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!

Saturday, January 5, 2019

Rotation 6: General Medicine - Internal Medicine

Posted by Unknown at Saturday, January 05, 2019

The General Medicine rotation that every single P4 goes through almost feels like a rite of passage. While its reputation for being difficult precedes it and may be exaggerated at times, the overall intensity is definitely a step up from most rotations. The patient care activities are not too different from other direct patient care rotations - you round with the rest of the healthcare team comprised of mostly doctors, and you take care of the anticoagulation and pharmacokinetic needs (read: vancomycin and aminoglycoside dosing and monitoring). However, what makes this rotation more challenging are the weekly projects, ranging from topic discussions to journal clubs. Nonetheless, I found the experience rewarding and had several interesting moments along the way that were quite memorable.

Diagnoses and ordering tests to confirm those diagnoses are usually under the physician's jurisdiction. We had a patient who had new complaints of mucosal ulcers. I patiently listened to the attending and medical students discussing potential causes. I then realized that I had been in a similar situation in my Surgical ICU rotation, and that patient had herpes simplex virus that was discovered using a HSV swab. So despite having no idea whether this would yield anything, I brought up the idea of getting a HSV swab on our patient. The attending and students seemed mildly surprised by my suggestion, but obliged. Turns out the patient did indeed have HSV, for which we started valacyclovir! The team gave me props for making this recommendation, and I have to say it is probably one of my proudest moments during rotations. It helped me realize that I was indeed progressing as a clinician, being able to take what I learned previously and apply it to a new setting. How exciting!

Another aspect of this rotation that I enjoyed was a MUE (medication use evaluation) on argatroban. Normally, this anticoagulant is used for patients with a documented heparin allergy or a positive HIT (heparin-induced thrombocytopenia) diagnosis. However, my preceptor suspected that we as an institution did not do a very good job of discontinuing argatroban upon negative HIT testing results. Sure enough, after combing through a year's worth of data, I found that we were spending tens of thousands of dollars on argatroban needlessly. It was towards the end of the rotation at this point, but we talked about setting up alerts in MiChart that would notify pharmacists whenever heparin antibody assay or serotonin-releasing assay results came back, so we can respond to such results in a timely fashion and avoid wasting more money. Perhaps getting trained in informatics could be useful...

All in all, I'm glad to be catching up on sleep this break. I won't miss waking up at 5 in the morning to get to the hospital so early, but I am glad we were put through the wringer. I have no doubt that these experiences will pay off when it comes time for residency interviews. I am also looking forward to my nontraditional rotation coming up next at the Michigan Oncology Quality Consortium. I'll be sure to update you on this in the near future!