Ambulatory Oncology -- A Different Perspective

Posted by Anna at Thursday, April 25, 2013

Before drafting this blog entry, I checked out Maria's post regarding this rotation. I was surprised to see how some aspects of the rotation stayed consistent with my experience while others were completely different! It does show how a given rotation will evolve as each student moves through it, as well as how the time of year may affect the tasks performed. Due to these differences, I’ve decided to share my experience, which is best broken down into two main categories: clinic days and project days.

Multidisciplinary Clinic Day:
7:30am: Present to specialty cancer clinic. Make a copy of the patient schedule for the day, work-up patients based on existing medications and disease states and determine any specific questions I want to make sure to touch on when I chat with them.
8:00-11am: Verify medication histories, answer patient medication-related questions, and make any recommendations. Document the information in the patient electronic medical record.
Afternoon: Repeat above if afternoon clinic day, otherwise work on independent projects.

The pharmacy role in the clinic flow was well established by the time my rotation started, and everyone was pretty used to seeing a student involved. I had the opportunity to chat with head and neck cancer (Monday AM), lung cancer (Tuesday AM), gastrointestinal cancer (Tuesday PM), and breast cancer (Friday AM) patients to get a thorough medication history and assess for any medication-related issues or concerns.

Project Day:
When not in clinic I would work on independent projects. This included preparing for topic discussion (five total), updating the febrile/afebrile neutropenia guidelines for the institution, and answering drug information questions presented to my preceptor. Additionally, I had the chance to shadow the Chaplain (provides spiritual care to oncology patients) and chat with the genetic counselor on staff, which provided a better understanding of the comprehensive care a cancer patient receives.

Pros:

• Beautiful hospital with a welcoming environment (and free parking ON SITE!!!)
• Good review of major cancer types and chemotherapy used
• Exposure to counseling on alternative therapy options
• Opportunities to interact with patients and support them in their fight against cancer
• A lot of autonomy and independence

Cons:

• Only a few days of clinic per week with variable volume—this meant there weren't many interventions made in a given day
• Not traditional ambulatory practice focusing on chronic disease states or delegated prescribing rights for the pharmacist
• Patients do not have appointments with the pharmacist, which can make finding time to speak with patients challenging
• Little one-on-one time with preceptor (maybe pro depending on the person!)
• Senioritis (I was very aware that this was my last rotation... this presents its own set of challenges)

Coming from someone with little interest in pursuing an ambulatory care position, I specifically chose an oncology-focused rotation for something a little more unique in the ambulatory setting. Additionally, my plan to pursue a residency post-graduation ensured I would gain exposure to chronic disease-focused ambulatory care if I so desired. However, I would say that if you are seriously considering a more traditional ambulatory care practice setting or a setting with delegated prescribing rights to the pharmacist this is not the rotation for you. Additionally, if you are the type who needs a lot of one-on-one attention, you may prefer a different rotation. Although my preceptor was always available by phone, email, page, or stopping by her office, she was much more hands off than other preceptors I had in the past. Case in point: my first day of clinic (day 2 of rotation) I was shown to the clinic, logged into the system, and then left to my own devices. I was comfortable with that, but it meant I had to be open to asking for help from the nurses and other clinic staff (all AWESOME, by the way). Overall, it was a nice way to end my final year. Due to the ample amount of project time, I only rarely had to bring work home with me and for the most part could enjoy my last few weeks as a P4 student.

This ends my P4 blogging adventure! I appreciated having the space to write about my rotation experiences, and I hope many others continue to take advantage of this opportunity. Good luck to the next P4 bloggers as you start your rotations in a few short weeks, and a HUGE congratulations to the PharmD Class of 2013!!

Another post about residency?!

Posted by Anna at Sunday, April 14, 2013

Yes, this is another post about residency. If you are so over it already, I completely understand—feel free to move on to the next post. I will say that Kristen posted a recent entry with a lot of great information and tips based on her experiences, and I highly recommend checking it out for a complete overview and residency how-to. Instead of rehashing that information, I wanted to reflect on just a few points that may be relevant to those who find themselves in my shoes.

Specifically, this could be meaningful to you if you are….

• A P4 student seeking PGY-1 hospital-based residency
• Planning to enter practice as generalist after completion of a residency, but open to further specialization via PGY-2 if you happen to find something that truly grabs you
• Restricting your search to Southeast Michigan based on a significant other or for other equally valid reasons

For the benefit of this post (and just for funsies), I have decided to interview myself:

Q: Why complete a residency if you want to pursue a generalist position? Do you even need a residency for that?!

A: You do not need a residency for a generalist position, and many people start in a generalist position immediately after graduation. Residency is a very personal decision and is not the right path for everyone—do not feel like you have to do one! For me, I wanted the extra year of hospital-based rotations, intensive study, and freedom to learn underneath an experienced pharmacist to either become a stronger and more confident generalist or to determine if further specialization is the path I want to pursue. I was also very open with my reasons for residency through my letter of intent and during my interviews.

Q: If I want to stay in Southeast Michigan, do I have to go to Midyear?

