glance, this classroom looked like any other classroom in the states. It had desks, chairs, workbooks, and drawings on the wall made by the students. But once the students entered, you noticed the difference immediately. Forty to 50 children rushed in, boys and girls ranging in age from four to 13 years old. Some walked in without shoes. None carried book bags. And there was only one teacher for the entire school. But, somehow, it all worked. The children had bright smiles on their faces, eager to learn.

The first day we went to the school, we handed out yellow toothbrushes to each child. We also taught them a song that went to the tune of “Mary Had A Little Lamb”:

Cepillense los dientes, los dientes, los dientes

Cepillense los dientes, dos veces al dia.

Si no lo hacen, tendran dolor, tendran dolor, tendran dolor

Si no lo hacen, tendran dolor, recuerde los cuidarte.

We quickly realized, however, that the kids weren’t familiar with “Mary Had A Little Lamb” when they started singing the song to the tune of “Frère Jacques” instead. Whatever works, right? After we lectured on the importance of brushing your teeth daily, we took the kids outside around the pila and practiced brushing teeth. The kids must have thought it was a competition, because they brushed vigorously for well over five minutes, until white foam bubbled out of their mouths and dripped down to the ground. When it was time to wash up, all the kids fought for the faucet. Some even went inside the pila to wash up. They tucked their toothbrushes in their pockets as we went onto our next activity: freeze tag. The brigaders were the “bad guys”: plaque, gingivitis, missing teeth, illness, etc. If a child was tagged, he could only be saved when tapped by a toothbrush from one of the designated “good guys”, which were one of the children we chose to rescue fellow classmates. We went back a second day to teach the children about wound care. Ultimately, we hope that we got an important message across about health and hygiene to the children. Understandably, one lesson may not change their behavior, but repetition of this lesson from their teacher may.

Our main work was to focus on helping a family that was chosen by the Basic Sanitation Committee (CSB) to build structures vital to good sanitation practices: a latrine (toilet), pila (sink), stove, and concrete floors. With only eight people in our group (seven females, one male) in our Brigade Team, and the majority of us with no prior woodworking experience, our work was cut out for us. Thanks to Habitat for Humanity, a few of us had some experience using tools. I was dubbed a pro with the hammer. Unfortunately, that skill was only limited to hammering nails straight down and at no other angle whatsoever. Sam discovered that cutting metal wasn’t her forte, but bending and breaking it was. Sheerali found a knack for the saw, and thank goodness for Andrew, who was a jack-of-all-trades. We all pitched in to mix cement, gravel, and dirt to form the concrete floors. I focused on building the latrine for the rest of the week, which required woodwork, brick-laying, melting plastic, and cutting aluminum and metal. After completing the final touches on it, I had the honor of testing it out.

The family, as I mentioned before, was chosen by the CSB. This committee was formed in June 2009 by members of the community who voiced concerns about the overall health and hygiene in their area. They created a survey which inquired each household about their living conditions, with specific questions such as “Do they have concrete floors?”, “Do they have a latrine?”, and “Do they use their latrine?”. After latrines fill up, a family has to dig another hole to hold the waste. Not everyone digs another hole, but instead, uses a neighbor’s latrine or goes out in the bushes. Recognizing that people who fail to meet the aforementioned criteria can damage their own health as well as the health of the entire community, the CSB goes out to each household once a month to follow up on each family’s progress.

This particular family consisted of husband Santos Velasquez, wife Maria Cardona, Maria’s sister Yoni (age 14), and children Deinis (age 10), Yosos (age seven), Milis (age 4), and Garis (age 2). Their “extended” family included a hen with her chicks, two doggitos, a mule, and one scrawny, orange cat. The cat was famished, dirty, and surrounded by mosquitos when we first saw him. I felt as if it was my duty to fatten this cat up by the time I left. I was even tempted to smuggle it back to the states with me. Sure enough, as the days went by, the cat looked healthier, cleaner, and cared for. On our last day working on the house, I started worrying about what would happen to the cat after we left. Who would feed him? Where would he get his food from? Would he ever reach a healthy weight? These questions triggered larger questions about the family and community. Would the amount of toothpaste, soap, and shoes be sufficient for one family? Would the children at the school still remember to brush their teeth daily?

I left Los Pajarillos with conflicting thoughts: a sense of accomplishment for the hard work we had done, but also a sense of urgency for all of the work that lies ahead. My goal is to return to communities like Los Pajarillos to implement improvements in health that are sustainable.

Change, whether for an entire community or just for a single individual like myself, doesn’t happen overnight. It takes hard work and a conscious effort to improve your life and those around you. But, as long as you make the effort and have the patience to see it through, a change is possible, and well worth it.

