Wednesday, July 10, 2019

Health System/Hospital - Rotation 1

Posted by Makenzie at Wednesday, July 10, 2019

For my first rotation I was back to where it all started.  I was able to go back to my hometown and complete my first APPE at the hospital I was born.  I work at a different hospital in the same city but I was surprised at how many common connections there were with pharmacists & techs across institutions (pharmacy is indeed a “small world”).

I also wasn’t lonely at this rotation - I was joined by 12 P4s from Ferris State who were completing all of their APPEs at this one institution.  Many of us would have lunch together, go to each other’s seminars, and bounce ideas off of each other.  For my first APPE, it was nice to have the safety net of a large group of students.

The rotation itself was great.  My preceptor took into account my previous work experience and personalized the rotation to my interests and gaps of knowledge.  For example, I am already experienced at sterile compounding but haven’t done TPNs before, so I was able to modify my schedule to spend more time on TPN verification and compounding.

This particular APPE also had the option of attending an open heart surgery with an anesthesiologist.  The procedure was a quadruple bypass & over 6.5 hours long.  The anesthesiologist placed me standing on a stool at the head of bed, with the heart only an arm’s reach away.  I was prepared for what it would look like but the smells (cauterization) and sounds (cartilage breaking) was not something I was prepared for.  Throughout the anesthesiologist taught me about what meds were put on cont IV vs bolus and how he monitors the patient while the surgeon explained the pathophysiology of the patient’s a-fib.

The next morning I followed the patient on CCU rounds & was astounded that he was already sitting in a chair & eating after such major surgery.  Attending the surgery helped me understand a patient’s cardiac journey and what role health care providers & medication management play throughout.

As amazing as open heart surgery is, it wasn’t apart of a “typical day”.  A typical day was divided into 2 parts.  The mornings were always scheduled.  I spent half of the mornings of the rotation doing staff pharmacist work.  Dosing, front counter, IV, med safety, etc.  The other half of the mornings I would do rounding in the PICU, ICU, or CCU and was able to spend additional days rounding in units based on my interests.

Afternoons were spent doing projects.  Daily, I did patient educations on post-AMI medications or anticoagulation teaching and had weekly audits for titratable medications.  The afternoons were also when students would do topic discussions, clinical questions, or present patient cases as final projects.  I found it helpful to attend these sessions as it kept ambulatory care, general medicine, ID, etc topics at the forefront of my mind.

For rotation 2 I am back in Ann Arbor for my gen med rotation in adult surgery & to present my PharmD seminar at the end of July.

Saturday, April 27, 2019

Rotation 7, 8, 9: Farewell, and Be Kind

Posted by Michael Tsai at Saturday, April 27, 2019


In a large academic medical center, I was specifically assigned to the operating room pharmacies in the main hospital, eye center, and children’s hospital throughout the week. In addition, I got to see the satellite pharmacy, the general infusion center, and the cancer infusion center pharmacies. Once a week, I attended meetings and worked on projects with a pharmacist working on the management side.

It was insightful to see how operating room pharmacies manage controlled substances and dispense kits for the anesthesia team. They also verify and dispense certain orders for patients before their operation. In the infusion center pharmacies, I saw the workflow of how pharmacists verified orders, how pharmacy technicians prepared medications, and how pharmacist checked preparations and noted stability of the medications. On the management side, I saw how space and workflow could impact delivery of patient medications throughout the hospital.

Since there were several pharmacists and pharmacy technicians on this rotation, I worked with different teams and had to adapt to different preferences and teaching styles. Also, while I was on this rotation, I was also interviewing for residency positions. Traveling was intense and time-consuming, but I’m grateful my preceptor was understanding and allowed me to make up days missed through additional hours or projects. Overall, it was a busy season for me, balancing rotations and interviews, but I am glad to have the experience as it allowed me to see the bigger picture of how pharmacies operate within the health-system.

