Friday, June 29, 2012

Erasing stigma...

Posted by Kristen Gardner at Friday, June 29, 2012

I just finished week 1 of my "Community" rotation. I am at a Walgreens Pharmacy located within the Howard Brown Medical Center (HBMC) for most of the week except when we travel to Mercy Hospital for the afternoon shift on Tuesdays and Fridays aka our clinic days. The HBMC provides healthcare to lesbian, gay, bisexual, transgendered, and queer clients many of whom have HIV/AIDS but not all. On the other hand, we only see patients with HIV/AIDS at the clinic.

I was asked a question the other day about my rotation experience. "Does your rotation make you sad?" My gut instinct was no, but I questioned the appropriateness of this. I was quickly reminded of an interaction my rotation buddy had with a patient and his family member. The patient's mother was frustrated because a clinician said, "I am sorry you have to come here for your care." Although slightly different, I believe the principle of both situations is similar. Patients, especially with illnesses that are stigmatized such as mental illness and HIV/AIDS, do not want your sympathy if there is no reason for it beyond the diagnosis. They simply want respect from healthcare providers and a promise to manage their illness just as you would someone with any other medical condition. Expressing sympathy, especially in populations previously described where the patient is clinically stable and healthy, could make the patient question if they should feel ashamed and further stigmatizes these conditions. Also, this mindset may potentially prevent patients from attending follow-up appointments.

On another note: I am enjoying this rotation for multiple reasons!

1) I am provided with the opportunity to counsel patients ALL THE TIME through new to therapy calls, new medication counseling, and opportunities at the clinic when the team decides to switch or intensify therapy due to suboptimal virologic response (HIV RNA either not dropping by 1 log in 4 weeks after ART initiated or the viral load has increased after virologic response (HIV RNA < 200) was previously achieved with ART.

2) I learn interesting things from this patient population such as there is a market to sell hormones on the street (and I only thought we needed to worry about illicit street drugs and prescription pain killers!)

3) how to approach a counseling scenario with a transgendered patient when you are unsure of their "preferred" name

4) I feel more comfortable with the fact that I have taken an Oath and follow a Code of Ethics where I care for patients regardless of whether or not I agree with decisions they have made.

I am posting links to the Oath of a Pharmacist and the American Pharmacists Association Code of Ethics because a little reminder never hurts!

I will be continuing to slowly read throughout the 240 page guidelines for HIV/AIDS until my next post.... :)

The Bright Side of the “Dark Side”

Posted by Tony Lin at Friday, June 29, 2012

This rotation was so fascinating I had to write two blogs about it.

In the last entry I briefly mentioned what pharmaceutical industry is and a little bit about Aastrom. I never told you what I did so here it is.

My preceptor was the head of the regulatory affairs but what does that mean? Does she work for FDA or Aastrom? Well, last time I asked she was on Aastrom payroll. So a good answer would be “Aastrom.”

Regulatory Affairs, as serious and critical as it sounds—it is. This aspect of the pharmaceutical industry serves as the interface for both the company (aka sponsor) and FDA. For example, FDA communicates their comments and concerns about your latest clinical study, you had better be able to interpret it correctly—all 100% of it. Vice versa. Whenever the sponsor wants to communicate with FDA to ensure it is following all the rules and regulations, it is best to have reliable personnel to deliver and translate your intents correctly. Every word, every punctuation and every tone in a message or verbal conversation can be misinterpreted for the undesired.

In fact, being in regulatory affairs is all about reading between the lines and extrapolate. In the few seemingly “simple” documents that I was supposed to summarize you know what I did? Well, I summarized it…in a traditional fashion that would have gotten me an A on a school paper but probably an F (for “you are Fired”) if I were doing a real job. Compared to my preceptor’s versions, she had extrapolated all sorts of conclusion from simple sentences that I would never even think of. But, they made sense. They absolutely made sense. The analytical skills and nuances that take place in the regulatory affairs world are nothing we ever see or learn in pharmacy school.

Just when I was wondering why some say you can’t learn everything in pharmacy school…

My main project at this rotation was to make a presentation to the employees during a Lunch & Learn session. With much assistance from my preceptor in selecting topic and analyzing available information, I delivered my presentation titled “Prochymal--Paving the Way for Stem Cell Products.”

Aastrom’s Ixmyelocel-T represents an unprecedented stem cell therapy that has not been caught on by most of the industry and regulatory authorities. The technology is cutting-edge and the science is exceptional. Knowing the right things to do in clinical trials and the important things that FDA looks for are tricky…did I mention the word “unprecedented” already?

That’s why I chose to present on Prochymal, a self-claimed “world’s first approved stem cell drug product” in Canada just last month. I researched in details and established parallels on the similarities and differences between Prochymal and ixmyelocel-T to see how this groundbreaking drug product got on the market despite our knowledge of stem cells are still in its infancy.

Two things I can tell you based on this presentation: 1) it was not easy for Prochymal to get on the market but rest assure the focus of the pharmaceutical industry is about to shift, 2) companies from all areas do this all the time—research and analyze similar types of products in order to learn from different experiences in the pathway to getting regulatory approval. .

