Saturday, January 19, 2013

Geriatrics with HBL PharmaConsulting in Saint Louis, Missouri

Posted by Beejal at Saturday, January 19, 2013

Oh my goodness, the last few months have flown by!  Here is a post about my block 6 rotation!

This rotation is a great one for those of you interested in geriatric pharmacy or even ambulatory care.  I have known Dr. Hedva Levy for a long time and her practice is very unique.  You get to see a lot of different things, and since you’d be relocating for 5 weeks she really tries to make the rotation as fulfilling as she can.  This is difficult to write about because it’s unlike any other rotation, so hopefully I do it justice!  

Could I be more vague? Well, go ahead, read on!

What does Dr. Levy do?

Dr. Levy’s purpose: She helps geriatric patients (we refer to them as older adults) stay in their homes for as long as they can, safely and independently.  In other words, she helps older adults stay out of nursing homes and retirement homes.  Older adults are known to have more side effects from their medications, and these can potentially lead to disability.  As pharmacists, if we can teach them how to take each of their medications safely we can prevent them from having to live in a nursing home.  

How does she find patients to help?  She receives referrals from social workers through federally or state funded programs when they see that an older adult could use some help understanding their medications better.  The state programs have contracts with geriatric communities, and she gives a presentation to them about safely using medications.  She also gets private referrals from physicians who have received letters from her (I’ll explain these letters below)!  

How does she manage and conduct this type of role?  She works out of her home, and will have one-time visits with referred patients in their homes for about an hour.   Her practice is very much like an ambulatory care setting.  You spend a significant amount of time educating the patient on the big things that you notice during your interviews.  Unlike ambulatory care rotations that are specific to 1 subject (cardiology, endocrinology, etc), Dr. Levy addresses all problems that she sees as significant.   

What will you be doing during this rotation?

General Information: You will give the presentations on safe medication use and you will conduct these patient interviews.  You then spend a couple of days putting together a detailed care-plan of all of the patient’s problems.  Once you have worked up the patient, you will meet with Dr. Levy and present the patient and every problem he/she has.  After you review the problems and the plan with Dr. Levy, you draft up a letter that prioritizes and summarizes your recommendations.  The letter should be written in simple language for the patient and should be concise.  The letter will also be faxed to the patient’s physician, so it should also be written respectfully. After several weeks, you do a follow-up phone call to the patient.  In the background, you'll also have three projects for this rotation.   
1) Write an article for a geriatrics-focused newsletter.  I wrote about the effects of caffeine in older adults.  
2) Write an extensive drug information consult.  I wrote about the use of venlafaxine for painful diabetic neuropathy.
3) Write a new drug review. I wrote about Myrbetriq for overactive bladder. 

Other tid-bits about these interviews: When you schedule a patient interview, there is very little you know ahead of time.  Also, every patient will have vastly different conditions and life situations.  You may find yourself counseling one patient on the differences between her insulin, another patient on warfarin and diet, and another patient on foot fungus.  If you don’t know the answer during the interview, Dr. Levy is always right by your side to offer her input.  

Patient work-up and care-plan:   This is a lot harder than it sounds, but this was the most valuable part of the rotation for me.  I learned a lot about topics that I will never see during rotations this year such as psychology, neurology, and insomnia.  I also encountered many topics that I was comfortable with such as hypertension and diabetes.  You will become very familiar with the Beers List, renal dosing, and the Geriatrics Lexi-comp book.

This rotation could be considered Drug Information, in my unprofessional opinion!  You learn about the appropriate references to use for your purposes.  You are generating a care-plan and you must have solid evidence to back up the recommendations you make to Dr. Levy for the patient.   She’ll ask you really great questions to make sure you've thought things through.  As I alluded to above, if a patient has a condition that neither you nor Dr. Levy are familiar with, she’ll likely ask you to present a topic discussion with treatment recommendations.  Additionally, everything you say or send to her has to have valid references.  You always need 2 drug info sources to double check your information, including drug interaction checkers.  