Managed Care

I was placed at a large health plan for this rotation and worked under a pharmacist who was a manager on the medical benefit, where drugs managed needed to be administered by a healthcare professional. This was different from my previous managed care rotation, which was a prescription drug plan and focused on pharmacy benefits, where drugs managed were usually self-administered medications.

This rotation was project- and office-based. My main assignments included updating medical policies with support from literature and clinical guidelines, providing summaries of therapeutic agents for hemophilia, and analyzing medical oncology data to complete a report with charts and graphs. During the rotation, I also had informational interviews with pharmacists working in different departments of the company, including drug pipeline, formulary and rebates, legislation and policy, operations, regulatory oversight, and sales and marketing. These pharmacists played very interesting roles, bringing insight to the variety of positions available within managed care pharmacy. I hope to learn more and experience these different positions as I start a managed care pharmacy residency in the coming months after graduation.

My preceptor during this rotation was working on a medical oncology program, so I sat in on several internal meetings regarding the logistics of implementation and external meetings with the vendor to ensure responsibilities were carried out on both sides. Other meetings I attended involved a quarterly drug pipeline update and internal sales and marketing meetings and consultations. While I had previous experiences in managed care through student organization involvement, internships, and a rotation, this experience added on to that, exposing me to the medical benefit, different pharmacist roles, and vendor relations. I am excited that there is still much more to learn about managed care pharmacy.

General Medicine/Pediatrics

My final rotation was in a children’s’ hospital on the mid-day shift. Here, I got to work under a pediatric generalist pharmacist, and my role was to assist in verification of total parenteral nutrition (TPN) orders and pharmacokinetic service of antibiotics. It was interesting to learn about pediatrics and nutrition, since these topics are not widely covered in the pharmacy curriculum. Pediatric patients should not be considered as smaller adults since they differ greatly in distribution and clearance of medication compared to adults. To verify nutrition orders, I navigated through a patient’s chart, collecting weight, fluid goals, recent lab values, urine output, relevant medications, and the order put in by the dietician. I would make sure that the volume of the TPN was calculated correctly and that changes to macronutrients and electrolytes within the TPN made sense. For the pharmacokinetic service, I was responsible for interpreting vancomycin or aminoglycoside levels that resulted during my shift. From these levels, I would make recommendations on whether to continue therapy or change therapy, noting the dose and interval of the drug regimen, and on when to check levels again.

The mid-day shift itself was different, but exposed me to the endless work that pharmacists put in at the hospital. Additionally, as my last pharmacy school practice experience, this rotation showed me that the learning never stops. I was constantly looking up answers to my preceptor’s questions and diving into the field of pediatrics. Even though my plans after graduation have been set, I still very much appreciated seeing and experiencing yet another perspective of pharmacy.

Now that my time at the University of Michigan College of Pharmacy has come to an end, I hope that you have enjoyed following the journey of my final year and gained insight into the practice experiences of a pharmacy student.

“For today, goodbye. For tomorrow, good luck. And forever, Go Blue!" 
– Mary Sue Coleman

Monday, March 25, 2019

Rotation 8: General Medicine

Posted by Unknown at Monday, March 25, 2019

Today was my last first day of school ever!! In 5 weeks I will graduate with my PharmD from the University of Michigan and will be preparing for a residency program in Colorado!! There are lots of changes coming in the next three months and I'm feeling a mix of excited, scared and sad. Excited because of the great adventures awaiting me and my husband out in Colorado (professionally and personally), scared because of the major changes and transitions about to happen, and sad because I'll be leaving my family, friends and home. I'm planning on taking some time over the next three months to prepare for these changes in an attempt to leave this place and these people well.

One thing I know has helped prepare me for residency is the general medicine rotation I just finished. I was in the inpatient adult hospital working with a clinical pharmacist and a medical team taking care of patients admitted to the family medicine service. This was my most difficult and demanding rotation. I learned a ton, but it was extremely stressful. The service I was on had a maximum of 24 patients (most others had a max of 12 or 16), and there were multiple times we got close to that max. There were also 4 projects/presentations throughout the rotation, a weekend shift, and a dental on-call pager we were responsible for at different points during the rotation.