The past 5 weeks have been a phenomenal experience. Perhaps my blogs have cleared up your stereotype of the pharmaceutical industry or maybe I dug an even deeper hole for the industry in your eyes. My conscious choice of selecting Aastrom over a large pharma was a good one. I had interactions with personnel from manufacturing to engineering, programming to finance. My presentation on Prochymal was deemed important enough that I even got to present it to the executive leadership team.

I enjoy presenting and I loved my first 5 weeks. The bar is set high and I wonder what the next 7 rotations will bring.

Tuesday, June 26, 2012

Inpatient A: Internal Medicine (Regal)

Posted by Charles Berklich at Tuesday, June 26, 2012

Hello pharmacy world-

Apologies for the delay. I will start out with a little about myself so the reader may decide how interested they are in what I have to say and how it relates. My name is Charles but a lot of people call me Chuck. I am an avid rugby player and fisherman. My interest is in pharmacy informatics/healthcare IT. My background work consists of working for UM as a hardware tech for 6 years. Weird or what?

Internal medicine with Dr. Regal was absolutely outstanding as a first rotation. Internal medicine casts a huge net of information to know, so if one's clinical knowledge is not up to snuff-it is obvious. Forget the fear, Regal will pave the path for pharmaceuticals to ponder. No seriously, the right attitude and some hard work is all you need. Dr. Regal is very professional and knows his stuff, but he also is a little more my speed in terms of finding the humor in life; the 'King of Alliteration.'

A typical day would find the student arriving before rounds to work up patients. After rounding with the medical team, checking in with Regal and following up with the medical team and patients is next. The afternoon usually consists of a meeting where the student is presented with new information and given articles to read for the evening. Last, a quick once over to make sure all patients are okay and then time to leave. Don't forget to review for the bench test on the last day!

Most important things to know or review for this rotation: Anticoagulation. Lot's of time is spent dosing warfarin and counseling patients on this drug. Antibiotics, especially dosing vanco. Renal dosing of drugs. Proton pump inhibitors. In that order.

A little bit of reflection. For my first rotation, there is nothing like being thrown in to the mix not knowing what you are doing. I learned to work with the medical team, interact with patients, and interact with other professionals. I must say looking back, I do miss my patients. I also got lucky with some great attending physicians, and a great student fellow student with me (thanks Dave!).

I would like to finish with a quote. After three consecutive days of making a recommendation for a change in drug therapy to the doctor, there was still no change made. I was stumped. I kept telling the doc, he kept agreeing, yet would not change the electronic order. I didn't know what else to do.

"Being a clinical pharmacist is about being uncomfortable." Think about it.

Monday, June 25, 2012

BMT- Rotation in Review

Posted by Anonymous at Monday, June 25, 2012

I completed my rotation last Friday in Bone Marrow Transplant at the UofM, and am still amazed at how interesting this field is!

Just think- clinicians have the potential to eradicate certain cancers in patients with high-dose chemotherapy followed by an infusion of allogeneic (donor) or autologous (self) stem cells to “repopulate” the patient’s marrow- its quite incredible! Whether a patient has arrived for transplant, or readmitted to the floor several years after, pharmacists play an integral role in the care of these patients.

In order to start to understand the complexities of BMT, the first several weeks involved extensive reading of primary literature and review articles to get a better view of the course of transplant and medications used throughout the process. By working up and following patients during their 3+ week stay, I was able to dive into how to approach patient workups, monitor labs, and implement medication changes. I really enjoyed being a part of the rounding team every morning, and felt the more I learned about the transplant process, the easier it was to suggest pertinent adjustments in therapy.

During the course of the rotation, I was able to get a better idea of just how important it is to truly appreciate the pharmacokinetics and dynamics of drugs. Dr. Frame, a master of pharmacology, challenged us to integrate therapeutic knowledge with an understanding of physiologic principles and literature-based evidence. Although this is not an easy task and will take practice, I believe that keeping this concept in mind will help me develop my clinical skills this year and beyond. 

I highly recommend this rotation to anyone interested in clinical pharmacy, as it features taking ownership of complex patients and developing knowledge of drug therapy. I will miss the BMT team, but am thankful to have had the chance to be a part of it!

Rotation 1. Check!

Posted by Kristen Gardner at Monday, June 25, 2012

I just completed my first rotation: Institutional or Hospital/Health System!  J

This will be a short blog thanks to Courtney K! I will attempt to elaborate on the excellent overview she provided.

To reiterate, this rotation requires a great work ethic to get a lot out of it. You can do as many extra projects as you want (provided you ask)! It is tempting to do the least amount of work possible- especially transitioning from P3 year/2.5 week break into P4 year. There were so many projects/agenda items I was trying to complete (Pharm.D. final report, Pharm.D. seminar literature search, Leadership Scholars Board of Governor’s project, reviewing therapeutic topics I had forgotten, etc.), it would have been nice to strictly be “on rotation” from 7am-3pm; however, I am glad that I was able to work on extra projects because I learn in the process and now I have even more things to talk about on residency interviews!

