Wednesday, September 25, 2013

Diabetes, High Blood Pressure, High Cholesterol, and More Diabetes!

Posted by Rachel Lebovic at Wednesday, September 25, 2013

Rotation 3: Ambulatory Care with Dr. Trisha Wells
While many ambulatory care pharmacists are only in clinic a few days each week, I was fortunate to spend my ambulatory care rotation with Dr. Trisha Wells who sees patients five days a week. The physicians at the University of Michigan Brighton Health Center are currently scheduling patients’ next appointments at least six months out, so they rely on Dr. Wells to see patients with chronic diseases in between their physician visits. Specifically, the chronic diseases I helped manage on Dr. Wells’ rotation were diabetes, high blood pressure (hypertension), and high cholesterol (hyperlipidemia).
A typical morning on rotation with Dr. Wells consisted of a combination of 30-minute in-clinic appointments and 15-minute phone appointments. For the in-clinic appointments, I would first present the patient case to Dr. Wells and we would discuss my plan for the patient, including whether I wanted to order any labs and how I would adjust the patient’s medications. Then, I would collect the patient from the lobby, get their weight, and bring them into Dr. Wells’ office. Next, I would ask the patient a set of routine questions about their diet, exercise, home blood sugar readings, caffeine intake, and medications. Then, I would take the patient’s blood pressure and perform a foot exam (if the patient was due for one). Lastly, Dr. Wells would discuss our plan with the patient. Sometimes, the plan involved adjusting the patient’s insulin doses, oral diabetes medications, or blood pressure medications. Other times the plan involved improving the patient’s diet or exercise. In the latter case, we used a technique called motivational interviewing by asking the patient what changes he or she wanted make for diet and exercise instead of telling the patient what to do. I really enjoyed individualizing a plan for each patient based on the patient’s lifestyle, daily routine, and values.
Some of the patients had multiple appointments with Dr. Wells during my five weeks in her clinic, and it was a great experience to build relationships with these patients over time and get to know each patient individually. For example, I loved it when one patient brought her dog to clinic. This was one of the best-behaved dogs I have ever met. He even carried the patient’s glucometer and test strips in a saddlebag! I also enjoyed building a relationship with a patient who was starting to use insulin for the first time. We taught her how to inject insulin, showed her how to use her glucometer, and answered all of her questions about diabetes. Building these relationships with patients made my time in clinic a rewarding experience.
After mornings full of clinic appointments, the afternoons were spent writing clinic notes to document each patient’s appointment and preparing presentations. Throughout the rotation, I presented topic discussions on diabetes, hypertension, and congestive heart failure. The other student on rotation with me, Haya, presented topic discussions on hyperlipidemia, diet and exercise, and asthma. Preparing these topic discussions often felt time-consuming and tedious, but after discussing each topic with Dr. Wells and listening to her clinical pearls, I definitely have a better understanding for how to optimally manage each of these disease states. I also presented two journal clubs on recent primary literature and gave a presentation on a patient case to other P4 students on rotation with U of M ambulatory care pharmacists.
Overall, I truly enjoyed the plethora of patient care experiences on my ambulatory care rotation. I was pleasantly surprised by the autonomy pharmacists have in this role. Ambulatory care pharmacists can order their own labs, take blood pressures, perform foot exams, schedule follow-up appointments, and adjust patients’ medications. However, I did not like limiting my patient care to three disease states. Diabetes, hypertension, and hyperlipidemia are complex chronic conditions to manage, but I missed managing all of the patient’s disease states like I did in the inpatient setting. I still think an inpatient clinical specialist position is a better career choice for me, but ambulatory care was a great experience because of all the patient interaction.

Drug/P4 Year Information Rotation

Posted by Unknown at Wednesday, September 25, 2013

While the first three years of pharmacy education did not necessarily fly by, P4 year is certainly making up for the first three (evident by my late posting of my blogs).  You blink and you’re already walking into rotation 3 or 4. 

