Monday, September 17, 2018

Rotation 3: Infectious Diseases

Posted by Andrea at Monday, September 17, 2018

This rotation was a bit more busy for me, because I had my P4 seminar presentation. P4s are required to put together a 30-40 minute presentation for our class about our PharmD Investigations (longitudinal research project) or a pharmacy topic. The topic I presented about was the controversy of using steroids in septic shock. While this rotation did not require much outside work, most of my days after rotation were spent working on my slide deck or practicing my presentation. I was so glad to have finished this!

Rotation 3: Infectious Diseases
My third rotation was Infectious Diseases. This was my first clinical rotation and ID was a difficult topic for me in P3 Therapeutics, so I was nervous before starting this rotation. I had a variety of experiences on this rotation, including rounding with the ID team and antimicrobial stewardship. A typical day of rounding would start with working up patients (8AM-10:30AM), meeting with my preceptor to discuss patients (10:30AM-12PM), and end with rounding with the ID team which consisted of an attending, a fellow, a resident, and two med students (1PM-4 or 5PM). Rounds take a long time, because ID is a consult service so their patients are scattered all over the hospital. Days on antimicrobial stewardship were much different. The ID pharmacists share these responsibilities. There is disease-based stewardship, where antimicrobial therapy is reviewed and optimized for patients based on targeted disease states (e.g. HIV). There is also drug-based stewardship, where restricted drugs are reviewed for appropriateness (e.g. linezolid, daptomycin). These days were spent reviewing patient charts on the computer, followed by discussions with my preceptor. I also attended antimicrobial stewardship committee meetings (pharmacists and physicians discussed initiatives to optimize antimicrobial therapy), presented a topic discussion, and journal clubs. My preceptor would often send studies to read and discuss the next day.

Something I learned from this rotation was how to “work up” patients. We focused primarily on the ID problem. For each patient, we had to assess if the antimicrobial therapy was appropriate including drug, dose, frequency. To follow up, we assessed vanco and aminoglycoside drug levels and monitoring parameters.

Some questions I encountered on rounds were: Does this drug require renal/hepatic adjustment? Anyone know the patient’s creatinine clearance today? How do I dose this if the patient is getting dialysis? I also liked seeing how there was opportunity for pharmacists to develop wide-reaching initiatives through policy and guideline development. For example, they were trialing a pilot program for penicillin skin testing, creating guidelines for community acquired pneumonia treatment, and pediatric animal bite treatment guidelines. I really enjoyed this rotation!

Rotations 1-3: A Triad of Non-Clinical Rotations

Posted by Unknown at Monday, September 17, 2018

Hello fellow COP students 😃  Thanks for visiting our P4 blog!  Before I go into my first post, here is a little bit about me (feel free to skip the rest of this paragraph if you're just interested in the riveting rotation details).  I am originally from Pittsburgh, PA, and I came to U of M for undergrad in 2012.  I joined the COP in 2015 after completing 2.5 years of undergraduate prerequisites (shout out to the non-degree-ers).  I have a long history with working in community pharmacy at CVS, a job which I truly LOVE.  In pharmacy school, I have been an active member in SMPA, PSA, and MPSO, and have enjoyed taking advantage of the opportunities that those and other student organizations have offered me throughout the past 3 years.  I am always willing to talk about my extracurricular experiences, so feel free to contact me with any questions about that stuff!  This summer I have been balancing starting rotations with buying my first house and taking care of two children (cats), so if anyone is looking for advice on home-buying or parenting, I'm pretty much an expert (ha).

Our first house.  Goodbye Ann Arbor rent prices!