Working in the 6th floor satellite was GREAT! As Courtney mentioned, I really started to feel like a real pharmacists verifying orders. I really took ownership of my patients by signing my name to the pages I sent out to the physician and answering phone calls (drug information requests by physicians and nurses and responding to physician pages). Recommendations/concerns I paged on mainly related to antibiotic dosing. Physicians love to start vancomycin 1g q12 hrs for every patient regardless of actual body weight and renal function; therefore, we were always paging on recommendations to modify vanco orders. We paged the clinical specialty pharmacist in ICU (intensive care unit) because one patient was started on traditional dosing (TD) tobramycin (an aminoglycoside), but did not meet any restrictions (basically anything that would alter volume of distribution or renal function, e.g. CrCl <40ml/min, burn patients >20% total body surface area, pregnant patients, obese, meningitis, ped patients, infective endocarditis, ascites, cirrhosis, end stage liver disease (ESLD), anasarca) for single daily dosing (SDD) of aminoglycosides. SDD is great because it provides a high Cmax (aminoglycosides are concentration dependent killing) and you take advantage of the post-antibiotic effect of the drug and allow trough levels to drop low which minimizes risk for toxicities such as ototoxicity and nephrotoxicity. I also happened to catch that the prescribed dose of metformin was incorrect for the patient based on her problem summary list (PSL ) in Careweb when I was trying to find a serum creatinine (SCr) level since metformin is renally eliminated and is contraindicated with higher levels (1.4-1.5; gender specific) due to risk of lactic acidosis.  There were also some pain regimens that would not optimally prescribed. I also learned some great lessons. For example, we paged because we wanted warfarin dosing clarified as they were increasing the dose when the patient’s INR just came back at 3.0 when their goal was 2-3. I overlooked that the patient was also on argatroban which falsely elevates the INR. The pharmacist was not aware of this fact or that the hospital uses chromogenic factor X as a monitoring tool in this scenario. Therefore, I took on the extra project of looking into this and reported back to the pharmacist my findings. It was a great educational opportunity because I corrected a learning deficit not only for me but a lot of other staff involved.

IDS was super fun! That is all I have to say. But, I love research which may bias my positive perspective.

The Clean room was great too because again I was verifying orders! I would verify kits (mostly antibiotics with IV bags containing the proper diluent for the drug) that the technicians put together (to prepare for orders in advance) as well as compounded products. I recommend looking at the actual product first and then reading the label because sometimes reading the label first makes you see things when looking at the product second!  J

I LOVED the administration week. I learned so much interviewing the different staff in administration. It was really interesting to gain their perspectives and it also helped us identify great questions to ask of other programs during interview season. Oh yeah!

Mott is much crazier/busier than 6th floor satellite and because of that I was unable to “drive” and do all the order verification with a pharmacist sitting beside me and checking my work 100% of the time; however, I was able to do enough where I was not terrified of dosing the kiddos. Note: They receive crazy drug information questions all the time and you will definitely be involved in answering these questions. Do not fear because the staff is SO nice in Mott! I was so hopeful that I would be able to attend a code during my week there, but unfortunately, the one code that was called occurred while I was gowned up in the Clean room. Oh well! I also went out with some of the medication managers (the technicians deliver medications to the bedside in the new hospital and there are a few techs dedicated to make sure nursing has all the medications they need- we are being proactive) which was nice because I saw the PICU, NICU, and PCTU. Through visiting these units I learned that I like to see my kiddies healthy vs. intubated with 10 different smart pumps hooked up to them or an ICP monitor. I saw a baby that was 1.5lbs! She was so precious! Projects included helping one of the pharmacists update the IV compounding book and creating a reference for which vaccines contain thiomersal/mercury as a result of a drug information call I took.

I am moving on to my “community” rotation with a Walgreens specialty clinic focusing on HIV/AIDS management at Howard Brown Medical Center in Chicago, IL. I am excited yet nervous because I heard our preceptor is demanding and constantly quizzes you. But, that is a good thing because I need repetition! Plus, I get to share this experience with my well-known study buddy/partner in crime, Janis Rood. Prior to the first day our preceptor asked us to know the generic names, brand names, abbreviations, and preferred/alternative treatment for treatment na├»ve patients. Check! I have also been reading random other information as well because I am known for going off on tangents during my studies. There is so much to know! Only time will tell what information I am able to retain in this brain of mine.

Also- this is my first time living in a big city! I am sure you will be hearing about interesting stories. For example, today I decided to figure out the “L” or the train in Chicago. That probably would have been fine on any other Sunday besides when the 2012 Pride Parade was being held. I observed many interesting people wearing/not wearing interesting articles of clothing. Unfortunately, these pictures would be inappropriate for this forum!

Sunday, June 24, 2012

Ambulatory Care in a Nutshell

Posted by Unknown at Sunday, June 24, 2012

Good Evening to everyone,

I've been trying to find a time to share with you my experience with you as an ambulatory care pharmacist and due to how extremely busy I was during rotation 1, I find that I am doing this the night before rotation 2. haha Without further ado- here we go:

I had the wonderful opportunity of working with Dr. Shimp and Dr. Tingen at four different UMHS associated health centers.

Mondays from 1:00PM to 6:00 PM I was at the Chelsea Health Center
Tuesday from 8:00PM to 5:00 PM-Livonia Health Center
Wednesday 1:00-6:00PM-Saline Health Center
And Thursday various times-Ypsilanti Health Center
I really enjoyed this as it allowed me to see a wide variety of varying patient populations.