The biggest thing I want to tell future P4's is that you're likely going to need to re-learn how to work up patients. The way we were taught in school was very different than what I was expected to do. Also, every inpatient rotation is going to have you work up and present patients a little differently due to the nature of the services. Make sure you ask the preceptor how they do it and what they expect of you. We were taught in school to look into all of the details about the patient including the diagnosis and history details. As a pharmacist, those things are important, but you cannot spend all of your time investigating them. You are likely not going to be asked on rounds to present the patient, and so it is more important for you to focus on other things. You need to learn how to be efficient in looking into the pharmacy-related problems and monitoring parameters. This took me longer than I expected, but once I did, working up patients was much more smooth and took less time.
Additionally, MiChart has a TON of really helpful reports you can run that will save you a TON of time when working up patients. Make sure you ask your preceptor/classmates at the beginning of the rotation to make sure you are capitalizing on the reports already available to save you time.
Finally, you will be amazed by what you are able to learn and accomplish during this rotation. This is a hard rotation. But, it is only 5 weeks (you can get through 5 weeks), your workload will build up over the rotation, you'll start to see repeats of the same disease states, and you'll figure out how to get the work done. You'll be able to make it through this rotation! I was so encouraged when things came up during rotation that I hadn't known only a few days prior. Even today (my first day at the new rotation), something came up that I could speak to with confidence because of what I learned on my general medicine rotation. All of these things will prepare you for residency/job/life after school.

With that, I'll be back one more time to let you know how this last rotation goes!

Saturday, February 16, 2019

Rotation 7: Oral Oncology (Ambulatory Care)

Posted by Unknown at Saturday, February 16, 2019

Over the last 6 weeks I had the opportunity to experience a new (to me) kind of Ambulatory Care clinic. I worked with the Oral Oncology team to follow-up with people who were on oral medications for their cancer.

This was a phone-based clinic where we did initial, 10 day follow-up, and 6 month follow-up calls. Initial calls included medication counseling on how to take the medication, possible side effects and how to manage the side effects. We followed up with these patients after they had been taking the medication for about 10 days (and then 6 months) to see how they were doing.

This rotation required critical thinking and problem solving as each patient case was different and needed to be examined in order to know the appropriate time to contact the patient. Follow-up calls also needed to be handled differently in terms of setting up additional follow-up by the team or by clinic.

I also had the opportunity to be in the Genitourinary cancer clinic one half-day a week. This was the first time I experienced an ambulatory care clinic where the pharmacist did not have a set schedule of patients to see during the day. The pharmacist would use a custom scoring tool in order to decide which of the physician's patients she was going to see that day. When she went and saw patients she did a lot of symptom management and medication counseling. She was also available for questions from the nurses and physicians. Being in the GU clinic helped break up my Monday's, but it also allowed me to see a different format of ambulatory care clinics; and for that I am very thankful.

One of the best things about this rotation was the people! I got to work with multiple pharmacists, residents and pharmacy students who were extremely passionate about the work we were doing as well as extremely knowledgeable about the subject.

As I finish this rotation and move on to the next I am taking with me a greater confidence and ability to counsel patients, communicate empathy and adapt to different situations quickly.

As a follow-up to my last post I also wanted to talk briefly about this last rotation in terms of residency interviews. This rotation was 6 weeks long (1 week longer than the others) to allow for students to miss up to 5 days for interviews. I am very thankful that I was able to finish all of my residency interviews during the 5 days this rotation. Now all I have to do is rank the programs and wait until March 15th!

Tuesday, February 5, 2019

Rotation 4, 5, 6: Drug Information, Critical Care, General Medicine

Posted by Andrea at Tuesday, February 05, 2019

Rotation 4: Drug Information

This rotation was with a drug information company and I was able to work remotely, as my preceptor also works remotely. We met two to three times a week for about one hour and communicated often during the week via email. My responsibilities were to write monographs for drug-drug interactions and drug-gene interactions (e.g. CYP2D6, CYP4A4, etc.). This consisted of reading lots of articles, learning how to scour PubMed for literature, and writing concise summaries.