Friday, September 25, 2009

Sue Come or Ella. Say what?

Posted by Shannon Hough at Friday, September 25, 2009

As a consult team, the pediatric infectious disease team sees many patients with complex infectious illnesses. Additionally, as a tertiary care center, Mott Children’s Hospital treats children with complicated medical problems. This month, many of the young patients we've seen were under some variety of precautions invoked by infection control. As a result, we would have to wear gloves or masks/gowns in order to enter the patient rooms.

Johnny was not one of those kids. He was being hospitalized for an infection in a central line. (Central lines are catheters used to deliver long-term IV medications into a central vein.) When we rounded, he was not usually in his room. He was running around the floor playing video games or hanging out in the playroom. This was not typical of the patients we had been seeing all month.

As with most patients with infections, Johnny was placed on empiric antibiotics that would treat the infections he was likely to have. Many times this includes multiple medications. Once we knew what pathogen was causing Johnny’s infection, we would be able to tailor his therapy specifically. A few days later, the microbiology lab informed our team that it was able to grow a bacteria from Johnny’s blood, but was not able to identify the gram negative rods. The bacteria was eventually identified by the State Department of Health as a species of Tsukamurella (pronounced: Sue-Come-Or-Ella). My immediate reaction was "What in the world is Tsukamurella?"

Even if I knew every single thing I had been taught in pharmacy school (which I don’t), I would have no idea how to treat a Tsukamurella infection. In this case, I did what any good pharmacist would do: I LOOKED IT UP! That's one of the things that makes the field of pharmacy so exciting. New bugs, drugs, and diseases are always being discovered. Treatment guidelines change. Thus, it is possible that the treatment protocols we learn in school today will not offer the best solutions a few years from now. But no matter what the advances in the medical sciences may be, knowing how to use investigative resources, and possessing a drive for lifelong learning are qualities that define a good pharmacist.

Image from:

Keeping A Cool Head

Posted by Kendra Yum at Friday, September 25, 2009

Today started out like most other mornings in the Surgical Intensive Care Unit (SICU) at University Hospital. My classmate, Karen, and I arrived early to review patients’ medical profiles. We then discussed our findings of medication-related issues with our preceptor, a clinical pharmacist in critical care and nutrition support. At 8 a.m., we joined the rest of the SICU team, made up of residents, medical students, nurses, a dietitian, pharmacists, and an attending physician. With the group assembled, we began the morning rounds.

On rounds, we stopped at each patient’s bedside on the unit. The team was huddled around a patient with all of us scribbling notes as we listened to an update of the patient’s status.

Suddenly, an overhead alarm began to beep in rapid succession. Team members stopped writing and looked at each other. Then we heard someone cry out: “We have a code in room number 20!”

The entire team rushed toward room #20. Karen and I looked at one another, each gauging the other's response as we accompanied the group. A code blue had been initiated, meaning that a patient was in cardiac arrest.

The team of doctors and nurses instantly gowned up and surrounded the patient to perform defibrillation and apply chest compressions (CPR). My preceptor immediately pulled open the medication drawer of the crash cart and began rapidly assembling syringes of epinephrine and atropine, so that they were ready for use, on command. (A crash cart is a set of trays/drawers/shelves on wheels used in hospital emergency rooms and containing the tools and drugs needed to treat a person in or near cardiac arrest.)

The attending physician called for multiple doses of epinephrine, followed by a bolus of amiodarone. The room was abuzz and bustling as commands were shouted across the room. The tension in was palpable, and remained that way until the patient's heartbeat stabilized.

After the crisis, our preceptor described the role of a pharmacist during a code blue and the pharmacist's responsibility for monitoring the correct administration of medications during emergency response.

Easier said than done... Experiencing the code today demonstrated how overwhelming an emergency response could be. The literal life-and-death urgency of an emergency situation could easily overwhelm clear and rational thought, and interfere with informed decision-making, including decisions about medication use. As a pharmacist responding to a code blue I could see the absolute need to keep a cool head in a heated crisis. Hopefully, I’ll get there.

Tuesday, September 15, 2009

They don't teach you THIS in pharmacy school!

Posted by Jeffrey Huang at Tuesday, September 15, 2009

I am only just at the midpoint evaluation for this rotation and Al Knaak at Village Pharmacy has already completely turned my perception of retail pharmacy upside down. I came into the rotation thinking that though I would still work hard, there would only be a slim chance I would consider a career in community pharmacy. Now, the idea of a small, independent pharmacy near the beaches of Kona, Hawaii doesn’t seem so bad of an idea! If I could duplicate the business model and work ethic of the team that Al has in place at this store, life would be pretty great – that also includes the flip-flops and boardshorts into work, of course.