As an Am-Care pharmacist at these locations we focused on three disease states: hypertension, hyperlipidemia, and diabetes.  Patients would be referred to the PharmD by their primary care physicians as people who would benefit from added disease management.  Within the collaborative practice agreement between the pharmacist and physician, the pharmacist has the ability to start and stop medications, order labs, and various other clinical responsibilities.

My daily schedule looked like this at the clinic:
  • Work up and discuss the days patients with my preceptor: 15-60min
    • We would go over pertinent labs, discuss possible therapy changes, and address what needed to be done when the patient showed up
  • Patient interaction: 15-20min * 5-12 patients/day
    • When the patient's arrived we would go over over their lifestyle (diet, exercise, caffeine intake, pain, smoking status), Blood glucose monitoring, home blood pressure monitoring, adherence to their medication regimen, and any other topics that they wanted to address at today's visit.  I would also manually check their blood pressure with a sphygmomanometer and stethoscope.
  •  Therapy Decision: 10min * 3-12 patients/day
    • After discussing with the patient and taking their blood pressure we would then assess patient's willingness to make necessary therapy changes.  This happened a lot and really helped me hammer home how certain medications are used and when to use them.
  • Pharmacy Notes
    • Documentation of the day's patient interactions.  Generally I would finish these at home
 I liked that I was directly effecting patient care at each and very patient visit. I found that patient's were willing to work with you as long as you took the time to hear them out.  I thoroughly enjoyed talking with each of the patient's I saw throughout the 5-weeks. 

On top of my clinic duties I would complete/work-on various projects for my preceptors. As you may be able to see I was extremely busy, but I would rather be busy than doing nothing.

I came into the my first rotation being very open to what ambulatory care had to offer.  I find that this mindset aided me greatly and found that I enjoy ambulatory care immensely.   Until next time

Next Up: Critical Care at UM Hospital

Institutional at U of M

Posted by Courtney K at Sunday, June 24, 2012

Hello all! It's hard to believe rotation 1 has already ended and a whole new experience begins Monday. I consider myself pretty lucky to have had my institutional rotation at U of M for my first one. I know this isn't the rotation at the top of the excitement list for most people, but I seriously enjoyed it and it was a really good one for easing into the P4 life. I'm not gonna say I wasn't a little jealous of the students I saw on a daily basis doing exciting things like going on rounds, counseling patients and wearing their own pagers (Victor and Alison!!), but my time will come :). Here's the run down of my 5 weeks:

-Week 1- 6th floor satellite- I spent this week with a pharmacist doing order verification and checking. Most of the pharmacists I was with let me "drive" so I felt like a real pharmacist- answering phone calls, paging prescribers, and calculating vancomycin and aminoglycoside doses. I feel a lot more comfortable with Careweb, Carelink and Theradoc after this week and I have a much better feel for how the satellite pharmacies operate. By the end of the week I was flying through orders. 
-Week 2- Mott 10th floor pharmacy- This week was similar to my first week, but in the new BEAUTIFUL hospital. Order verification with peds is A LOT different. For every single order that comes through you have to calculate the mg/kg dose to make sure it's appropriate. Lexicomp peds was my friend. A good portion of my time in Mott was spent in the new clean room. There has to be a pharmacist in there at all times because they have to check doses before they are added together and then do a final volume check at the end. I love pediatrics so it was cool to spend some time over there before my peds surgery rotation (#6)
-Week 3- Investigational Drug Service- I'll be honest, I didn't think I would like this week. Research and studies are just not my thing. But IDS was awesome and the staff was all so friendly! I knew little to nothing about this service prior to this rotation and it was so cool to see how they manage the 350-400 active studies going on in the hospital. I spent time dispensing, prepping for site visits, reading/discussing articles, and even writing a section of the Dispensing Guidelines for a new study that will be starting up soon. 
-Week 4- Administration- This week I got to spend some time with the other students on this rotation (Alicia, Kristen and Paul) interviewing the different pharmacy administrators. It was very interesting to hear what they do from day to day and ask questions about some of the things we had seen in our first 3 weeks. The 4 of us also used this week to work on our CE presentation for the pharmacy technicians on Infection Control. 
-Week 5- Clean Room- My last week was spent in the clean room in B2. I worked with different technicians the first two days making the IV batch and the last three days with the pharmacist, Lisa, checking them. Even though I have IV making experience from work, I saw a lot of things I hadn't seen before and learned from everyone I worked with. During this final week, we also presented our CE to the technicians in two separate sessions. 
-Other thoughts- You really get out of this rotation what you put into it. There is minimal outside work, so I used my evenings to wrap up my PharmD write-up. Yes, some days may be a little boring, but attitude and enthusiasm really help. Ask lots of questions and be involved. I had a pharmacist offer to let me go down to the OR one day while she was working. I got it ok'd by Dr. Kraft and spent one morning during the admin week checking out how the OR pharmacy works. One day during my last week I was in the right place at the right time when the med safety pharmacist needed help on a special project. I got to work with him to identify all the physicians at U of M who had ordered a particular IV iron product that was causing adverse drug reactions so we could inform them of the risks and offer alternative therapy. 