Buffalo Yoda Green

Lady Macbeth Green

As for my rotations so far:  my first, second, and third blocks were all very non-clinical based, which has turned out to have both positive and negative impacts on my rotation experience...on one hand, they provided a fairly smooth start to P4 life; I wasn't inundated with intense responsibilities, pharmacokinetics, or rare disease states to learn about.  I didn't do any topic discussions or any outside projects and I worked fairly consistent hours.  Each rotation had it's challenges, of course, but overall they were straightforward and stress-free.  However, it was very, VERY easy for me to fall off the clinical skills wagon.  Because I didn't really keep up with studying or reviewing notes during the first 15 weeks (even though I told myself I was going to...), it was difficult for me to switch gears back into analyzing doses and writing SOAP notes for my 4th block (more to come in my next blog post).  Looking back, my advice to myself (and to anyone reading this preparing for rotations) would be to listen to our Deans and be a life long learner!  Remember that if you don't use it, you will lose it, and that just a few minutes a day of review and staying up to date will really pay off when you need it.

Rotation 1: Non-traditional (Managed Care)

My first rotation provided a nice easy transition from P3 to P4 life.  My primary responsibilities at my Managed Care rotation were to call members to complete comprehensive medication reviews (CMRs), then to complete a write up that included important counseling points from our conversation and an updated medication list, which I would then mail out to the patients for them to use for their records and share with their families and doctors.  On the surface, these daily tasks were simple and straightforward.  However, they involved unique opportunities to provide individualized patient care in order to empower our members to improve their health.  For example, I would often get questions and comments from members about how they did not agree with a medication prescribed by their doctor, or about what medications were for and why they had to take them.  As a future pharmacist, this is where I felt my expertise in pharmaceutical knowledge and patient counseling came into play.  I was able to provide the information that the patients needed to become educated about their medications and health, and even if the patient didn't always agree with my input, they at least gained the knowledge necessary to make more educated health decisions.  Additionally, through our conversations and the write-ups that I would send, patients would receive references and information that they could use to empower themselves to start conversations with their doctors about their health an become a more active participant in their health care.  

These patient care aspects of the rotation were rewarding to me as a student because I felt that I was able to make a true impact on the members' health, either by simply sending them an organized medication list or being able to answer their health questions that they felt were previously unexplained by other health care providers.  Another special patient-care responsibility was that of sending targeted medication reviews to prescribers; if I identified the potential for medication optimization (such as duplicate therapies, target dose optimization, and finding lower-cost medication alternatives), I would send a notice to the prescriber.  On several occasions, the prescriber accepted my recommendation or would respond back that he/she had reviewed the patient's health profile as a result of my intervention.  To me, this was an unprecedented example of interdisciplinary health care and the impact it could have on a patient.

In addition to the CMRs, I also took part in several meetings and teachings about the workings of a managed care setting.  This included aspects such as formulary management, specifics of different insurance plan options and the details of payment, and STAR criteria, among others.  Overall, it was an all-inclusive rotation with a good balance of patient care and operational work that allowed me to refine my written and verbal communication within a specialized population.

Rotation 2: Community

As I mentioned, I have a long background working in community pharmacy, so this rotation was pretty ordinary for me.  However, although I was generally familiar with the everyday flow of the pharmacy, my experience here taught me to never discount the potential for new learning opportunities, even in familiar settings.  From picking up clinical pearls from different pharmacists, to being in charge of managing the a Shingrix shortage, to learning new ways that individual pharmacies operate, there was always an opportunity to broaden my community experience and knowledge.  Most importantly, this rotation taught me to always approach my pharmacy experiences with lots of questions, an open mind, and a willingness to learn.

Rotation 3: Health Systems/Hospital

My third rotation was where I really started to feel comfortable with the P4 rotation experience.  Initially, I was apprehensive about this one;  it was my first out of area rotation, which was intimidating in itself, let alone the fact that my preceptor happened to be the senior director of pharmacy AKA knows everyone AKA could have a real influence in me getting a job/residency in the future 😉.  The rotation was set up to be very independently driven; I was given a schedule of shadows and events to attend, but my preceptor made it clear to me that I could make the rotation what I wanted.  I could follow the schedule, or I could skip all of the events and do research in the library every day for 5 weeks.  For me, this was a refreshing approach to precepting, because it meant that I could build my rotation around what I personally valued and what I knew would be the most beneficial to me.

