Tuesday, December 30, 2014

Nontraditional Paths: My Experience in Industry

Posted by Unknown at Tuesday, December 30, 2014

I spent my second rotation block in Cincinnati, Ohio, with a specific focus in Feminine Care Product Safety. When initially received the assignment, I honestly did not know what to expect. However, I realized soon after I arrived that I had been given an invaluable opportunity to improve the knowledge base of individuals working in this area once I learned more about the project I would be working on over the next five weeks.

The main project that I was given was to look into mucosal absorption of chemical compounds. Many of the individuals that I was primarily working with had backgrounds in toxicology and regulatory affairs, so they were truly excited about gaining some perspective from someone with a different perspective. Overall, my project involved gaining an understanding of key physiological features of these physical membranes, and also revisiting the importance of physicochemical properties when trying to look at what may or may not be absorbed across mucosal tissues. These components required numerous literature searches to retrieve and compile a lot of this information. However, as I came to the end of my rotation, I was able to also apply my pharmaceutical science knowledge to my final recommendations for what to do next, and was even able to discuss my suggestions with other scientists in the area to confirm that my thoughts were valid.

Throughout this project, I met with my preceptor and others in my focus area in order to understand their needs and also ensure that my project remained on track throughout the course of my rotation. My project culminated in a thorough written summary of all of the literature that I came across as I worked on the project. In addition, I gave a 50-minute presentation at the end of my rotation to the individuals in my area so they could learn about everything I had worked on, and what the next steps were that they needed to take in order to progress my project. What was especially neat about this presentation was that they turned it into a continuing education (CE) credit for all of the PharmDs at the company. 

P&G also provided us with a list of PharmDs at the company to reach out to about their experiences at the company and the career paths that led them to where they were at that time. They specialized in numerous functional areas, and were all truly passionate about the areas and projects that they were working on. The consistent message from each of these individuals was that P&G was oriented around their personal and professional development, and many noted that they had been able to pursue projects outside of their own scope of practice in order to broaden their exposures to the many products and initiatives that the company was working on. In addition, many of the individuals that I met with pointed me to other professionals in areas that I was interested in learning about.

Overall, my rotation at P&G was an amazing experience. This rotation truly pulled on the knowledge that I had developed as a PharmD student, but also challenged me to dive into an area that I had never really considered previously. I would highly encourage anyone interested in more of a research or industry career to definitely consider this rotation as part of your fourth year experience.

Internal Medicine: A Pun-tastic Rotation

Posted by Unknown at Tuesday, December 30, 2014

Deep breath... turn on your music... okay.... here we go.

I still remember those words that I uttered to myself as I turned on my iPhone and headed to UMHS for my first APPE rotation. During my P1-P3 year, I had shadowed my P4, paid attention to the orientation, and emailed my preceptor about the ways of the rotation. Yet, I walked into the hospital that day feeling completely unprepared. How early did I have to wake-up again? How much detail should I work-up my patients? And frankly, what does work-up even mean? I let these thoughts be drowned by my music, as I cleared my head and stepped into UMHS hospital.

My preceptor was Dr. Regal, a pun-tastic preceptor who uses his seemingly endless array of jokes to help students remember tricky concepts. Known for being challenging in his P1 pharmaceutical care course, I was worried that this rotation would hold me to the same level of difficulty. However, I learned that this rotation would turn out as one of my favorites, and it would completely change my mind in pursuing residency training after graduation.

At internal medicine, we would see patients for every-day conditions, from suspected hepatitis C diagnoses to severe infections to unresolved nausea and everything in between. Instead of learning a few disease states in great detail, I learned a moderate amount of information about many of the common conditions that can land an otherwise healthy adult in the hospital. On my first day, I gave a recommendation of a vancomycin dose for a middle-aged woman, suggested a warfarin dose for a patient with afib, and observed as the medial team tried to find a therapy for a woman with a persistent GI bleed. The simple variety in patient conditions made rounds every morning feel like a new adventure.

Differing from some specialty rounds, internal medicine rounds started at 8 or 8:30am. I usually arrived at the 8th floor of the hospital, where our medical team gathered before rounding, between 7 and 7:30 am to review the patients' charts. Since the medical residents and medical students present patients and offer recommendations to the attending, I did not have to have every patient formally worked-up SOAP note style before walking through the door. As the course of the 5 week rotation progressed, I learned what aspects of patient care I needed to know as a pharmacy student and I was therefore able to work up patients very quickly. By the last day of rotation, I could work up one patient in 10 minutes.