Good luck to everyone in rotation 2! I'll be heading to Chelsea for my Non-Traditional LTC rotation! 

Another break in the wall of text

Posted by Tom Vassas at Sunday, June 24, 2012

Well my experience with administration has come to a close. Though the past 5 weeks did go by fast in retrospect, there were so many times where I actually wished for another week....but just so I had enough time to finish my projects! The entire rotation has given me a great appreciation for just how needed leadership is in pharmacy.

Most of the topic discussions the past 3 weeks have revolved around the advancement of our profession. Until recently, our roles as pharmacists have been roughly the same for 50 years or so. Pockets of us around the country are experimenting with new forms of service; decentralization of RPhs, patient centered medical home (PCMH), home infusion, specialty pharmacy etc. But this does not represent pharmacy as a whole. If we want other professionals to think "I absolutely NEED a pharmacist" instead of "What can I do without a pharmacist?", the shift in thinking has to come within our own profession and not with legislature or educating others. Complacency is a big hindrance. Many of us know a pharmacist who grouches about a new IT system being put in place, or moving the workflow of an area, or trying a new delivery service. But going into practice, we 'young ins ' need to have high value on changing anything we can whenever we can, because there is always a better way.

Unfortunately, most of pharmacy operates archaically compared to other professions. Surgeons with nanoscopic imaging and laser assisted cutting devices? Well some of us still use baskets and stickers to know where our patient's script is. NPs and PAs offering primary care in highly accessible clinics? Well some of us can't hear with a phone glued to our heads. One of the most pragmatic things to help us as pharmacists is one of the few things that we as a profession love by nature yet don't implement; technology! Bar code administration, secure tube delivery, cart-less drug models, robots, CPOE, EMR, point-of-sale delivery and signature; I could go on but the point is yes some health-systems and pharmacies employ these, but the vast majority don't. The premise is simple; simply our fulfillment and distribution practices, allow technicians to take on more of our old 'busy' work, and both techs and pharmacists can finally operate at the top of our licenses. When you fill our days with work we deem more valuable, the profession advances itself.

A lot of this can lie with leaders in helping us get there. There is already a large gap in age for managers and directors, and with the newest generation of Pharm.Ds entering practice, there needs to be a wealth of us interested in leading. This is not a call for new pharmacists to start getting managerial positions; it's a wake-up call for them to be engaged. This means helping our peers and leaders understand what doesn't work for us, try to fix it, fail, and try again until it works. That drive to do things a better way so you can add more value to your day is what leading is all about, no matter how many letters are after your name.

So I must digress from the soap box to finish with the updates from last post. I was fortunate enough to give an inservice to East Ann Arbor staff about specialty pharmacy. That niche has grown so much I guarantee all who are reading this will be involved in the next few years. But it was suprising how well PCMH and MTM fit with providing specialty service; following up with patients, monitoring labs and compliance, advising physicians on drug choices, DDI (omg so many). Among all that is the super important piece for us to be the shining knight in armor for the MD and patient, in their war with 3rd party payers and PBMs. To understand how to fight that fight, is one way to get the MD to say "What do you mean MY pharmacist isn't available?! How can I work without MY pharmacist!?"

Next week begins my ambulatory care rotation in Canton with Stu Rockafellow. Until then I'll leave you with this; Why on earth has it taken us so long to make changes that seem so obvious?


Friday, June 22, 2012

Walmart..good times..

Posted by Andrew Chang at Friday, June 22, 2012

As I am sure most of you guessed, I just finished my community rotation. It was at Walmart in Saline, located just out of Ann Arbor.

Now I know I'm supposed to talk about what my rotation was like, what I did, how long I worked, etc etc. It's a community is exactly what you would imagine it to be. There's a transfer here, a new prescription called in there. Insurance troubleshooting everywhere and a ton of patient interaction. Patient interaction is either the most fulfilling part or the most aggravating part of the community setting in my opinion. There is no greater feeling than knowing you made a difference in someone's life no matter how small that may be. On the flip side, there is no greater frustration than talking to a wall. But that's life, you got to take the good along with the bad.

I believe that most people have had some community experience, whether working or through their IPPEs, so I do not want to bore you with those details. What I wanted to focus on was the importance of having a good work environment with enjoyable and deft coworkers. Everyone is a beginner at one point or another in their lives and usually they need help to get started. Working with people that are skilled and knowledgeable in their craft makes life infinitely easier, especially when they are willing to help. In my rotation I was surrounded by people who would take their time to make sure that you learned and understood what was going on. Lisa, the preceptor really tried to go through the over the counters, which was something our c/o 2013 did not get a course on. I also remember getting help from Elizabeth, now a P2 at UM, on troubleshooting insurances. It's an empowering feeling to know that people want to help you so you can do well and learn. Don't worry Debbie, Erin, Paul and Nora I love you all too. :) The work environment was quite entertaining as well. I had the privilege of working with Mr. Charles Heidbreder. For those of you guys who were in our disease management discussion.. yeaaah. Imagine instead of 2 hours a week, it multiples into 40 hours a week. We added our dynamic into an already diverse group of people and somehow it clicked. I would not say anyone in the pharmacy is particularly similar to another, but we were able to have a real good time together. And that makes a big difference on those days that just never end.

