Wednesday, August 9, 2017

Rotation 2: Less Is More In Critical Care

Posted by Unknown at Wednesday, August 09, 2017

Less is more. That was the recurring theme of this rotation. Less is more, especially in the ICU. I just finished up critical care in Detroit and “less is more” is the phrase I kept hearing from my preceptor, my attendings, and even some of the medical residents. During my first week, my preceptor and I were sitting down talking about possible interventions for a specific patient and he said, “Less is more in critical care. If you walk into a patient’s room and you don’t know what to do, the patient has a greater chance of survival if you just close the door and do nothing.” I always kept that in the back of my mind when working up patients. The exciting part was that during my second week, the new medical residents were starting their residencies. I learned that they had a tendency to take a more conservative approach with their interventions because they wanted to be safe. Because of that approach, I have had many situations where I had to try to convince a resident to discontinue a drug or decrease the dose, depending on the situation.

Because I was in Detroit, I dealt with a much sicker patient population than what we see in Ann Arbor. I would say that’s what made me most nervous when starting this rotation. It was my first inpatient rotation, it was my first rotation overall, and I was doing a specialty. Because it was critical care, I was trying to prepare myself for the worst of the worst. As I’m writing this, I can tell you that I have seen almost every type of patient out there on this rotation. From gunshot wounds and stabbings to drug overdose to cardiac arrests and COPD exacerbations; I’ve seen it all and I was learning so much.

Here is an insight to what a normal day looked like for me:
6:30 AM-7:45 AM—Arrive to hospital and work up patients
7:45 AM-8 AM—Pre-rounds discussion with preceptor
8 AM-11 AM—Rounds with MICU team
11 AM-Lunch—Post-rounds discussion with preceptor
1:30 PM-4 PM—Topic discussion, clinical questions, updates on patients

Throughout my rotation, I had 4 different attendings. Each attending had a different starting time and different pace during rounds. I had to learn how to manage my time for each attending. Towards the end of my rotation, I had to show up at the hospital at 6 AM because my attending started rounds at 7:30 AM. I needed time to work up old patients and new patients (and sometimes that still wouldn’t be enough time to prep).

I was extremely lucky with my preceptor for this rotation. He was very knowledgeable and he always challenged me. On my first day, he said, “I’m going to ask a lot of pathophysiology questions. You’re going to hear ‘why?’ from me a lot. You’ll be tired of it by the end of this rotation.” And boy, was he right! I had to explain the rationale for anything and everything that had to with a patient. Whether it was my dosing recommendations, the side effects the patient may be experiencing, why the patient is improving, why the patient is not improving—I had to explain it all. Most of the time, I didn’t know the answer. Sometimes he would explain it to me, sometimes he would make me look it up and explain it to him after lunch, and sometimes he would make a topic discussion out of it. Looking back at those moments, I’m glad he challenged me that way! Pathophysiology was never my forte but understanding the “why” behind everything allowed me to be innovative with my recommendations.

One of the things that stood out to me the most during this rotation was how the nurses and physicians appreciated pharmacists. I admired the respect they had for my preceptor and his recommendations. I enjoyed watching some of the residents and attendings lean on my preceptor for his input and really depend on him. If he disagrees with something, they will listen to him. If he has a warning, everyone on the team will make note of it when monitoring the patient. It was refreshing to see. I have been told by multiple attendings that I was lucky to placed with my preceptor because I was going to learn so much from him and they were right!

I learned so much on this rotation and by the end of the 5 weeks, I felt like there was still so much more I needed to learn. I feel like this rotation has prepared me well for my upcoming inpatient rotations. If all my rotations are going to be like this one, then I’m in for a ride this year!

Saturday, August 5, 2017

Rotation 2: The Crazy World of Detroit ID

Posted by Josephine at Saturday, August 05, 2017

My Rotation 1 was community pharmacy so this ID consult service rotation was my first inpatient/hospital rotation. I will preface this entire blog post by saying it was one of the most character-building and mind-changing experiences I have had thus far in pharmacy school.

The Typical Day
6:30 AM: Arrive at the hospital
6:30 – 9:00 AM: Work up patients, check labs, solidify assessment/plan, etc.
9:00 – 10:30 AM: Meet with preceptor to discuss patients and go through topic discussions, would sometimes meet for longer depending on when rounds started.
10:30 AM – 6:30 PM: Various, schedule built around attending and the ID consult team (ID medical fellow + 2nd/3rd year medical resident + medical student + ID clinical pharmacist + me! the pharmacy student). For the pharmacy student, priority was given to rounds, which could sometimes go as late as 6-7 PM. Other things would fit in such as attending grand rounds/different lectures, working up patients for the next day, preparing topic discussions, answering any questions from the preceptor or consult team, etc.