After the initial meeting with the medical team, rounds would go until 10am-noon. After rounds I would call my preceptor to summarize interventions that the medical team made and answer any questions that he had. If I did not know an answer to a clinical question, I would look up the answer during my lunch break. The afternoons were spent in Victor Vaughan, as Dr. Regal would print out articles for us to read and teach us therapeutic concepts. The main points I learned from this rotation included warfarin optimization, calcium and vitamin D supplementation, antibiotic therapy, and different types of anemia. These concepts were solidified with an exam during the last week.

Along with the above therapeutic concepts, I also learned how to be "annoying" as the clinical pharmacist rounding with the medical team. I learned to pester the medical resident to make sure the patient was taking iron due to a ferritin deficiency, that there was a specific indication for a patient's omeprazole use, and that the patient using over-the-counter pseudophedrine had well-controlled blood pressure. I was surprised that the majority of my interventions were medication discrepancies that could have easily been settled in the outpatient setting. From this rotation, I learned that our community and outpatient pharmacists must try to optimize their patients' medication regimen as well.

On my last day of rotation, I walked home from the hospital, again taking a deep breath and turning on the music on my iPhone. I had survived my first clinical rotation, and I had learned more in those past 5 weeks than I had the entire year before. And I finally felt ready to tackle the rest of P4 year.

Welcome to Detroit City

Posted by Unknown at Tuesday, December 30, 2014

On the first day of my community APPE, I hopped in my car and headed to a place as unknown to me as the arctic tundra: Detroit. A city where my grandparents had once found careers and raised my parents, who, like most other Polish-American middle-class families, fled to the suburbs the moment they had the opportunity. Once established in Troy, my parents only visited the Motor City for downtown hockey games and theatrical performances. Before this rotation, I had only known the city for its stretch of I-75, and everything beyond was left to footage seen on the news and the internet. Little did I know, I would be experiencing Detroit first-hand during my third rotation in community pharmacy.

I first arrived at midtown, on the northwest portion of Wayne State University's campus, on a warm September morning. After an hour and 15 minutes of sitting in traffic, the 5 minute walk to the independently-owned pharmacy felt nothing short of amazing. When I stepped inside the small downtown-like shop, I knew I would be walking into the most interesting 5 weeks of my fall semester.

University Pharmacy is an independently-owned pharmacy by an Rph whose main professional goal is getting PharmDs health provider status. While one pharmacist manages the daily duties inside the store such as checking prescriptions and maintaining inventory, the owner, my preceptor, spends her time in the community providing services and advocating for the profession. My first day, while I figured out how to park at Wayne State's campus without being a student, my preceptor quizzed me on my strengths, weaknesses, and future plans for the profession.

While I didn't spend any time during this rotation learning therapeutic concepts, I instead spent my 40 hours per week providing TB tests and flu shots to different sites within the Wayne State Physician group. My preceptor alerted me to the worries some health care workers had regarding the shot and the pharmacists that provided them. While in the clinics, the complaints patients had about pharmacists providing immunizations stung as much as the shot itself. We even had one secretary ask for a nurse to provide the shot instead of me!

In addition to perfecting my flu shot education and technique, I also learned about the unique challenges that independent pharmacies face. For example, during my internship at CVS, I never had to examine the pharmacy reimbursement for each prescription, the inventory and production used scanners for accuracy, and all tasks, including flu shots and other services, were provided right at the pharmacy front counter. At University Pharmacy, I was able to see how little the pharmacy gets reimbursed for selling generic medications, that the pharmacy did not have the funds for scanner-integrated technology, and that all services, including flu shots, were provided in a separate office in back. In order for the pharmacy to stay competitive against the nearby chains, they partnered with Wayne State University to run flu clinics, provide lectures for the medical students, and screen blood pressure, cholesterol, and glucose for Wayne State faculty and staff.

In a brisk day in mid-October, I hopped onto the Lodge freeway and headed from Detroit to Ann Arbor one final time. Even though I was excited to have less of my money spent on gasoline, I was sad to leave University Pharmacy and Midtown Detroit, a place that had very quickly felt like home. Although I did not leave my rotation with new clinical knowledge about certain disease states, I felt invigorated to become a leader in the community pharmacy setting. And I felt excited to once again visit Detroit, a city which now feels a little less unknown.