For those of you guys who follow us, you have big shoes to fill! Haha I'm just kidding. Good luck!

Rotation 1: Everything I expected and more! Do I really have to leave?

Posted by Krystal Sheerer at Friday, June 22, 2012

I just finished my community rotation at Village Pharmacy II, an independent pharmacy. My preceptor was Allan Knaak. I cannot believe how fast these five weeks went by. I left today with a tear in my eye. I loved every minute there. The pharmacists and staff are one of a kind!  Al is an amazing preceptor. He is very knowledgeable, knows his patients, and loves his career. Whether it is 8am or 9pm, Al is ready to go! He has been a great mentor and preceptor throughout this rotation.

One aspect I love about community pharmacy is no two days are alike. I love the direct patient interaction every day. I became the compounding and drug information expert. If there was a compound, I would make it. If there was a question that a patient or physician asked, I researched and answered it. I have not made compounds since P1 year, so it was nice being able to refresh my knowledge regarding compounding.  I also participated in doctor calls, was involved in the final check of prescriptions, and counseling of patients. Additionally, Al would assign me OTC cases to help prepare me for some questions that may come up in my career. The next day we would go over the case together. After I went over what I thought I would do, he would go over what his approach would be.

Two weeks into my rotation, a student from Midwestern started her rotation with Village Pharmacy II (Alyssa). This was an amazing experience being able to work with another P4 student. We were able to learn from each other. We had a few patients that came in with some questions which required research. Both of us would work up the patient and then come together and present our findings and decide how we would approach this situation. We are now working together to plan a health fair in September. I am excited to continue to work with her on this project as we had such a great time learning from each other.

I had the opportunity to investigate three drugs (ONFI, QNasl, and Tradjenta) and made recommendations as to whether the pharmacy should stock them or not. I created a brochure and poster entitled “What can YOU do to lower your blood pressure?” This gave me an opportunity to counsel some patients on nonpharmalogical things they can do to help reduce their blood pressure.  Alyssa and I then came up with an idea in which involved stickers(with space to record 8 blood pressure readings). We used stickers that we can place on business cards to give to patients when they measure their blood pressure in the store. We feel this will give the student a great opportunity to counsel patients on their blood pressure. Additionally, I was able to participate in a MTM. After my meeting I sent the patient a letter thanking them for meeting as well as summarizing our meeting. I am looking forward to coming back to see if the patient was able to meet the goals she set.

I also had the opportunity to go with Al to the preceptor symposium. I am thankful he invited me to go. Al and I were inspired by some of the guest speakers and decided to put together a proposal. At the symposium they encouraged preceptors to become innovative and think of unique experiences for pharmacy students. Over the last week of rotation, in addition to my normal day activities, I also worked on a proposal. The next student will fine tune the proposal and present it to the College.

I AM SO THANKFUL FOR THIS AMAZING EXPERIENCE! I would recommend this site to everyone! It is one of a kind and I am thankful I had the opportunity to be a part of the Village Pharmacy II pharmacy team!  In fact, I am looking forward to working something out so I can come back and help finish some projects I started and perhaps work on some others! Thank you Al for being a great mentor, pharmacist, and preceptor.
Posted by Unknown at Friday, June 22, 2012

What better way to mark the last day of rotation than with QMP cupcakes?

Thursday, June 21, 2012

“If you can’t explain it to a 6-year-old...."

Posted by Unknown at Thursday, June 21, 2012

“If you can’t explain it to a 6-year-old, you don’t understand it yourself.” ~Albert Einstein

This has been my mantra of late. Over the course of my non-traditional rotation in Quality Management, I’ve often sat and pondered how I would explain what transpires in this office to my nieces and nephews should one of them ask me, “Anam Khala [Urdu for ‘Aunt’], now what do you do in school again?” as they occasionally do. This rotation has deeply increased my appreciation for the various tools and resources we have used along the course of our pharmacy training. To give you a better idea of what I mean, let me begin with the basics.

The Quality Management Program, or QMP, as it’s affectionately referred to around here, is the branch of the University Hospital that is responsible for all of the data that lives in the shadows of clinical care guidelines, pay-per-performance protocols, and medication adherence efforts. I share an office with clinical information analysts and programmers, allowing me to appreciate the diversity of skills required to impact healthcare. My preceptor, Dr. Annie Sy, is a clinical pharmacist who practiced in the hospital for 5 years before joined the Quality Improvement & Decision Support Team for the FGP Quality Management Program in 2007. Dr. Sy became the manager to this team 2 years ago. She currently works in an ambulatory care clinic for a portion of her week, and spends the rest of her time running the show at this office, where she divides her time between leading meetings, giving presentations, analyzing data for incentive programs such as FGP and BSCSM PGIP, helping to develop and maintain chronic disease registries and overseeing various programming protocols in preparation of the upcoming MiChart implementation. To give you an idea of what interns do on this rotation, some of the projects I have completed for Dr. Sy and her various committee leaders included helping to update the medication portion of the Asthma Clinical Care  Guideline, analyzing external data from the BSBSM PGIP Generic Dispensing Rate Initiative, performing medication reconciliation reviews on Careweb for an Accountable Care Organization initiative, and computing drug prices on the brand new CKD Clinical Care Guideline (coming soon a therapeutics class near you!). Another important part of what Dr. Sy does is to bring a pharmacy/clinical perspective to UMHS’ quality improvement efforts by sitting with physicians, nurses, social psychologists, and analysts on each of UMHS’ QI committees. These committees include but are not limited to the asthma, COPD, diabetes, heart failure, and controlled substance committees, the last of which I helped validate the opioid and benzodiazepine registries for while on rotation. As I’ve worked on my individual projects and attended various team planning and QI meetings, I have been grateful for the background in statistics and EBM that UM equips its Pharm D. students with, as both have been integral in helping me understand quality management.