I would typically arrive at 6:30 AM in the morning and leave the hospital around 6:30 PM… and do more work at home. Saturdays were for completing the additional work of this rotation – writing a paper, doing a journal club, etc. Sundays were for working up patients for Monday.

*Fair warning, this was not an easy rotation. It might have been easier for someone that has already had an inpatient rotation, but even as a baseline, it was very challenging.

The Main Responsibilities
1.     Patients: I would work up 2 new patients each day in an accumulating fashion (Day 1 = 2 new patients, Day 2 = 2 more new patients + 2 patients from Day 1, and so on). For each new patient, I would be required to prepare a topic discussion on the primary reason for ID consult (so, 2 topic discussions daily), in addition to an assessment and plan. The consult service itself followed perhaps 15-25 patients, but the most I had to follow at one time was perhaps ~10 (which was already a lot for me..) In total I think I did about 30 topic discussions. 
2.     Dosing: For each of the patients I was following, I was required to do dosing calculations by hand for vancomycin and aminoglycosides (no shortcuts with PK calculators).
3.     Review paper: a minimum 4-page well-cited review paper was required. The topic could be an ID topic of the student’s choice. In my case I wrote about Carbapanem-Resistant Enterobacteriaciae with a focus on new agents in development. Very exciting stuff.
4.     Journal club: As is typical in the other rotations, I was required to give 1 journal club on an ID topic, preferably comparing 2 drugs.

Why was this rotation so exciting?
ID in Detroit is definitely NOT like it would be at a small community hospital. For one thing, the consult service sees patients with more difficult to treat or unusual/uncommon infections. The Detroit patient population is also interesting (lot of HIV/AIDS and IV drug abuse.) The types of infections we encountered were also skimmed over or not really covered during P3 therapeutics. For example – in addition to a lot of MRSA, I saw multidrug-resistant pathogens (like carbapenem-resistant acinetobacters/Enterobacteriaciae), strange but problematic pathogens we never even hear about in school (like stenotrophomonas), and even uncommon disease states (like neurosyphilis).  And of course, we also got the whole slew of infections caused by opportunistic pathogens in the uncontrolled HIV population – so cryptococcal meningitis, PCP PNA, etc. I definitely learned a lot in preparing my topic discussions, that is for sure.

Because of all this, I was able to see how we might use unconventional and creative methods to treat patients. Remember those “big-gun” typically non-formulary agents we barely learned about in P3 therapeutics? (linezolid, daptomycin, carbapenems) Yeah, we used those a lot. Also used other interesting combinations like polymyxin B + meropenem, vancomycin + cefazolin, daptomycin + ceftaroline. All of this leads me to see that ID practice in Detroit is quite progressive.

I should also mention that my preceptor is very involved in gram-positive research. Therefore, part of what made this rotation so exciting is that I got to learn about how the anti-infective research being done at this institution is creative and quite literally practice-changing – no joke, I only spent a month here, but I was quickly able to see that the data coming out of this lab (and others like it) actually affects the ID treatment decisions and pathways in place at the hospital. And that’s kind of incredible.

This rotation also gave me a great opportunity to practice my vanco dosing. I say that especially because this institution doses vanco by AUC instead of by troughs. I was really lucky because through doing all of those calculations by hand, and through discussions with my preceptor and his fellows, I gained a more full understanding of vanco PK/PD. Yes, it was tedious… but it sounds like more institutions might be adopting this in the future, so it was a good thing for me to learn.

The People: A huge factor in making this rotation so enjoyable.

My preceptor is super knowledgeable about ID and clearly very passionate about the field. I will say that he’s very high in demand and also very busy, but he always made time for me; in addition to the morning discussions (sometimes going on for hours), he was constantly available through email or text or phone call. He was instrumental in getting me to think with an evidence-based mindset (see below) and helped me learn to question things like the patient's condition, how certain infections occur, the team's recommendations, why guidelines recommend certain therapies, etc. He also spent considerable time coaching me on developing my “voice” on the team – how to make recommendations and give information in a respectful way. As a student doing my first inpatient rotation, I was very grateful for that. From what I’ve heard, not every preceptor will invest quite so much in a student, so this was definitely something to appreciate.