Thursday, October 23, 2014

Surgical Intensive Care Unit

Posted by kamer234 at Thursday, October 23, 2014

It’s hard to believe that I have finished half of my rotations. It is one thing to know P4 year will go by quickly, and quite another to experience it!

So far I have completed my community, drug info, institutional, and surgical ICU rotation. I have had wonderful preceptors and experiences across the board, but I think the SICU tops the list. I worked with extremely complicated patients and was continuously exposed to new disease states and twists on familiar conditions. There was a steep learning curve, and it took me longer to feel comfortable on this rotation than any of the others because of the complexity inherent in each patient.

I started off the rotation following 2 patients and worked my way up to "owning" 10-12 and keeping tabs on the rest of the patients in the unit. One major plus of this rotation was the autonomy that Dr. Miller afforded me. I determined when I was ready to take on more patients.

My typical day started at 6 am when I began working up my patients. While working up patients I would look for medication related issues and would run it by either the resident or my preceptor prior to rounds. I would work up patients until rounds started shortly after 8am. Most days I rounded with the PGY2 resident or the pharmacist, but occasionally I would round by myself. Rounds on the SICU last anywhere between 3-4 hours, which can feel long some days, but I found that increasing my patient load helped keep my interest engaged. I also tried to listen for at least one unfamiliar condition, lab, drug side effect, etc per patient that I could look up later. 

My afternoons were spent reviewing patients, following up on questions, and one of my favorite parts of every rotation - topic discussion! I may be an outlier among my classmates, but I find topic discussion to be an efficient learning opportunity. In theory, it may sound similar to preparing for a therapeutics class or an exam, but in reality the material feels more practical and easier to remember after the topic. I find my learning to be facilitated by the opportunity to connect the topic to patients I see every day. 

My family and friends often asked if this rotation was difficult from an emotional perspective. During my 5 weeks in the ICU I saw many different types of patients and outcomes. While some cases were more difficult to face, most patients recover enough to leave the ICU, and there are a few patients who make the type of rapid recovery that refreshed my emotional stores. 

This rotation provided innumerable learning opportunities. This rotation is great for anyone looking to challenge themselves and learn a lot in a short amount of time. 

-Kallie Amer, PharmD Candidate 2015

Wednesday, October 22, 2014

Community Pharmacy in St. Ignace, MI

Posted by Unknown at Wednesday, October 22, 2014

Growing up in Southeastern Michigan, my family and I made many trips over the Mackinac Bridge into Michigan’s Upper Peninsula for vacation, recreation and exploring “Pure Michigan”.  However, this time over the bridge into St. Ignace was different.  It was time to move away from Ann Arbor to develop an understanding of how pharmacy operates in the Public Health Service and to experience the culture of a unique population, the Sault Tribe of Chippewa Indians. 

I woke up just after sunrise to make it to my first day of Rotation 2 at Mackinac Straits Health System working in the Tribal Pharmacy.  When I arrived at my site, I took a few moments to take in the scenery and saw this gorgeous view:

Immediately, I thought, “I could get used to this!”

After orientation to the pharmacy, clinic providers and systems, I started counseling patients as they picked up new prescriptions or inquired with questions.  On the second day, I began meeting with patients prior to their provider appointments in the Tribal Health Clinic.  These patients presented with either acute conditions or for chronic disease management.  During my time with the patients, I assessed vitals, reviewed medications, discussed concerns and ultimately made recommendations to the doctors or nurse practitioner after discussions with my preceptor.  Over the next five weeks, I spent about half of my time working and interacting with patients in the pharmacy and the other half of my time with patients and providers in the clinic.  This is a very unique practice setting aside from the traditional community pharmacy.  Here, the pharmacy is directly connected with the clinic, allowing for significant interprofessional collaboration and access to the patient’s medical and medication history and pertinent lab results.  This rotation and practice model allows for a unique blend of community and ambulatory care pharmacy in order to provide exceptional patient care.

On the afternoon of my first day, one of the clinic doctors posed a question regarding hallucinations and acute mental status changes in an elderly woman.  When this discussion started, I immediately associated the symptoms with a urinary tract infection (UTI) and sought the lab results from the urinalysis (UA).  The patient had documentation of a UTI two weeks earlier and completed a course of empiric therapy with ciprofloxacin approximately one week before returning to clinic.  Upon review of the results with my preceptor, we determined that the bacteria causing the UTI was resistant to ciprofloxacin.  The prescriber planned on extending the course of therapy with ciprofloxacin, but after reviewing the culture and sensitivities and performing a repeat UA, I recommended changing to an agent that the bacteria was sensitive to, nitrofurantoin.  Fast forwarding through the rotation, the patient’s UTI and symptoms resolved over time with this treatment.  As a student pharmacist early on in my Advanced Pharmacy Practice Experiences, it was extremely exciting to make a significant intervention and to impact patient care from the start of the rotation!