Time management was incredibly important in this rotation. I had the freedom to create my own schedule each day, but this also allows for time to slack off. I had to hold myself accountable and ensure I completed my work. I learned a lot about what goes into writing the monographs when we search our drug information resource for quick answers about drugs and interactions. I always thought I would enjoy working by myself, so I was surprised that I missed interacting with co-workers and patients daily. Looking forward, I hope to find a position that balances independent work with teamwork or direct patient care.

Rotation 5: Critical Care

This rotation was in the surgical intensive care unit (SICU) at a local community teaching hospital. Going into this, I was nervous and intimidated by the complexity of critical care patients. My typical day started with working up patients (6AM-9AM), round with the team (9AM-11AM), eat lunch and finish working up patients (11AM-12PM), then meet with my preceptor (12PM-1PM). After this, I would work on assigned drug information questions or projects for the rest of the day. Working up patients in the ICU is based on the head to toe systems approach, rather than problem based like how we learned in class. This means problems were categorized by systems, which could include neurological, pulmonary, cardiovascular, GI/FEN (fluids, electrolytes, nutrition), I/O (ins and outs), ID, and heme. Patients were very sick and often had multiple problems within each system listed above.

I am very grateful to have had this rotation. I have a much better understanding of anatomy and how surgical changes can affect drug action/metabolism in the body. I also learned about weaning patients off pressors, opioid conversions, and nutrition. I had the opportunity to work with a large team, which consisted of an attending, fellow, residents, medical students, and dietitian. I also enjoyed working with my preceptor who was a great teacher and with another pharmacy student from a nearby school! Overall, this was a great learning experience and I am glad I was able to try it out.

Rotation 6: General Medicine (Adult Internal Medicine)

All P4 students are required to take the Gen Med rotation and I was placed on the Adult Internal Medicine service. This was a busy rotation, due to the patient load and weekly projects. My service capped at 11 patients and by the end of the rotation, I was managing the entire service. Patients had a variety of disease states, including pneumonia, UTIs, atrial fibrillation, and diabetes. The typical day started with working up patients (5AM-7:30AM), pre-round with my preceptor where I would present patients and run my recommendations by him (7:30AM-8AM), round with the team (8AM-11AM), and post-rounds with my preceptor where I would update him with any changes (11AM-11:30AM). The rest of the day was spent educating patients discharged on anticoagulation, meeting with my preceptor to go over patients or topics, and meeting with the other students also on Gen Med to present our projects. Time management and efficiency are key to this rotation and each student will develop their own schedule or system that works for them.

Pharmacists play an important role in antimicrobial stewardship and anticoagulation management on this service. I enjoyed the variety of patients and activities in this rotation. I was constantly learning and it made the long days fly by. My advice to students is to embrace this rotation and challenge yourself to learn as much as you can!

This rotation ended just before the holidays and I am currently on my off block. After this, only 2 more rotations until graduation!

Gen Med Block 6 students wearing our ugly Christmas sweaters!

Wednesday, January 16, 2019

Preparing for the next step

Posted by Unknown at Wednesday, January 16, 2019

2019. This is the year I graduate from Pharmacy school. After 8 years at the University of Michigan I will finally be done! 

I've been doing a lot of reflecting recently as I am on the precipice of many major changes: the end of school, transitioning into the role of a practitioner, and possibly moving (with everything that entails). I think it is extremely important to take a step back and reflect on where you've been and where you hope to go at times like this. 

I am amazed at all I've learned and how much I've grown in the last 8 years. These years have provided me countless joys and moments of growth and I am so excited to see where the next 8 years bring me. 

I am so thankful for all the experiences and opportunities I've been blessed with because of my education, family, friends, and connections. I have been able to travel, learn from people different than me, discover what I'm passionate about and begin to make a plan for the rest of my life. 