The ID fellows that co-precepted me are part of my preceptor’s anti-infective research lab. I think it was a huge benefit for me to have context with them because since they are pharmacists too (completed PGY1 and/or PGY2), they were able to teach me about a variety of things – PK/PD (this was huge), therapeutics, pharmacology, navigating interdisciplinary team dynamics, practical advice on rounding, midyear, residencies, LIFE in general etc. Not to mention they were really fun and down to earth.

And… the ID consult team! I really loved being at this hospital. The attending physicians are very good at precepting, not just the medical students/residents/fellows but they would ask me questions too! The residents and fellows are also really receptive to pharmacy input. There is a clinical pharmacist (ID specialist) who generally rounds with the team and became a sort of informal preceptor for me. He helped me learn to consider the whole patient and how to ask the right questions, and was also also available during the actual rounding time on the floors in case I didn't understand something from the pharmacy perspective. Something that I didn't expect was that I got pretty close with the medical student that rounded with me. She taught me quite a few things from the medical perspective – not to mention it was also easier to ask her questions when everyone else was busy doing other stuff.

What were the challenges?
This rotation was a HUGE test of my time management and emotional resilience. First off, my preceptor challenged me to only take information from the primary literature for my topic discussions and drug info questions. It was so difficult for me at first because if you think about it, that kind of rules out resources like textbooks, class notes (didn’t really use these anyway...), and UptoDate. But I got faster and more efficient at doing those lit searches (feel like a pro now). Looking back, I’m grateful that I was pushed to consume the literature in that way because I feel like I have a good method now for answering any questions I might have in the future.

As expected, making ID-related interventions on the ID consult team is a challenge. It’s humbling to know that I was among experts and I most likely knew the least out of everyone there. However, I quickly learned that there are ways to still catch the things that others didn’t think about – for example, a couple of the interventions I made had to do with renal dose adjustments of antibiotics. So this is encouragement for anyone else who feels like they are struggling to make interventions – keep pressing on!

This next challenge was unexpected - I will say it took me like 2 weeks to overcome being intimidated (don’t laugh!). I mentioned above that I realized I was among experts. Additionally, some preceptors are very big and well-known people in their respective fields. My particular preceptor definitely falls into that category. And then there’s me, a tiny little pharmacy student who knows next to nothing and has never had an inpatient rotation. I definitely let that hinder my confidence a lot. But I eventually got comfortable enough to see that preceptors are real down-to-earth people too who really want to see their students grow and learn. I’m speaking to anyone reading this who feels crippling self-doubt, lack of confidence or discouragement – it’s okay and natural to feel that, but it’s also worth it to work towards loosening up and learning under a growth mindset. Definitely something I’m trying to develop as I go along.

I also want to say that I grew a ton personally. The reason I’m sharing all of this is because I want to be real here. I still remember during that first week, I drove home crying because I didn’t think I could handle the rotation (it was raining a ton and thankfully I didn’t crash into something). I was overwhelmed, sleeping like 4 hours a night, feeling like I was a disappointment to everyone including myself. Basically I felt like the biggest hot mess ever. In hindsight, I realized that I placed unreasonable expectations on myself – thinking that if I didn’t become some sort of ID expert after my month in Detroit, then something was wrong with me and I wasn’t working hard enough. But I realized the more important thing for me as a student might not necessarily be to focus on retaining and regurgitating all of that knowledge, such that I would get it right and win at life all the time. Instead, perhaps the more important thing is to learn how to ask the right kinds of probing questions. Because in the end, I’m pretty sure that the discipline of learning how to ask the right questions will set the foundation for further growth and learning.

OVERALL, this rotation shows me that some of the best things are indeed hard-won. This was an extremely challenging but exciting and rewarding experience. The reason why I say that this rotation was mind-changing is because of how unexpected it was. I went into it thinking that ID was kind of a static field, without the fast-paced changes I had come to see with something like Heme/Onc. Thankfully I was wrong. ID is one of those fields where you have to be very up to date all of the time. Resistance is a very real concern. And any recommendation you might make regarding an antibiotic now, has the potential to affect other patients in the future. To me, that’s kind of exciting and it makes me hungry to learn more…I'm a week out from this rotation but I already miss it so much. I would definitely recommend ranking an ID rotation in Detroit for any student that might be interested. 

If there are any questions, just shoot me an email (! And for a different take on this same rotation, please see a previous student’s post (Jared Borlagden).

For now, it’s off to rotation 3 – health systems!