A: Absolutely not. The SE Michigan Residency Showcase and Career Gateway events both occur in mid-October to early-November, and are great venues to learn about the local residency programs. Unfortunately, I was not able to attend these events due to being out of the area on rotation. I did go to Midyear primarily to present a poster on my PharmD research, and I was able to chat with Michigan programs at the residency showcase there. If you do end up attending Midyear, do not feel bad speaking to Michigan programs! The only one I would stay away from is UofM, strictly because if you are a UofM student you will have easy access to resources regarding the program back in Ann Arbor.

Q: How many programs did you apply to and how did you choose?

A: I ended up applying to seven programs. Knowing you want a SE Michigan residency really helps narrow down the initial list of possible programs, but still leaves you with a considerable list. With my personal goals, I wanted a program that had teaching opportunities, diverse rotation opportunities, a bigger residency class, and a large health system. I was able to narrow down my list to seven programs—which is still sort of a lot until you realize that Detroit Medical Center requires separate applications for each site—through information on websites as well as what I gathered at Midyear. I accepted interviews at all seven sites, as I wanted to physically visit the hospitals and experience the learning environment. I do believe that you get a definite feel for each residency once you actually interview, and this feeling played a big role when I ranked my programs. Additionally, since I was within a 40-50 minute drive from each interview, it was feasible for me to go to many interviews without spending money on flights, hotels, and other travel expenses.

Initially I was jealous of my classmates who had the freedom to apply to any program in the nation, with no geographic limitations. However, I found that Michigan has many amazing residency opportunities, and I did not have to compromise any of my “must haves” in a program in order to stay in the area. Hopefully these few points will be helpful to those who find themselves in similar situations, and good luck!

ID in the D

Posted by Anna at Saturday, February 16, 2013

I spent the last six weeks on an Infectious Diseases (ID) rotation at Sinai-Grace Hospital located in Detroit, MI. An ID rotation was a top priority for me when scheduling my P4 year, and after finishing up this rotation I stand behind my decision! Infections are seen across all areas of practice, and it was great to have a rotation specifically focused on improving my ID skills.

This rotation was an Antimicrobial Stewardship rotation, which meant I worked behind the scenes monitoring antibiotic treatment for patients and contacting physicians with any recommendations to optimize antimicrobial therapy. Sinai-Grace Hospital has a unique ID consult service which is run by independent ID physicians who round on the patients, which meant that rounding was not a component of this rotation.

One of the highlights of this rotation was the fact that although I did not have a team to round with, I was surrounded by my own pharmacy “team.” Beyond my primary preceptor—Dr. Jason Pogue—I worked under the ID PGY-2 resident for the first four weeks of my rotation. Also on my “team” was the Sinai-Grace PGY-1 resident as well as a fellow P4 student from Wayne State University. I absolutely loved having such a diverse group of individuals to work with, and I was sad when each person slowly left for other rotations leaving me all alone on my final week.

A typical day consisted of:

• Following up on my “old” patients to see how they were progressing and if anything needed to be modified or addressed
• Work up new patients and develop a care plan for their infections
• Present new patients to my preceptor and comment on any follow-up needs for “old” patients
• Call/page physicians to make recommendations as needed
• Topic discussion / Journal Club / Follow-up questions

I was responsible for my patients from the time they were assigned to me until they were either discharged or no longer had any infections requiring antimicrobial therapy.

Overall, I really loved this rotation and highly recommend any ID rotation for a P4 student. I feel that this rotation specifically provides a lot of benefits:

1.       The patients. The patient population in Detroit has a lot of infections caused by multi-drug resistant organisms. Obviously, this is not so great for the patients; however, it is the perfect setting for pharmacy students to learn about how to treat complicated and challenging infections. It also allows you to see the significant role pharmacists play in this aspect of patient care.

2.       The preceptor. Jason is a fantastic preceptor. (I’m writing this after my final evaluation so you know I’m being honest and not just trying to get a good grade). He does a great job of asking questions and challenging you to know the information without making you feel bad when you don’t. He also tries to work with you on your personal weaknesses, and he will modify the rotation to complement your specific professional goals. For instance, he knew I was trying to obtain a PGY-1 residency position post-graduation, and for my final week he cranked the workload up to “resident” mode which forced me to work at a much higher level and also allowed me to focus on some areas for improvement.

I also want to touch on some of the possible drawbacks of this rotation to provide a well-rounded evaluation:

1.       Commute. The hospital is in Detroit. I live in Ann Arbor. This meant I had a 40+ minute commute (one way) to the hospital with the other billion people on the road. Coupled with the potential for bad January/February driving weather, I was a little concerned going into this rotation. That being said, I got used to the commute and lucked out with pretty mild winter weather for the most part. I would not let the commute deter you from choosing this rotation, particularly as the weather is only a key player in a few months out of an entire year that you could take this rotation!