First off, Al loves his patients – he knows 90% of them all by name, and they all know his. His pharmacy is completely patient-focused – the staff prides themselves on the unique services they provide for the patients free of charge. In fact, a project that is required for the rotation is to challenge the P4 student to formulate a service plan and pitch it to Al and the other pharmacist, ultimately with the hopes to implement the service at the pharmacy.

I’m becoming proficient at MTM’s (Medication Therapy Management) for the unique patients Al selects, a pro at doctor office calls (3 hours straight today), and wowing the staff with my spatula skills for compounding. I enjoy each morning when we review a new patient case, and I am always impressed with how knowledgeable Al is in areas that can only come from years of practicing experience. He loves sharing all the tidbits where “they don’t teach you this in pharmacy school” and I enjoy picking his brain whenever I get the chance.

The Village Pharmacy community rotation is definitely a great opportunity to learn. Al makes a lot of effort and dedicates specific times during the day to teach and engage his students. It is clear that Al loves his job as a pharmacist – I am trying to make the most out of my time with him and know I will finish this rotation with a newfound appreciation for community pharmacy.

Saturday, September 12, 2009

Hi!!! Bye!!!

Posted by Shannon Hough at Saturday, September 12, 2009

My second rotation is at the C.S.Mott Children's Hospital at the University of Michigan, in pediatric infectious diseases. I really like kids, so I was unsure of how I would feel about seeing sick kids. The first day of rotation we rounded in the afternoon. Our team of eight had a small patient load for the day and was able to spend a long time discussing each patient before we went up to see them. After making a plan for each patient, the eight of us piled into an elevator. I was a little bit nervous, as it was my first time actually rounding and being part of the team. As the elevator doors opened on the seventh floor, we were greeted by a three year-old girl, dressed in a maize and blue cheer costume, complete with very cute pigtails. She waved "HI!!" and "BYE!!" to each person getting in and out of the elevator. As the whole team smiled, and waved "hi!" and "bye!" in return, and I couldn't help but think that this was going to be a fun rotation.

Pediatrics really does have fun moments. Even while delivering a sad plan to a patient and family about a prolonged hospital stay, the team still took the time to talk to the child about whatever seemed to interest them. We've heard about Webkins, Dora the Explorer, dinosaurs you name it.

Besides all of the fun, so far this month I have also really taken a dive into anti-infective therapy. Most of the patients we have seen have unidentified infections, and are quite complicated. It has been a challenge to appropriately select and follow the medications on these patients and contribute to the team.

Thursday, September 10, 2009

Don't get too comfortable

Posted by Akin at Thursday, September 10, 2009

I think I am one of the few students who for the first two rotations is doing them both at inpatient rotation sites within the University of Michigan Health System. During my first rotation, the patients were adults with cancer. This month, I am doing pediatrics at Mott Children’s Hospital. Knowing that I was going to remain at UMHS and feeling good about my last rotation, I figured I would just be able to pick up where I left off. But my transition from adult to pediatrics is certainly a transition worth blogging about.

Aside from getting used to weight-based pediatric dosing, unfamiliar pediatric-specific disease states, and different lab values that I need to pay even more attention to, I also must rebuild my comfort level all over again. The clinical rounding team includes four medical students and three residents, which is a change from the smaller PA service I grew accustomed to. With such a large team, finding a niche and knowing when it is appropriate to speak up is another new challenge. I hope to learn a great deal in the next few weeks.

With all this in mind, I guess if I had to give myself advice for the next few months, I would tell myself not to get too comfortable with each rotation. The school year is just beginning, but I now anticipate a dynamic year full of transitions and adjustments. From month to month, I’ll be changing more than just my daily monitoring form. I’ll be placed into foreign environments outside of the haven of the College of Pharmacy classrooms and into hospitals, clinics, and offices. Our preceptors may put us in situations where we are on our own, fending for ourselves amongst medical doctors and residents. We may sink, we may swim, but regardless of the outcome, we will gain some sort of insight. And by the time we gain any sort of confidence, it’ll be time to move on to the next experience.

My preceptor told me last Friday that most pharmacists don’t get comfortable until about a year of working on a service (not including residency/ fellowship/ or other advanced training.) This made me think of Michigan's Head Football Coach, Rich Rodriguez. The football team is off to a good start and the young team is looking much more comfortable on the gridiron after a rough year in 2008. So I am going to start thinking about my early career right now like I do the University of Michigan football team. The next few years are going to be a time of transition, but I will be winning Rose Bowls and national championships before you know it.