My P4 year started off with a Drug Information rotation through Sparrow Hospital in Lansing.  I am very fond of the Lansing area as I did my undergraduate work at the Michigan State University and currently live there (when not in school) with my wife who is currently a medical resident at Sparrow as well.  Seems like last week that I was trying to muster up the courage to walk into my first day of rotations with absolutely no idea what to expect.  I had a good idea I had left the tests and IRATs behind but you can never be too sure with U of M.  Every rotation has a steep learning curve at the beginning, whether it is getting accustomed to the computer system or fitting into the pharmacy and health care culture of the location.  The group of clinical pharmacists I got to work with was a great, close nit group eating lunch together almost every day.  While each day was filled with a few drug information questions, I got to spend a lot of time working in the offices of the other clinical staff, observing their role in patient care and their interactions with the other members of the healthcare team.  While the drug information part of my drug information rotation was a little light, the difference was made up with projects and presentations which really increased and improved my presenting skills.  Mainly out of necessity when you are presenting to a room of some of the most important decision makers in the hospital at a P&T committee meeting.  While my goal is to end up at Sparrow eventually, this first rotation was a great eye opener to the culture of Sparrow, the pharmacist workflow which I will address in my rotation 3 blog, and the opportunities for pharmacist advancement and services to be offered.  Each rotation teaches you something different, regardless of how “interesting” it was at the time or how prepared you feel leaving.  Thankfully, I had another taste of Sparrow on rotation 3 in the critical care unit.  But I won’t spoil that story just yet.


Friday, September 20, 2013

Ambulatory care- Oncology

Posted by Unknown at Friday, September 20, 2013

I had the pleasure of spending my third rotation at St. Joseph Mercy Health System, oncology clinic.

Monday, Tuesday and Friday consisted of initiating medication reconciliation with the cancer patients.  I would also talk to the patients and answer any questions they had regarding their medications.  Many of the patients were on other dietary or herbal supplements, providing me with ample opportunities to look up the latest research on various herbal supplements and their role in oncology patients.  Additionally I was able to sit in with the physicians and observe physician / patient interactions, as well as non pharmacological therapies such as surgery and radiation treatment options for these patients.

On Wednesdays and Thursdays I spent my time studying the various types of cancers, the various treatment options and the latest ideas regarding these types of cancer.  In my rotation, I covered Lung, breast, lymphoma, and colorectal cancer.   I also worked on a medication surveillance project in which I developed a tool to assess employee exposure to neoplastic / carcinogenic agents.  This assessment tool was developed to be used for all employees at the St. Joseph Mercy health system.

One patient experience I encountered which really touched my heart was of an elderly lady who came in with lung cancer.  She had relapsed after 20 years cancer free.  This lady told me a story of how she once assisted a young mother by holding one of her babies.  A man drove by and spit on her, because the baby and the mother were African American.  When she asked her father why this happened, her father said, because the man was ignorant.  She then asked her father where ignorance comes from, to which he replied, lack of education.   The lady decided to dedicate the rest of her life to improving education; she was the president of a university for many years, which had increased its student body by 5 times, during her tenure.  Meeting this woman changed my perspective about patients, specifically it taught me to never lose touch of the fact that every patient you interact with has a story. 

Finally, I had the opportunity of attending meetings in which my preceptor and other pharmacies discussed challenges with the recently implemented electronic medical record.  I also attended meetings where we discussed pharmacy operations and communication with other health care providers.   I learned a lot about how St. Joseph’s health care system operates and the role that pharmacy specialists play with physicians and nurses.  While this setting is ultimately not for me, I learned a great deal about pharmacy practice in an oncology setting and have developed a large appreciation for the role pharmacists play as providers.  

