Wednesday, September 28, 2016

Rotation 3 - Specialty Pharmacy

Posted by Jared at Wednesday, September 28, 2016

My third rotation brought me to the community site for a specialty pharmacy up in Flint, MI. I was really excited for this rotation, as I have interned in the community setting since P1 year, and I felt this would bring a new angle to it.

When I walked in the first day, I was honestly shocked at the manpower this pharmacy had. There were 3-4 pharmacists + the pharmacist-in-charge (PIC) working at the same time, along with roughly 20-30 technicians (I honestly don't know the exact number, but there were a lot) working on various things (i.e. processing, register, counting, shipping, inventory, etc.). Coming from pharmacies where the norm is one pharmacist and a few techs, this was certainly like sticker shock to me.

Typical Day

The other P4 on rotation from Ferris State and I would usually arrive in the morning at 9 AM. We would generally start by doing doctor calls and following on problems that the pharmacists or techs wanted us to resolve. Afterwards, we would do a number of different things. We might help out in the pharmacy with answering phones, counseling patients, answering questions, or practice verifying prescriptions. We would have a half hour break for lunch, and then essentially doing similar things until I left for the day at 5.

Sprinkled throughout the rotation, I would work on various projects, topic discussions, along with shadow different parts of the pharmacy and ask questions. It was interesting to me that interns at this site had office space, so it allowed me to get away from the busy, loud environment of the pharmacy and gave me some quiet time to get away. Also, we did immunizations and MTM sessions as well! I would also often tell patients that were getting controls or narcotics about issues we had filling them. These often involved warnings about how we might not fill them in the future for whatever reason, or if we were denying them because they had filled too many of these types of prescriptions at too many pharmacies. I certainly had a lot of interesting interactions from these encounters.

Overall Thoughts

Having a community background from interning, I was a bit nervous in general about how this was going to go. I had heard horror stories from previous P4s and different classmates about how many people on their community APPE just get stuck doing tech work because it's too busy for them to really talk with their preceptor and learn. Luckily, this site was nothing like that at all. My preceptor really tailored the rotation to things that he felt would help me the most in terms of learning. Due to the nature of the site, I was exposed to a lot of specialty drugs I had not really heard of in the past. From this, I was able to learn different regulations that go into being able to dispense these medications, along with the limited amount of pharmacies nationwide that are able to dispense them.

Also, my preceptor didn't have us do any typical tech work at all (counting/processing), which I was really thankful for. The topic discussions we did really helped me to revisit OTC medications, which I honestly hadn't dealt with since P1 year. I also got much stronger at my counseling skills, due to the sheer number of questions we fielded either from prescribers, nurses, or patients. Furthermore, my projects I did were really tailored to what I was interested in looking at. For example, I did a topic discussion on Hepatitis C and a presentation on transitions of care and the potential role community pharmacy could play. Finally, I was able to go to the company's corporate headquarters for a few days and shadow different people to get a further sense of what specialty pharmacy is really like, along with their daily operations on a national level.

Ultimately, I think this rotation was really fantastic. I'd highly recommend it if you have previous community experience and want to see a different side to things. The pharmacists and techs are great and really emphasize student learning, as they almost always ask a student to deal with the problem first if we're capable of doing so. However, I will say that if you have never worked community before, I would almost recommend going to a larger chain, as I feel everyone needs the experience of counting a lot of medications, along with processing insurance to really get a comprehensive community experience. Due to my site's system, along with some of the complex, expensive medications that might have to be billed, I don't know that P4s would necessarily be able to jump in and deal with insurance, as it would really interrupt the site's workflow.

Tuesday, September 27, 2016

Rotation #3 - Ambulatory Care Oncology

Posted by Unknown at Tuesday, September 27, 2016

On this particular rotation, it was certainly a mix of emotions. While there were certainly some low points, the high ones outweighed those by a wide margin.

This rotation was not nearly as complicated as the others and I was able to establish a routine from nearly the end of the first week. I’ll break down how my days generally went based on the day of the week.

Monday – Most of my time Monday was spent preparing for Tuesday-Thursday patient interactions. Working up patients, presenting them, and answering various drug information questions took up a majority of my time here.

Tuesday – In the morning, I would continue to work up patients, wrap up drug information questions, and work on special projects. In the afternoon, we had our biweekly chemotherapy teaching sessions. Myself and nurse would go through various IV chemotherapy regimens with patients that were going to receive them. We would go through what their regimen was, what days it was on, how it was administered, other medications that came with it, side effects that are common, side effects that are specific to their chemotherapy, and field a variety of other questions. These sessions typically had 10-16 people in them (family and friends could attend too) and lasted on average 3-4 hours.