Wednesday, September 2, 2009

The Compromise

Posted by Akin at Wednesday, September 02, 2009

My adult heme/onc rotation ended last week, but I thoroughly enjoyed the experience and would like to further comment on my time there.

I worked on a PA service which was composed of an attending physician, four physician assistants (PAs), and a clinical pharmacist. I generally woke up around 6 a.m. and worked on patients' therapeutic plans at home. Other times, I would develop patients' medication therapy plans in the hospital. I would then meet with my preceptor (Shawna Kraft, PharmD'06, PharmRes'07 and '08), at 8:30 a.m. to review any recommendations that I might have thought of before patient rounds at 9 a.m. Approximately half of my recommendations were vetoed or tweaked by my preceptor and the rest were OK'd meaning I could recommend an intervention during rounds, if it hadn’t already been changed, and later on document the change.

Little did I know that my preceptor would be giving me a summary of all the interventions I made on the last day of rotation, during my final evaluation. As it turns out, I made 20 clinical interventions, 26 patient care alerts, and four drug monitoring notes. I also saved the hospital $94.77! So I’m writing a letter to the University of Michigan Health System. This is how it starts. Let me know what you think:

“To whom it may concern,
I am a P4 student who just finished a clinical pharmacy rotation in the hematology/oncology department. As you know, the clinical pharmacist plays a vital role not only in ensuring appropriate medication therapy, but also in various other services including reducing health care costs. With all this being said, I think it’s important that you know that in the month of August, I saved the hospital $94.77. Let’s keep in mind that this is an underestimation as I may have forgotten to document some my interventions. As a poor student, I believe I’m entitled to at least some of this money. I think half is a fair compromise. Please make a check out to me for $47.39...”

But seriously, it feels good to have a summary of all the clinical interventions that I was a part of for the past month. Perhaps I can also say that I helped our clinical team to prolong a few lives or at least helped to make a patient or two (many of whom were terminal) feel a bit more comfortable in their waning days. This was the most rewarding part of my August experience.

Tuesday, September 1, 2009

Rotation Interim - 55th IPSF World Congress, Bali Indonesia

Posted by Jeffrey Huang at Tuesday, September 01, 2009

International Pharmaceutical Students’ Federation (IPSF)

To give a little background on IPSF, my first involvement with the federation began last summer with its Student Exchange Program in Prague, Czech Republic where I worked in a local community pharmacy. I learned about the role a pharmacist played in the Czech health care system and the similarities and differences of their system compared to our own. Immediately following the exchange, I attended the 54th IPSF World Congress in Cluj-Napoca, Romania in which pharmacy students from over 30 countries were represented. The theme of the Congress revolved around counterfeit medications, where speakers from around the world traveled to conduct workshops, symposiums, and lectured on the growing problem. It also was fascinating to hear about the ways in which my student colleagues were involved in global health issues, and how their roles compared and contrasted with my own.

I returned home with a great desire to become more involved with IPSF and began applying for leadership positions in the federation. Whereas I began the 2009-2010 academic year the University of Michigan College of Pharmacy IPSF chapter liaison, I was recently appointed the Regional Relations Officer (RRO) for the Pan-American Region Office (PARO) of IPSF. In my new role, I promote IPSF throughout the North, Central, and South American regions, recruit new country memberships, as well encourage the involvement of existing IPSF members.

55th IPSF World Congress, Bali Indonesia

August 3-13, 2009

Rotation Interim

When the secretary general of IPSF, Mary Poon, asked me if I would be willing to serve on the federation's motions committee, I had just arrived in Bali after a 35-hour commute from Detroit , baggage still in hand. I blinked. “Yeah. I guess so. Sure.”

What I did not realize was that being on the motions committee for the general assembly was a huge responsibility, adding, as it did, about 30 hours of work on top of my responsibilities as the PARO RRO. I was already responsible for holding a two-and-a-half-hour workshop for the attending members of PARO helping to lead a discussion regarding the future of IPSF; and was later told that because the PARO chairperson was unable to attend the congress, I would be responsible for presenting the PARO annual report to the general assembly. This was going to be a challenge as I was only appointed to my position a few months previous.