Wednesday, September 11, 2013

Catching up: Cardiology and Managed Care

Posted by Patrick at Wednesday, September 11, 2013

Diving into Cardiology – University Hospital

       My P-4 year began in earnest in the cardiology department at UM Hospital, ably managed by a team of three preceptors (Dr. Dorsch, Dr. Pogue, and Dr. Hanigan). So much of this rotation was defined by the structure these three preceptors had built for our experiences. On day one, myself and my three colleagues all received a list of expectations for the coming five weeks. The cardiac pharmacy team has a variety of services to provide and several of those services were strictly the within the purview of the pharmacy students. These services include counseling patients on anti-coagulation medication, obtaining an accurate medication history, counseling patients on all new medications at discharge, and conducting daily medication reviews electronically to seek out discrepancies. Should I find any, and as the weeks proceeded I got better and better and catching potential medication problems, we would (depending on our interpretations of the time-importance of the intervention) mention it to the medical team directly during rounds or bring it up for discussion during our daily meetings with our preceptors (generally in the afternoon).

       It soon became apparent that this rotation was going to be teaching me three primary skills: cardiac pharmacy and therapeutics, how to appropriately interact with the medical team, and most critically, moment-by-moment time management during a hectic day. We received tremendous support from our preceptors (in my case Dr. Hanigan for the first week and a half, with Dr. Pogue working with me for the remainder of the time). We students would conduct weekly topic discussions, reviewing and discussing a slew of key cardiology papers. During the week leading up to my presentation of stable vascular disease, I learned more about the history of statin therapy and the evidence supporting their use than I had ever known before. Our afternoon discussions would often include impromptu mini-lectures on medication issues encountered on rounds regarding individual patients. I never stopped being amazed at the time and dedication all three preceptors showed helping us to master the topics critical to proper practice of cardiac pharmacy.

       The second important teaching point was how to interact with the medical team. It was important to build a relationship with the resident physicians and help them to know that you (the pharmacy student) could be relied on in a pinch. When a minute could be spared, I found it helpful to spend more time on the floors, participating in their discussions about patient care; sometimes I was able to offer helpful input, especially when it came to medication decisions. For example, when one patient had an issue with a statin drug interaction, I (having done my patient-specific research early in the morning) had an appropriate substitution at the ready. It was moments like that which helped me to find my niche in the team.

       Time management was by far the biggest challenge (in my humble opinion) faced by students on this rotation. Patients were seldom in their room when you expected (hoped, prayed) that they would be. Every day was unique and full of surprises. Some tasks would take far longer than expected, others would pop up in the form of a page and quickly become priority number one, pushing all other tasks back up to an hour. Becoming efficient in the all important tasks of “working up” patients in the morning as well as typing up notes in the afternoon were the critical pieces required to make everything fit into the day.

       Week by week I found myself more comfortable with my role in the hospital and on the health care team. I needed less and less immediate support from my preceptor. As my skills improved, she developed trust me in and my judgment, and as she developed trust in me, I developed trust in myself. Half-way through week five, I found myself feeling truly capable of pharmacy practice at a relatively high level; it was an immensely satisfying feeling. As the summer solstice approached, my cardiac rotation came to an end and I was off to Seattle to explore the world of managed care. My first five weeks were a wonderful, challenging, and exciting introduction to the life of a fourth year pharmacy student.

Managed Care in Tukwila, WA

       For rotation block 2, I made the long, long drive from Livonia, MI to Renton, WA (25 minutes southeast of Seattle) to the home of a kind couple, with whom I had made arrangements to spend the next five weeks via A small, possibly helpful side-note: Airbnb is a great housing alternative for these stays of intermediate length (five weeks). There are options with affordable prices and none of the hassle of a short term lease.

       Arriving at my rotation for the first day, I was immediately surprised at the variety of the workload. On the very first day, I had three separate projects with varying approaches and methods. One project was a long-term assignment concerning a clinical review of injectable anti-psychotics. The second project was a response to a physician who had a question about a potential side effect of gabapentin, and the third project was an inquiry into dosing options for citalopram in patients at a variety of weights. The upside of this diversity was that I could mix and match over the course of the day. If I got stuck on one project, for one reason or another, I would always have something else I could work on productively. As a result, I’m proud to report, I accomplished a great deal.