Words of wisdom and other logistical things to keep in mind

·      Saint Louis is a lively city.  You have to be careful to choose housing in a safe part of town.  If you are unfamiliar with the city or the area around it, Dr. Levy is more than willing to offer her two cents, and anyone is more than welcome to contact me as well (even if you’re reading this 10 years from now!) 

Since Dr. Levy doesn’t have a practice site, you will meet with her to review patients at public libraries.   I liked this because it added an element of change to my day to meet at different places.  Additionally, you will do all of your work-ups at home.  There are usually 1-2 days every week that are just work days for you, so there is a lot of flexibility (besides for when scheduling patient interviews). 

It would be good to bring a car to Saint Louis.  Partly because you are in a new city, and it is easier and safer to explore that way.  It’s also helpful because you travel to each patient’s home as well as to the public libraries.  If you are unable to have a car, Dr. Levy will make it work still. 

Dr. Levy only precepts 1-2 students from UMich every year since she also precepts students from Saint Louis College of Pharmacy.  Make sure your have a strong out-of-area application!


This was a very valuable geriatrics rotation.  You are not just doing profile reviews; rather, you are learning about each and every condition and medication that comes your way.  I also learned how relevant the subject of health literacy is, and learned how to communicate with older adults more effectively.

Thursday, January 3, 2013

She's got CF, she's 7, and she can run faster than you

Posted by Tom Vassas at Thursday, January 03, 2013

Being on break for 8 weeks has a way of making you lazy apparently. While I had aspired to catch up on the blog, it would appear I also aspired not to. So without further adieu, I'll jump in to where I left off and what you missed.

Peds! My general medicine rotation at Mott hospital to be precise. It was a cool rotation I will say that. As soon as I heard we could do a peds option for gen med, I gave it no second thought. There was a lot to get used to at first; cardio was full on 15 patients a day on rounds with heavy input from pharmacy, whereas on the gold team in peds we were lucky to get 4 kids a day and pharmacy would be even luckier to make one recommendation.

Since much has been said about the rotation already, I claim brevity and here's the attention-grabbing version of the interesting things, now in parable form!

Here is the story of the little girl who was largely epileptic refractory to nearly every safe seizure medication. The treatment that stuck with her though was a ketogenic diet (think Atkin's, but with some real science behind it). She was spry and happy, but her finicky diet would make most fad diets seem normal. Lucky for her, she had a brilliant pharmacy student to aid in her recovery. As the gallant pharmacy student discovered, diet was but one thing to monitor for her treatment at Mott. Food, medication, IVs, boluses and beta-hydroxybutryate levels oh my. Carbohydrate counts in everything needed to be known, and the pharmacy student was amazed that the dietician taught him all this!

I did figure out a few weeks in that a majority of patients on the gold team are psych and neuro kids. Psych in this case really means autism and neuro means epilepsy. A LOT of kids I saw had seizure meds and it was a great time to brush up on the differences in AEDs and what to be aware of when monitoring these kids.

Now is the tale of one poor little girl in particular, who was no more than 8 months old and had a near SIDS episode, resulting in an anoxic brain injury and subsequent seizure disorder. To the girl's dismay, she was trached and tubed (tube feedings that is) and her days were wrought with high doses of phenobarbital Q12. Her body was failing her, and her eyes showed the struggle. Her solace came with being able to take the phenobarb, but she could not stomach it and she could not hold a line (IV access that is). The gallant pharmacy student could see this, and act he did. With kids you may learn unique ways of giving meds, and this girl needed one. The gallant pharmacy student knew she had an NJ tube, and commenced the privelage of spending 6 or 7 hours trying to find out if phenobarb can be put in solution, then stable in the feed going through the NJ tube, and would be absorbed well enough. Long story short it could and it did and the peasants rejoiced.

Overall the rotation was just one of those chances to see a side of pharmacy rarely seen and not well understood at that. I would recommend it for anyone slightly interested in kids, and anyone who doesn't mind learning new info that could set you apart. I can't say how many times at my internship I've been able to help solve a problem because I had experience with peds.

Up next is drug info! Stay tuned -- TV