This sunset is from one of the last few nights as my rotation grew to a close.  While I only had the pleasure of working and learning at Sault Tribal Health and Human Services for five weeks of my last year of pharmacy school, I would go back in an instant!  I am so grateful to have had this community pharmacy experience to develop personally and professionally. 

P.S. The excellent providers and co-workers that I had the opportunity to work with and the gorgeous scenery are just an added bonus! 

-Jessica Fennelly, PharmD Candidate 2015

Tuesday, October 7, 2014

Rotation 1: It's a thin line...

Posted by Lauren Leader at Tuesday, October 07, 2014

... between bleeds and clots

MR is a 50 year old male who has had an LVAD machine since 2009. He presented to an outside hospital for management of continuous bleeding after severing a finger. The outside hospital held his warfarin and gave him a single dose of 5 mg of vitamin K, what do we do?

I spent my first rotation in ambulatory care specializing in anticoagulation. The service was a nurse run warfarin management facility with two pharmacists on staff. Pharmacists were specifically in charge of patients with LVAD (left-ventricular assist devices). These devices require more intense warfarin management due their increased risk of clotting. The majority of my time was spent monitoring patients INRs and having phone interviews to assess their regimen and make changes if necessary. The other valuable portion of this rotation was that the pharmacists on this service worked with the cardiology team to consult and follow TSOAC (target-specific oral anti-coagulants).


TSOACs are new medications and extremely useful medications. I was able to learn about the studies that the FDA used to approve these drugs, why one might be better for another give specific patient parameters and it was exciting to learn so in depth about something so new.

Also, on this rotation I had weekly meetings with other students on ambulatory care rotations throughout the health system. We had topic discussions, journal club meetings and case presentations which helped to increase our learning and prepare use for life-long learning opportunities in the field.

oh, the patient... almost forgot! We hardly ever give LVAD patients vitamin K since it directly inhibits the anticoagulation effects of warfarin and it is imperative that patients on LVAD machines stay anticoagulated. We gave him a two consecutive bolus doses of warfarin (one that day and one the next day) then restarted him on his previous maintenance dose. We were able to keep the patient from needing other forms of anticoagulation which was a win for everyone.

Rotation 3: Sleepless in Seattle (but it's a good thing)

Posted by Lauren Leader at Tuesday, October 07, 2014

Day 1: I woke up early to get to rotation by 9 am since I knew I would encounter traffic on the I-5 Southbound. Between watching the road and the GPS, I barely missed it. Right in front of me was a phenomenal view of Mt. Rainier. Seattle in late summer is void of its traditional rainy weather and is instead a beautiful, crisp 70 degrees, which lends to clear skies and amazing views from all around town. Enough about the city, for now. I arrived at the managed-care organization I would be working with and met my preceptor. We immediately started talking about the expectations for the rotation and what I would like to experience and what she would like me to accomplish. The list started out small. I knew I would like to get experiencing writing a drug-monograph, work with formulary management, answer drug-information questions and spend time at the help-desk assessing insurance claims. I thought that would be absolutely plenty to accomplish in the next 5 weeks. I met the team and the pharmacy residents I would be working with and set out to my first meeting to receive my first assignment. I met with the formulary coordinator and she said she had a drug monograph she would like me to write, now, never having written a drug monograph before I was extremely intimidated and concerned I would not be able to accomplish the task. The coordinator and I set goals for the different parts of the formulary and decided to meet weekly to review the sections, that made me feel MUCH more comfortable. I began to work on research for the monograph, when suddenly it was time for my second meeting of the day. I met with another team member in charge of prior authorizations. This company does formulary reviews every quarter and new prior authorization templates are typically required after each review. My task would be to create templates for the drugs that were new or needed to be updated. This was something I felt that I could accomplish much quicker and more easily. Eventually it was time to head home and this time I didn't miss a single bit of scenery.