Wednesday – In the morning, I had my oral chemotherapy patients come in for chemotherapy teaching. We typically had three, one-hour block sessions set in the morning. Patients typically came with one to two other people and we would sit in our library and go over their chemotherapy regimen. These regimens were a bit different than the IV ones. These were all taken at home, and aside from laboratory monitoring, they did not come in to see us again (barring side effects). These sessions typically did last the entire hour. We went a lot more in depth on how to manage side effects and what to do if they experience them in these sessions compared to the IV chemotherapy teaching sessions (in my opinion).

Thursday – This day was pretty much a clone of what I did on Tuesday. Often times, we would have patients rescheduled onto different days and this often led to last minute work up of patients on Thursdays, prior to our IV chemotherapy sessions.

Friday – If patients had been scheduled for next week, I would work them up first. Otherwise, I would be working on special projects, drug information questions, and patient education materials.

Random special events
-        Shadowing nursing during various procedures and administrations (IP chemotherapy (Fascinating), IV Iron, bone marrow draws, etc.)
-        Inspecting chemotherapy rooms for compliance
-        Journal clubs
-        P & T committee meetings

What I was doing when I was not working up patients or chemotherapy teaching:
      Patient education materials – At the institution that I was at, we made up most of our patient education materials. These were tough to make because you often times had to go through the clinical trials of the oncology drug in question, look at the adverse events reported (and all the other information), and create them based off of that. I wish I could provide a sample here but they are institution-specific and I cannot. Sadly, words will not do justice to what goes into these but they were tough to create and took up quite a bit of time.
      Drug information questions – LOTS of drug information questions. They mostly centered around herbal medications and supplements. I cannot tell you how many of these I answered. Often times, patients would be on several of them at once. It became extremely difficult to manage drug-drug interactions and safety in general with patients being on numerous medications, oncology regimens, and anything else they were taking. I recall one patient being on over twenty different prescription + over-the-counter products, while taking ~7-8 different herbal medications and supplements. This did not include their oncology regimen.

      Overall, I had an absolutely wonderful experience on this rotation!

Sunday, September 18, 2016

Rotation 2 – Solid Organ Transplant: A New Lease on Life

Posted by Emily VanWieren at Sunday, September 18, 2016

Rotation 2 – Solid Organ Transplant
A New Lease on Life
First Impressions
I was super excited to start my first day with the surgical transplant team. There are a multitude of complex medications used in transplant recipients, and I knew there would be a great role for a pharmacist on the team. I wasn’t super excited that rounds start at 6 AM. The first day I set my alarm at 4:15 was painful - I am not a morning person!

There were over twenty people on the surgical transplant team, which turned into a super intimidating herd of white coats blocking the hallways on rounds. The team was inter-disciplinary and consisted of physicians in all ranges of training from attendings on down to fellows, residents, interns, and medical students. There were Physician Assistants, Nurse Practitioners, and also the pharmacist. You could tell the team respected my preceptor because they straightened up when they heard her walking down the hall. She had recommendations on dosing, stopping this drug, starting that one, ordering new labs, and the team accepted the changes she suggested. I was so impressed by all her knowledge of the patients and their medications!

A Day in the Life
The team I was with transplanted livers, kidneys, and pancreases. My typical day consisted of early morning rounds with the surgical transplant team followed by rounds with the nephrologists in the morning and the gastroenterologists in the afternoon. In between rounds, I would look up questions from the medical team and talk to the patients. I interacted with even more interdisciplinary members of the team and I got a full appreciation of all the care that goes into each transplant recipient. There were social workers, nurses, discharge planners, dieticians, and even interpreters for a deaf patient.

My favorite part of this rotation was educating patients on their new medications. There are a lot of new medications transplant patients have to take to suppress their immune system and prevent infections and they have to take them on a very specific schedule. I taught them the names of their medications, why each one is important, when to take them, and when they need to get their blood levels checked. I got to establish relationships with the patients and it was cool to see their new lease on life and how serious they were about taking their medications to keep their new organ.

Megan and I were able to watch a kidney transplant from a living donor to a recipient. We weren't sure how our stomachs would handle it, but we were both so fascinated and didn't feel squeamish at all. The surgeons talked us through the procedures and we were able to see inside a living human's body! It was also cool to see the anesthesiologists in action since they choose, prepare, and administer all of the medications on the spot. It was humbling to see the whole process from donor to recipient and then educating the recipient on their new medications.


On this rotation, I learned a lot about transplant medications and many other therapeutic areas such as diabetes, hypertension, and kidney and liver disease. It was very rewarding to be able to make an impact on patients’ lives by teaching them about their medications and how to support their new organ. On my next rotation, one of my patients recognized me and waved me down. She wanted to thank me again and tell me how well she was doing and that she hasn’t missed a dose. I spent many long days at the hospital and sacrificed sleep on this rotation, but it was well worth it to see the full impact of a pharmacist’s role on the medical team.