       As I accomplished one project, my preceptor, Dr. Arnold, was always prepared with a new question or direction for me to explore. There were always a few plates to be spun at once, but never more than I could handle. I felt extremely lucky to have a preceptor who so ably helped me to balance my workload.
With the bulk of my major projects completed, the last week gave me the chance to branch off into new dimensions, taking on assignments that were more often the domain of the pharmacy residents, rather than students. I conducted a few dozen “Targeted Medication Reviews,” or TMRs as they are ubiquitously referred to. TMRs are interventions by a pharmacist in response to a “flag” identified by automated computer searches, indicating potential sub-optimal patient care. For example, a patient may be taking a brand name medication when a more affordable generic is available. Another common example would be medications flagged as potentially unsafe in the elderly population. In either case, the role of the pharmacist (my role on this particular week) would be to use clinical judgment to decide if an intervention is warranted and if so, to propose a change to the physician and the patient. I also had the chance to conduct a CMR (Comprehensive Medication Review), which are available to specific sub-groups of Medicare Part D patients. These reviews involved 15 to 30 minute phone calls with patients involving complete reviews of their medications and disease state, addressing any problems found.

       My five weeks in Managed Care surpassed my expectations. It was empowering to take charge of a major project and see it through to completion, knowing that in the future, it may have an impact on patient care for hundreds of patients. Managed Care and Drug Information are both paths that I’ll be considering as I move forward toward residency and beyond.

Sunday, September 8, 2013

The Real Rules of Communication

Posted by Unknown at Sunday, September 08, 2013

Pharmacy administration rotations are often underrated, they are stereotyped as an easy “A”, and administrators are often viewed as individuals with very cushy jobs, and are all talk.  It was very short sighted of me to perceive the them this way. 

                First, the pharmacy administrators work 60 hour weeks, they put in hours on the weekends and many take their work home.  The ones I have had the privilege of working with had a tremendous dedication to patient care, and to their staff.  These leaders would move mountains on a regular basis to make sure that their employees had the best working conditions to be successful in their jobs.

The first thing I learned on this rotation was the art of connecting with people, not just communicating with people.   When I was not working on projects, I learned about and discussed every aspect of communication and social dynamics. I have used these skills to great effect in every rotation I have had since.  I learned how to connect with anyone, to let people know that they are important, to make them feel valued and respected. I know the names of all the janitors in the college of pharmacy, I wrote thank you letters to every physician, pharmacist, nurse, technician, MA, secretary that I interacted with on a regular basis.  I now approach every work environment with the mindset that everyone is important, everyone has a big role and everyone deserves to be respected, and thanked.  Such mindset makes it incredibly easy to get along with preceptors and co-workers, to the point where it’s actually very enjoyable to go to rotation and work.

 I still have much to learn, but I have developed an incredible sense of social awareness, confidence and proficiency in my presentation skills.  I am not, talking about power point.  I am talking about how I present myself in social settings, how to share the best side of me at any given time, and how to be an expert in body language and sub-communication. I can now walk into a room and accurately assess how people are feeling, which allows you to calibrate yourself so that your presence becomes constructive to the group. 

When I left this rotation, I felt like I was ready to take on the world.  So far, I've done a pretty good job.  I have had great relations with my subsequent preceptors, mentors, coworkers and colleagues.  I have also been able to apply a lot of the skill sets I learned on this rotation to my personal life.   I encourage everyone who read this, to add another dimension to each rotation experience.  Don’t just stop at pharmacy and therapeutics.  Take the time to really learn about people, and how they interact in each environment. 