Day 25: By the last day of rotation I never thought I would have completed as many projects and learned as much as I had. Not only did I muddle through, develop and present my own drug monograph, I was able to publish a nationwide article comparing the use of testosterone products and cardiovascular events, observe a statewide meeting to develop a standard protocol for prior authorizations among managed care organizations, assess pharmacist reporting and outcomes for MTM services and present the analysis to the pharmacists for improvement, make decisions on whether a particular drug should be covered for a patient, and of course experience the life and food of Seattle. As I think back on this rotation I am glad I took the opportunity to travel and I had so many more experiences than I could have ever imagined.

Sunday, June 15, 2014

The Final Rotation

Posted by Adam Loyson at Sunday, June 15, 2014

Lightning McQueen fast. That is how quick my rotations seemed to go by in my final year of pharmacy school. For those of you who have joined me in completing their pharmacy education, congratulations! For those starting rotations or beginning your summer break, I write to you about my final rotation with the pediatric emergency department team.

As a prelude, the foundation of this pharmacy rotation was similar to that of the adult emergency department rotation I completed last August. Nonetheless, I was very excited to work with children and soon discovered the many unique pharmacy aspects there are to consider when working with this young population. I started the rotation with a bang and the excitement just kept building from there!

A diverse population

Children make up approximately a quarter of the population. Yet, about 60% of medications do not have FDA approval or dosing recommendations for pediatric patients. From premature infants to children big enough to be considered adults, several challenges exist when considering pharmacotherapy for children. There are differences in pharmacokinetics and pharmacodynamics, limited evidence for medication use, and lack of appropriate formulations.

With much of the data extrapolated from adult patients, I quickly found working in pediatric pharmacy more of an art than a science. Recognizing that children are not just little adults, I was faced with the challenge of taking absorption, distribution, metabolism, and elimination into consideration for each individual patient. Dosing was no longer constant, but calculated per body weight and surface area. Vital signs and laboratory values were also different from adult patients, which drove home the need for pediatric health care providers to have an eye for detail and accuracy.

Ready to work

Realizing that standardized treatment algorithms for disease states in pediatrics are extremely hard to come by, I rolled up my sleeves and prepared to round up treatment evidence in the National Library of Medicine. Monitoring patient admissions, I quickly discovered the wide level of acuity that children present with when arriving at the emergency department. Although there were a large number of children with low acuity conditions, such as mild playground injuries, but there were also many that required extensive health care provider input. These cases included asthma exacerbations, anaphylactic emergencies, traumatic brain injury, diabetic ketoacidosis, seizures, headache/migraines, cystic fibrosis, and many others.

As the student pharmacist on rotation, I was responsible for assisting physicians and recommending treatment options, providing transitions of care medication reconciliations, antibiotic kinetics, and counseling about discharge medications. This was no ordinary rotation though. I experienced a heart-tugging desire to do everything I could to help the sick children.

Another really neat aspect of my rotation was extensively helping the health care team with incoming traumas. It was not uncommon for me to anticipate the use and draw up a wide array of medications for resuscitation (epinephrine, atropine, calcium, magnesium), along with those used for rapid sequence intubation (procedure for a breathing tube), antiarrhythmics, anti-seizures, and medications used for pain control. I also frequently communicated information about the rate of administration and methods of drug delivery. I was always up to the challenge, knowing that each second counted.

Dream come true

Finishing my rotations as a student pharmacist has been bittersweet. I have had amazing hands-on learning experiences, great preceptors, and will miss the many opportunities to make a difference in so many different health care environments. From working with patients with chronic kidney disease on dialysis to studying the implications resulting from the New England Compounding Center meningitis outbreak to providing medication therapy management services to Native Americans, I couldn't have asked for a better final year. I can’t wait to use my knowledge gained to make an immediate impact after graduation.

Looking to the future, I am happy to announce that I have recently accepted a job offer to work at FDA in the Office of Generic Drugs–Division of Bioequivalence as a pharmacist project manager. In this role, I will supervise a team of pharmacologists and will act as a lead liaison to industrial applicants. As someone who has dreamed about entering the public health field right out of pharmacy school, I couldn't be more excited to see where the future takes me!

I have really enjoyed writing about my rotations in the UofM College of Pharmacy's On Rotation blog and hope I shed light on the rotations and highlighted new career opportunities that you might want to pursue in the future. I look forward to new practitioner life and continue to support the pharmacists of tomorrow.

Once again, congratulations to all of this year’s graduating pharmacists!

Adam Loyson is a 2014 graduate.