Of course, everything works out in the end! Although my friends from the 54th IPSF World Congress were stumped at my reasoning in choosing to take on a much bigger workload this year, I was still able to find a balance between work and play. With the motions committee [photo below], Pedro Lucas (Portugal), Jin Chiong (Singapore), and I were able to work with the IPSF executive on pressing issues, such as the IPSF Membership status of Taiwan, in coordination with UNESCO regulations. My PARO workshop went great. We were able to map out a plan to strengthen our region and provide more value for our existing member countries. I helped lead a group of students that included representatives from Canada, Indonesia, Malaysia, and the Czech Republic on sensitive issues surrounding IPSF. My annual report to the general assembly gave a brief summary of the year and focused on the future of PARO, as discussed in the earlier workshop. Even with my added responsibilities, I was able to take off a full day for surfing; a Balinese massage; and roaming the local markets in Kuta with my international friends. All I had to sacrifice was (a lot of) sleep!

On a side note, here are two funny observations I would like to share:

Much of Asia, including Indonesia, cut their foods cut into smaller pieces as part of their dining culture. In contrast, Europeans almost always eat with a knife (right hand) and fork (left hand). So when there was only a spoon and fork on the table during the Congress meals, almost all the European students replaced the knife with a spoon to help them eat.

Also, students from around the world are generally taught British-English in their foreign language curriculum. Interestingly, they told me they really dislike this because they find British-English more difficult to understand than American-English. And British-English is not as applicable to Hollywood media as is its American counterpart. So even though the American accent is often ridiculed as sounding overly nasal, the foreign students I met claimed that the American accent is much easier to understand.

The Congress was a great experience, one that I look forward to each year. It’s amazing to meet students from around the globe — Kenya, Iran, Slovenia, Australia, the Czech Republic, Finland, Indonesia, and many more nations as well. Our commonality is pharmacy, but when you hear just how diverse pharmacy practice is around the world, every conversation becomes an educational experience.

I really hope to keep alive my ties with the students of IPSF and am determined to find a way to focus my pharmacy career endeavors on an international level. I would also like to thank the College of Pharmacy and newly established Center for Global Health in providing support to attend the conference. Viva la Pharmacie!

Sunday, August 30, 2009

When a patient brings you flowers…

Posted by Kendra Yum at Sunday, August 30, 2009

The patient poked his head into the doorway, hesitant to enter when he saw the clinical pharmacist in conversation about antihypertensive treatments with this Michigan PharmD student. The pharmacist was my preceptor, Gloria, employed at Detroit’s Veterans Affairs Medical Center. The patient had arrived for a follow-up visit at the VA's Hypertension and Risk Reduction Clinic (HRRC).

“Come on in," Gloria said, rising from her seat to greet the patient at the door.

He smiled. But instead of walking in, he turned the opposite way, returning a second later with a bouquet of pink and white carnations. He spoke with a gentle voice. “These are for you, Gloria," he explained. "I really do appreciate all the help you've given me.” I was struck by the sincerity of his gesture.

Gloria started each patient appointment with blood pressure and weight measurements. She also checked for ankle edema (swelling) if the patient was on a calcium channel blocker. Then, she would ask the patient if he had completed his “homework”: recording his blood pressure twice a day at home in order to review this data with his pharmacist. (
HRRC provides an automatic blood pressure machine free to its VA patients.) Next, the pharmacist asked about unusual symptoms, tolerance to medication, and compliance with the prescribed medication regimen. A large portion of the session was devoted to lifestyle assessment, wherein the pharmacist extensively reviewed the patient’s dietary consumption, smoking habits, and exercise levels. She would then offer advice on how to make lifestyle changes to improve blood pressure.

Between patient appointments, Gloria explained to me how to develop a patient-specific drug therapy tailored to the patient’s biology, disease complexity, and pattern of compliance. She also identified what symptoms and lab values should be monitored.

"Although this is a hypertension and risk reduction clinic, I spend two minutes modifying the medication regimen and explaining how to take the medications,"Gloria
explained. "The rest of the time, I advise on lifestyle changes that can help reduce the risk factors contributing to hypertension.”

I learned from Gloria that clinicians often minimize the importance of patient participation in their care. She has achieved success by equipping patients with practical disease management tools, and by helping patients establish reasonable lifestyle modification goals.

Evidence shows… When we increase the dose of an antihypertensive drug, or add a drug to the regimen, we aim for a decrease in blood pressure of 10-15mmHg. Regular physical activity reduces systolic blood pressure by 4-9 mmHg. A weight loss of 10kg correlates to reduction in diastolic blood pressure by 15mmHg. A similar reduction is achieved by lowering salt consumption. Thus, multiple lifestyle changes can reduce blood pressure by 30mmHg: two to three times more than what medications achieve, and without ANY harmful side effects.

The patient who brought Gloria flowers had an excellent blood pressure measurement while at the clinic.
“Your blood pressure looks great today," Gloria smiled. The patient offered an explanation, “Well, maybe the clinic has something to do with that," he replied. "When I'm here, I feel comforted.”