Tuesday, September 3, 2013

Nephrology at its Finest

Posted by Adam Loyson at Tuesday, September 03, 2013

Beginning my last year of pharmacy school about to start rotations, I was bottled up full of emotions with many questions unanswered.  Am I up for the challenge?  Was I going to be able to recall every guideline from all those long study nights?  What is going to be expected of me?  Hesitant and uncertain, I admittedly entered my first advanced pharmacy practice experience nervous.  Yet, at the same time I felt eager to enter the final stage as a student pharmacist.  What I didn’t know was how fast my first rotation was going to take my knowledge of disease management to the next level.

Strictly the Kidney
Entering the hospital on my first day, I knew my first rotation was going to be in an environment I had never experienced before: enter the world of nephrology.  Combining components from both ambulatory care and inpatient care, I found myself following patients who were brand new to hemodialysis and peritoneal dialysis as inpatients and continuing with their transition into the outpatient hemodialysis clinic.  Not only did I find patients requiring dialysis who had progressive kidney damage due to comorbidities but also those who developed acute kidney injury from a single toxic drug exposure or severe hypotension episode.    Never before had I recognized the immense delicacy of our kidneys!  It became apparent after interviewing several patients with kidney disease that health professionals have to consider multifaceted physiological, economic, and quality of life factors when managing drug therapy in this population. 
Another neat aspect in covering kidney disease was observing how mechanical dialyzers, responsible for cleaning patients’ blood of chemical waste products, operate through filtration.  Pharmacy plays a big role in overcoming the challenges these machines present by determining which drugs are filtered out and by how much.  For substantial portions of my day, you will find me performing antibiotic regimen calculations and referencing alternative dosing regimens for medications that are cleared from the blood during dialysis, being certain not to over- or under-dose patients to prevent toxicity and protect residual kidney function.  For those patients with remaining kidney function, I am reminded of the importance of having the handy Cockcroft-Gault and Modification of Diet in Renal Disease (MDRD) equations memorized along with a calculator available at your fingertips to quantify kidney function and to adjust drug dosing.

Comprehensive Patient Care
Unable to adequately perform the necessary kidney function to sustain life, kidney disease patients utilize mechanical dialyzers on a scheduled basis, multiple times per week.  Such regular visits to the dialysis unit present me with countless opportunities to further develop the clinical skills I learned thus far from my pharmacy education.  Every day, I am able to complete medication histories and inform patients on how to slow the progression of kidney failure.  I really get a kick out of encouraging patients to follow a healthy diet, participate in an active lifestyle, how to better adhere to their medication regimens, and educating them on appropriate medication administration for improved outcomes.  In addition, I actively participate in a multidisciplinary healthcare team of nephrologists, renal dieticians, renal social workers, and outpatient dialysis nurses to make certain that patient electrolyte values are within normal limits (many accumulate), supplementation is made with erythropoiesis-stimulating agents when appropriate, proper vaccinations are administered, and quality of life is assessed.  I find that the healthcare team is always very accepting of recommendations on my behalf to change therapy if needed.  Moreover, my interviewing and counseling skills are placed in the spotlight during each patient discharge given that the management of kidney disease relies heavily on individual patient participation for optimal therapy.

Learning As I Go
Every day of rotation that passes, I grow more confident in my pharmacy knowledge and become increasingly satisfied knowing that I made an impact on patient care.  With two weeks under my belt, I can already feel my career interests molding into a clearer picture of what I would like to pursue upon graduation.  While pharmacy rotations can be daunting at first, I have learned to embrace these diverse experiences.  After all, this is the best time to get your hands dirty and learn your perfect fit in pharmacy.  Stay tuned to read about my experiences in critical care next!

Sunday, September 1, 2013

3-for-1 Special: Internal Medicine, Hospital/Health System, and Ambulatory Care

Posted by Silu at Sunday, September 01, 2013

Hello everyone! Silu here, blogging from the cafĂ© at Plum Market in Ann Arbor. Like 95-100% of my fellow P4s will tell you, I cannot believe how fast this year is going by. In the spirit of Labor Day Weekend sales, this 3-for-1 special post includes my first 3 rotations. Please scroll to the headings you want to read if you don’t intent to read this lengthy post in one sitting. My apologies in advanced to the other bloggers whose posts I have probably displaced onto the next page x_x.