Last rotation was my "Off rotation". At UofM we can choose to take one rotation off. I chose the last one so I could focus on residency applications, work at the hospital and have flexibility to be with family over the holidays. I had many great conversations reflecting on the past and dreaming about the future. I am so thankful I had this time to prepare for the next steps in my life. 

In just a few months things will be very different, and I am going into that change thankful and ready to take on the challenge. 

Thursday, January 10, 2019

Rotation 4, 5, 6: Keeping up with Therapeutics

Posted by Michael Tsai at Thursday, January 10, 2019

Inpatient – Cardiology
On this rotation, I got to experience the day-to-day of a clinical pharmacist specialist in a health-system. My schedule would consist of working up patients early in the morning to make sure I had the most up-to-date lab results for the patients on my service and to check if anyone was admitted overnight.  I would start rounding with the medical team at around 9 am. The team consisted of an attending physician and 3 medical residents. During rounds, the medical residents would update the attending about the patients and make suggestions. They would also see the patient and update them on their progress. My role during rounds was to collect information and make any recommendations I previously discussed with my preceptor. I was actively thinking of labs to order and optimizing medication regimens. Outside of rounds, I also was responsible for medication reconciliations to ensure the medications the patient was taking at home was the same ones ordered in the hospital. I educated patients if they were put on a new anticoagulation medication and oversaw warfarin dosing and monitoring.

Throughout my rotation, I had the opportunity to work with three different medical teams, which showed me different leadership styles and receptiveness to recommendations. Additionally, I picked up on procedures and surgeries commonly seen in the cardiology floor. While they are not taught in our pharmacy curriculum, they may determine which medications the patient should receive.

Days were long on this rotation since there were up to 16 patients to follow at times, but it was a worthwhile experience as it sharpened my clinical knowledge. It also provided an experience in interprofessional teamwork. Working with physicians showed me how little I knew about medical procedures and surgeries, but also gave me confidence in my pharmacy knowledge, as I answered many of their questions about medications.

Drug Information – Managed Care
My next rotation was with the prescription drug plan of an employer group. This was my favorite rotation so far since I am interested in pursuing a managed care pharmacy career after graduation. Assignments on this rotation were project-based. The first task I had was to prepare documents for advisory committee meeting, where formulary decisions would be made. With a new medication recently approved by the FDA, I summarized the characteristics of the medication, clinical trial results, proposed place in therapy, and economic considerations. After presenting this to the advisory committee and hearing the committee’s final decision, I drafted the prior authorization criteria and medication request form for this medication. These were to be used by the plan’s pharmacy benefit manager to determine if coverage would be provided for patients requesting the medication.

Another highlight of the rotation was learning to use Microsoft Excel. Managed care deals with large populations, so datasets are commonly analyzed through Excel. I conducted a drug utilization review, where I identified an at-risk target population from medical and pharmacy claims data. Using this information, the plan sent out letters to prescribers identifying their patients who were at-risk.

During this rotation, I also got to sit in on several meetings, including ones with a mail-order pharmacy, specialty pharmacy, pharmacy benefit manager, and medical benefit. These meetings showed me how a health plan interacted with these other healthcare stakeholders. Additionally, my preceptor allowed me to attend the Academy of Managed Care Pharmacists (AMCP) Nexus conference. On top of learning from multiple sessions about trending topics in managed care pharmacy, I also had the opportunity to network with managed care pharmacists and speak with residency programs at the residency showcase.

I enjoyed seeing projects from beginning to end on this rotation. Since it was a smaller health plan, pharmacists were the jack-of-all-trades and worked on all aspects of managed care pharmacy. I learned much more about this career field and gained valuable experiences.

Open rotation
At the University of Michigan College of Pharmacy, there is an option to leave one rotation free. I chose to have this rotation off to work on residency applications, serve as a groomsman in a friend’s wedding, and visit friends and family in California. I was glad to have some time off to rest and recuperate (and catch nice photos like the one below).

Now that the sun has set on 2018, I’m looking forward to new experiences in 2019!