In my years working in a community pharmacy and even now at my current job as an intern at an inpatient pharmacy, I’ve never experienced a working environment quite like this. For one, I’m far removed from the usual hustle and bustle of a pharmacy, but rather spend most of my day working on projects in my cubicle, whence I emergeth occasionally for meetings. :) In a pharmacy there is a constant stream of new faces, but here I am part of a team of only about 15 people whom I see every day, and whom, by the way, have truly gone out of their way to make me feel at home. Last week, for example, I participated in a taco salad potluck. I was touched when the kind officemate of mine who was coordinating it correctly extrapolated from the way I choose to dress that I might appreciate some Muslim-friendly meal options. She then took it upon herself to bring non-pork-containing refried beans (I signed up for the gelatin-free sour cream :)). One of my favorite things is watching my officemates pick each other’s brains at meetings when they are presenting their individual projects to the group. A spreadsheet that looks like hieroglyphics to me, for example, might elicit a string of very technical questions from a colleague, which are answered with just as much detail. As you can imagine, my role in these particular meetings is usually silent observation, except days like when the word “membranoproliferative glomerulonephritis” appeared in someone’s research and all eyes in the room simultaneously turned to me to pronounce it.  

I purposely waited until the end to write this post so that I could do this rotation justice in my reporting, and I’m glad I did because each day has brought forth exposure to new topics and increased my appreciation for the field. With that in mind, readers, for you I have done my best to accurately express what this rotation is all about. For my nieces and nephews, I think I’ll stick to, “We use computers to make sure sick people are taken care of in the best way possible.”

Wednesday, June 20, 2012

BMT: a badge of honor

Posted by Anna at Wednesday, June 20, 2012

I can't believe my first rotation is coming to a close. Five weeks have really flown by, and I'm shocked by how much I have learned in such a short period of time. While I am thrilled to be coming out of this rotation only mildly battered, I am sad to leave the welcoming health care team that staffs 7W as well as the amazing patients.

As promised in my last post, I wanted to briefly touch on how pharmacists (and student pharmacists!) make an impact on this service. Pharmacists are well recognized as experts on medications, and their wealth of knowledge is not lost upon the health care team running adult BMT. In order to keep this concise, below you’ll find just a small taste of the questions directed at pharmacy:
  • A patient has consistently dropping cell counts, which is not altogether uncommon in this patient population. However, could any of the patient’s medications be contributing to this trend? If so, what change would you recommend?
  • A patient is unable to keep anything down due to the chemotherapy regimen we conditioned her with. What do you recommend after standard anti-emetic therapy has been attempted?
  • The patient is still throwing up. What else can you suggest?
  • A patient has been admitted with severe graft-versus-host disease of the skin. What type of therapy would you recommend to control the disease? What literature is your recommendation based on?
  • A patient is experiencing significant changes in mental status. Which drugs could be the culprits? Are there any specific tests or concentrations you need to assess? What about drug interactions?
  • Your poor patient has been hiccuping non-stop for a day with no relief in sight. We've tried Thorazine, but what else could help him?
  • A patient has end stage renal disease. Does this change your recommendation for chemotherapy doses? What is the basis of this decision?

Overall, this rotation was eye-opening. It truly helped me to determine my strengths and weaknesses, and it also allowed me to start developing important skills crucial to a successful career in pharmacy. I highly recommend this rotation for anyone who wants exposure to a unique and dynamic patient population. You also typically have at least a few other classmates on rotation with you, which honestly was pretty awesome!

The next time you hear from me I will be reporting from my rotation with a generalist pharmacist in the Pediatric Emergency Department!

Saturday, June 16, 2012

Rotation 1: Cardiology with Dr. Dorsch

Posted by Alison Van Kampen at Saturday, June 16, 2012

Hello Everyone!

After reading a few of my classmate's previous posts, I now realized I am woefully under-qualified to write entertaining, catchy blogs.  So I would like to apologized in advance for any future writings that are so dry you feel as though you are reading an extensive "Statistical Analysis" section in a research article.  That being said, all that follows are my experiences from my Cardiology rotation at UMHS with Dr. Dorsch.

Since beginning this rotation, I have had several anxious classmates ask me about the experience (most likely anxious because many have heard that Dr. Dorsch has changed his rotation format, and they will have this rotation in the near future).  If you fall into that category, do not fret, it really is not bad and I have really enjoyed myself.