It turned out to be somewhat of a career-defining rotation.  Throughout my time, I saw just about every aspect of how a health system runs: operational, financial, inpatient pharmacy, pediatric pharmacy, purchasing and inventory, and business management.  Additionally, because my preceptor was a director, I had a lot of exposure to the administrative side of the hospital, which is where I really felt in my element.  Prior to this, I had suspected that I might have an interest in pharmacy administration, and when I finally got to work in that setting, my interest was confirmed.  Because of my preceptor's willingness to let me forge my own rotation path, I was able to tailor my experiences to the administrative side of things, and in doing so I rubbed elbows with several higher-ups and worked on hospital-wide projects, including a shortage management project and one on reducing hospital readmissions for acute kidney injury.

While each of my experiences on this rotation were valuable to both my education and personal growth, the biggest message I took away from it all was to be fearless.  While it's definitely a cliché, it's a valid one.  Although I was a bit intimidated by the environment an the people with whom I was interacting, I tried to approach each situation with confidence and motivation to succeed, and it couldn't have been more beneficial.  I met a lot of successful people who were very encouraging and willing to share their knowledge and experiences, which was invaluable.  I can definitely see myself pursuing a career in this setting, which is such an exciting thing to be able to say!

Sunday, September 9, 2018

Rotation 3: Specialty Ambulatory Care

Posted by Unknown at Sunday, September 09, 2018

This was my first experience dealing specifically with specialty drugs, which are commonly referred to as "high cost, high touch" drugs. The high cost part makes sense, but what was not immediately apparent to me was the concept of high touch. I soon learned that high touch simply meant that these drugs needed more hands-on management in the forms of baseline evaluations and follow-up calls with the patients, which is not like what a regular community pharmacy would do. I liked this aspect, since it gave me a sense of how patients progressed through a short-term treatment plan. In particular, I gained some familiarity with hepatitis C treatment, which was usually treated for a duration of 8 - 12 weeks. Having previously done the HIV community rotation and now this, I also developed an appreciation for how far we have come in terms of improving medications. Compared to the antiviral options we have today, the early drugs just seemed much more burdensome in every way possible, not to mention that their efficacy was also not as good. The problems with side effects, frequency of administration, and other administration considerations (e.g. with or without food) are mostly not an issue with today's options.

Another aspect of therapy that I understand a little more of after this rotation was the prior authorization process. While the majority of submissions from our service to insurance companies do get approved, occasionally we had to submit appeals after receiving the denial verdict. While writing appeals to insurance companies did not sound appealing at first, this exercise actually proved very insightful. I was forced to delve deeper into the primary literature and use the data to demonstrate that my patient truly would benefit from getting this drug approved. Depending on the insurance, I also may have needed to collect lab results to illustrate the severity of the patient's condition, and it was not just limited to the Child-Pugh score that we learned in class.

Aside from my main priority in doing baseline and follow up calls with patients mostly for hepatitis C medications, I also had the opportunity to contribute to some quality improvement projects. Specifically, I collected the data to show that compared to the national average, our specialty pharmacy financial coordinators did a great job in terms of PA and appeal approval rate. Furthermore, I also looked into the average turnaround time for prescriptions filled by Michigan Medicine versus those filled by outside pharmacies. These small side projects allowed me to look at the bigger picture of healthcare, and see that there is clearly much more to treatment than just the drugs themselves.

Although I prefer more in-person consultations as opposed to telephonic ones, this was still a valuable learning experience. I learned how to manage my time and juggle multiple responsibilities, but I also now understand that taking extra time to be meticulous about your work is important to. In other words, try to avoid speeding through tasks just to get them done, and really spend some time to think about what you're doing. All good things to take with me as I head into my next rotation (and first inpatient) at the neuro ICU here at Michigan Medicine!