Rotation 1: Internal Medicine (Inpatient A), Mercy Memorial Health System
Preceptor: Dr. Tina Melanokos

Having only had experience in a large academic hospital so far, I was glad to have this opportunity to work in a Mercy Memorial Hospital, a small 200-some-bed community hospital in Monroe, MI. This was a unique opportunity to experience pharmaceutical care in different type of institution. Being a much smaller hospital, Mercy Memorial had a close-knit pharmacy staff, all of whom work together in order verification and clinical responsibilities including renal dosing, pharmacokinetic/antibiotic dosing, anticoagulation, TPNs, patient discharge counseling, and attending care coordination rounds. As students, my rotation partner Matt Allsbrook and I were responsible for these clinical duties on a daily basis. A typical day would include working up patients for any one of the clinical services offered and discussing recommendations with our preceptor in the morning, then project time in the afternoon. Beyond our clinical duties, we had special projects and additional responsibilities, including:
  • Drug information consults – our preceptor had a strong relationship with many providers, and several would ask drug-related questions. We researched and prepared write-ups to answer the more in-depth queries.
  •  IV Administration Guidelines – edited the hospital’s unit-specific IV push and IV infusion guidelines, compiling information about IV administration from several drug information sources. This was a huge undertaking, but was very much appreciated the nurse managers, who had been looking forward to a document like this to implement in their units.
  • Drug use evaluations

In addition to our daily responsibilities and projects, we also were able to spend one week in the adult ICU, where we monitored all medication therapy for the patients in the main medical/surgical ICU.  We also attended weekly safety meetings and any administrative interdisciplinary meetings of any committee our preceptor was a part of.

Overall, this was a great rotation to start with. We able to learn about these basic clinical duties offered common to many hospital pharmacy departments at a comfortable pace and low-pressure environment. Tina was an excellent preceptor and provided teaching opportunities from our everyday duties. The best aspect of Mercy Memorial was the family environment of not only the pharmacy, but the whole health system. Located in a small town, nearly all staff were from local area, and patients were often familiar to those participating in their care, giving a true meaning to taking care of their own community.


Rotation 2: Hospital/ Health System, William Beaumont Hospital (Troy Campus)
Preceptor: Dr. Scott DuFour

My second rotation was at Beaumont Hospital in Troy, MI. Slightly smaller than its main hospital campus counterpart at Royal Oak, Troy Beaumont is nonetheless a state-of the-art hospital with comprehensive inpatient and outpatient services. In addition, it’s one of the most beautiful facilities I have seen!

My rotation started off on an interesting note, where my preceptor, Dr. Scott Dufor, Director of Pharmacy, was on vacation the first week and half. Assistant Director, Dr. Dena Stout, and Clinical Coordinator, Dr. Jennifer Priziola, kindly adopted me and became my surrogate preceptors throughout this rotation.  I spent each day working with a different staff pharmacist on clinical services similar to those described in the previous rotation at Mercy Memorial. This was an interesting opportunity to see the differences in how similar duties were performed by different health systems. Besides working with the staff pharmacists, I was able to have a broad array of experiences in different areas of pharmacy operations, leadership, and clinical development, including:
  • Working with specialist pharmacists in OR, emergency, oncology, and intensive care
  • Weekly Family Medicine Rounds – an interdisciplinary group (nurses, pharmacist(s), attending physicians, residents, medical students, physical and occupational therapists, social workers, and case managers) lead by the family medicine team would gather weekly and discuss one patient, and use the expertise of each discipline to discuss treatment for the patient as a whole, even beyond the main concern for which they were hospitalized
    • **This was my favorite part of the rotation. The family medicine team truly respected the internal medicine pharmacist and valued all of the input, even eliciting further information and asking additional questions as a teaching tool for the residents and students!
  • Webinar series on pulmonary hypertension, a serious life-threatening disease requiring specialized intensive care
  • Leadership meetings/seminars with leaders of the hospital
  • Reporting adverse drug reactions and medication errors

I was also given
 several small projects, from writing an article about drug shortages for the hospital newsletter to developing a department procedure for splitting tablets to creating a comparison chart of antiplatelet drugs for nurses (and those of you who know me know my predilection for making tables/charts…).