Here is basically how the set up has been operating

Week 1:

  • One day orientation to Dr. Dorsch's expectations and our responsibilities
  • Got a pager, you know you have arrived when you have a pager :)
  • We would be following the Medicine Coronary Service in the hospital which is composed of 3 teams
  • I am on this rotation with another student, Victor Truong, and we split up the teams so we would each follow one team and we split the other. This meant that we follow approximately 8-15 patients at a time.
  • Arrive at 7:30 ish in the morning to collect data on the each patient on the team, perform medication reconciliation on patients that have been admitted in the last day, and perform discharge counseling on any new medications for the patient. 
  • The teams rotate days on which they admit new patients, so each team only gets new patients every 3 days.  This means lots of work on the days that my team admits new patients, moderate amounts of work on the days that the team we split admits patients, and very little work/catching up on days that the third team admits patients.
  • We are also responsible for looking at antibiotic doses to see if they need altering, checking if the patient's insurance covers particular medications, and a few other things.
  • All of these interventions are recorded in notes on Careweb.
  • In the afternoon we meet with Dr. Dorsch and his resident, Jen Lose.  Here we went over the notes we had written in the morning and discussed why they had certain therapies.
  • We were generally able to leave by 3:00-4:00.

Overall Impression:  This week required a lot of work at rotation and outside of rotation, this was primarily because I was still figuring out the best way for me to collect the data and where to find the data one the patient's profile.  I learned a lot about the hospital system.  Both Dr. Dorsch and Jen were really great to learn from.  They ask you questions to make you think but also inform a lot about things that were kind of glossed over or not covered in class. Things like aortic stenosis and the studies that are used in diagnosis.

Week 2 and 3:
  • All of week 1's activities plus afternoon topic discussions.
  • Arrived at 7:30 ish in the morning
  • In addition to the basic med rec, we were expected to start looking more at the patients medications in terms of their medical needs (does each medication have an indication, is each medical condition adequately treated, appropriate doses, interactions, is dose adjustment needed based on lab values, etc). 
  • Often answered
  • Topic Discussions:  
    • We held topic discussions after discussing our patients in the afternoon.
    • There were 7 topics (ACS, HTN, Arrhythmias, HF(1 and 2), Pulmonary HTN, and Stable Vascular Disease) that Victor and I split up between the two of us.
    • I took 4 (2 average length and 2 short topics) and he took 3 (2 average length and 1 long topic).  
    • For these topic discussions we were expected to write a background and summarized about 4-14 research articles and present these informally in a 45 ish minute presentation.
    • These presentations actually ended up lasting around one and a half hours.  Often Dr. Dorsch or Jen would interject to add clarification to certain points, discuss a study more in depth, or deviate to a new topic entirely.
    • Topic discussions were often pretty fun.  It was a really great way to learn about optimal therapy for a particular condition and Dr. Dorsch and his residents often went off on really entertaining tangets that frequently had nothing to do with the topic at hand.
    • The purpose of the topic discussions was to give us a good knowledge base before starting rounds.
  • We usually left around 4:00-5:00 on topic discussion days.
Overall Impression:  These weeks I really learned a lot about treatments in cardiology and became more comfortable with suggesting treatments. Topic discussions were very helpful, but required A LOT of work outside of rotation, I talking dedicate your weekends to this kind of  work.  This was primarily because I did 2 topics each week and I am kind of a slow worker, so maybe it will not take others in the future so long.

Good Advice from Jen: Know all the little things about the drugs (half life, route of elimination, which might be a little better at one thing over another).  The physicians know which classes are needed but they rely on the pharmacists to know which drug in a class will be best in an individual patient. Ex.) A patient needing a beta blocker but has poor compliance and poor renal function should avoid atenolol (renally eliminated) and carvedilol (BID) so could get Metoprolol succinate.
It all seems so obvious now, lol

Weeks 4 and 5:
  • Same as weeks 1-3 but we have finished our topic discussions except for Victor's last one which he did on week 4.
  • Started rounding with the team, which means getting to the hospital at 6:30 ish in the morning to collect all the latest information on the patients and identifying any ways to improve therapy in order to be ready for rounds at 8:00.
    • Rounding is interesting because it gave me a better idea of what was going on with the patient and helped me to better understand the best way to treat the patient.
    • Also it was easier to understand what exactly was going on when I could be a part of the discussion rather than just read a note on Careweb.
  • We discussed our patients in the afternoon and found any other possible areas for therapy improvement to either bring up to the team the next morning or pager a team member about that afternoon.
  • Afternoon discussions were primarily held with Jen on week 4 and will be with Dr. Dorsch on week 5.
  • We generally left around 5:00
Overall Impressions: I was glad to start rounding because it felt more like real clinical pharmacy practice but it does take up an unpredictable amount of time (mine lasted between 50 min and 4 hours).  The rotation is very time consuming but rewarding.  Working with Dr. Dorsch and Jen has been awesome because they are so knowledgeable and try to test your knowledge but do it in a way that does not make you feel like you are a failure as a human being.  They will often have you look up an answer and then provide further clarification. 

I have really enjoyed the rotation and for all of you that have the rotation in the future, Good Luck!