Despite driving over 1 hour daily drive to and from Troy, I truly enjoyed this rotation. Some of the pharmacists I worked with were great teachers, and most allowed me the autonomy to perform tasks independently under their supervision (inputting orders, adjusting antibiotic doses, and suggesting changes for optimizing therapy). Other perks of Troy Beaumont? They have
 amazing home-made peanut butter granola bars and potato chips. If you’re there in the summer/fall, they have a farmer’s market by the parking lot too =). Get the kettle corn.


Rotation 3: Ambulatory Care, UMHS Canton Health Center, Canton, MI
Preceptor: Dr. Stuart Rockafellow

Having been interested in ambulatory care pharmacy since P2 year, I was beyond excited for this rotation in U of M’s ambulatory care practice. I really hoped to sharpen my patient communication skills, gain a more in-depth understanding of chronic disease management, and decide if ambulatory care is the right career path for me.

My site was at the UMHS Canton Health Center in Canton, MI. Having spent the past 10 weeks driving 2 hours every day to and from rotation, I was thrilled this site was 4 miles away from my parent’s house, where I was staying at the time. This clinic was mostly composed of family/internal medicine physicians and pediatricians. Our patients are referred from the family medicine doctors for management of diabetes, hypertension, hyperlipidemia, and polypharmacy. Dr. Rockafellow has clinic 3 half days and 1 full day per week. Patients could be called for a phone visit for 15 minutes, or be seen in clinic for 30 minutes. New patients would always have a clinic visit first, then can be followed up by phone depending on their/the pharmacist’s comfort level.

On the first day, Dr. Rockafellow and I discussed my responsibilities and goals for this rotation. I imagined he might have standard expectations of how a student should progress in terms of autonomy in patient visits, but he very much individualizes the rotation to the skill and comfort level of the student. In the first few days, I  listened/sat in on phone/clinic visits and wrote SOAP notes for each in-clinic patient. I was surprised that by the end of the first week, I was taking medication histories by myself, and at the beginning of the second week, I was seeing patients independently.

The best (and perhaps most challenging aspect) of seeing patients is the holistic approach Dr. Rockafellow uses with his patients. Not only would we manage medication therapy, but discuss lifestyle factors that may contribute to disease management such as diet, exercise, stress, and sleep. I spent about as much time discussing medication changes and dose titrations as I did providing nutritional counseling and recommending exercise regimens.  (Yes, ask me about the sugar content of a Venti Caramel Frappuccino with whipped cream, I dare you).  The challenge was trying to fit all this into a 30 minute visit, especially with the more loquacious patients.  I also had some unique opportunities to discuss with a few physicians in the clinic about optimizing medication therapy for patients and answer drug information questions.

This was my favorite rotation so far, not only because I love the ambulatory care setting, but because of the impact of excellent patient care by a pharmacist. It was inspiring to see the trusting relationship patients had with Dr. Rockafellow, most of which see him as a provider similar to their doctor. Additionally, this rotation also challenged me to become more effective at balancing quality patient care with the constraints of time and patient volume. I self-titrated the number of patients I saw throughout the weeks, taking both phone and clinic patients, and met my personal goal of running an entire half-day of clinic on the last day. This site also had a diverse array of patients of different ethnic and socioeconomic backgrounds, offering opportunities in learning how to individualize therapy based on these factors.

That is all for now! I hope you’ve enjoyed this account of the past 15 weeks so far. Stay tuned for the next chapter: Pediatric Generalist at C&W Mott Children’s Hospital!