2.       Interviews.  Although this rotation block was designed to provide a week to take off for interviews, an interview day is not really a relaxing day “off,” and on busier weeks I found it challenging to switch from interview mode to rotation mode. Even though my interviews were all located in Southeast Michigan, I still felt overwhelmed at times. On the flip side, having rotation responsibilities prevented me from stressing out about interviews too much—no one has time for that stuff when you have patients to take care of! I also want to say that the preceptor worked with me on scheduling and I never had an issue where rotation conflicted with a possible interview. Again, this “con” really only applies for the rotations that typically fall during interview/job search months.

After the past six weeks being surrounded by ID, a possible future as an ID pharmacist is definitely on the table. It is a really interesting area of practice and (now that I am starting to get the hang of it) I get why people love it so much!

My next rotation takes me… nowhere. I am tired, and luckily I have the next five weeks to recuperate on my “off” rotation. Once I catch my breath I will attempt to tackle a huge to-do list which includes a lot of figuring out what my next steps will be as graduation approaches.

I also want to send good luck to all of my classmates starting it all over again on Monday—only two rotations left, we can do it!!!

What is an Administration – Technology Systems rotation?

Posted by Anna at Thursday, December 20, 2012

This was a common question I received after informing people the title of my nontraditional rotation. After completing this rotation, I finally have a good answer!

The rotation was an administrative rotation within the context of the technology systems used in a hospital. These different systems include automated medication packaging, automated dispensing cabinets, and automated inventory management, to name a few. I worked under a pharmacist responsible for understanding the various systems, and who uses their capabilities and the data they collect to improve efficiency and safety within the health system.

My rotation followed a similar format to the other administrative rotations discussed by my colleagues already. However, I also spent the first week or so working with pharmacy technicians and actually using the technology. This included receiving medications from the order, picking medications for delivery, and going on runs to stock automated dispensing cabinets. This was not my favorite part of the rotation; however, it was important I understood how the systems worked in order to interpret the data they generated.

My day can easily be summarized into two main tasks: meetings and projects. I attended meetings that covered the administrative side of things (management/operations, policy review, and Joint Commission preparation) and those more specific to supporting the technology systems (purchasing/contracting, drug shortages, and quality improvement). Projects I completed include:

-          Review of pharmacy technician medication kit filling records to determine utilization of extra technician hours

-          Assessment of stock out data from Omnicells and recommendations for how to meet goals

-          Creation of a new database to store controlled substance research prescriber information

-          Collection of data and development of a timeline for implementation of consolidating purchasing of a product for the health system

-          Review of medication usage and current par levels in Omnicells and recommended changes

-          Evaluation of usage of bulk compounded products by outpatient areas

All of these projects involved ridiculous amounts of data which I had to sift through and make sense of. As a result, I became intimately acquainted with pivot tables.

I am very happy with my selection for a nontraditional rotation. I learned a lot about the administrative side of hospital pharmacy, and I better understand the challenges faced in this environment. This rotation taught me that how we get the drug to the patient is just as important as choosing the right drug. After this experience, I would be very open to an administrative position in the future.

This concludes my very last rotation at the University of Michigan hospitals—sad!!! Starting in January I test my winter driving skills (if we ever get a winter) as I venture out to Detroit’s Sinai-Grace Hospital for an Infectious Disease rotation!

AMBUTUTIONALIST: an "institutional" rotation at Spectrum Health

Posted by Anna at Friday, November 09, 2012

I have just completed my rotation at Spectrum Health Butterworth Hospital in Grand Rapids, MI. Although technically an advanced institutional rotation, I feel it would be better classified as an ambu-tutiona-list rotation. This new classification stems from the varied components of this rotation that went beyond the traditional “institutional” requirements by combining ambulatory care, institutional tasks, and generalist activities. A list of some of my experiences better demonstrates this variety:

Ambulatory Care:
- One week at the West Michigan Heart clinic working with pulmonary hypertension and heart failure patients
- Performed medication histories and patient counseling
- Made recommendations to the provider and charted my interactions in the medical record

Institutional:
- Product dispensing and medication order verification
- Patient chart review
- Discharge counseling (Meijer Heart Center)
- Antibiotic pharmacokinetic monitoring
- Developed nurse-directed educational project on QT-prolonging agents in conjunction with nursing
- Two journal club articles and a formal patient case presentation

Generalist:
- One and a half weeks with the medical surgical unit performing patient chart review and work-up for 12 to 16 patients per day
- Rounded with interdisciplinary team and made treatment recommendations when warranted

My hours typically ran from around 7:30-4 (although this varied a bit), and for the most part I worked with a few select pharmacists. My preceptors were clearly dedicated to my education—you could tell they wanted me to be there and that they enjoyed teaching. This specific rotation was only introduced at Spectrum Health this year, and I was their second student. Many of the kinks had been worked out with the previous student (sorry Mary Lou!), and everything flowed much more smoothly for me. Although there were a few of those inevitable days where it felt more like a shadowing experience than a practice experience, overall the preceptors allowed me to be very independent and kept me busy!

I applied for this rotation specifically for the opportunity to see how things were done in a different health system. I personally benefited greatly from being in a different environment, and it provided me a chance to see how another health system is making changes to advance pharmacy practice. I also loved the opportunity to interact with other pharmacy students, as many Ferris State University students have rotations at this site. I was surprised by how inviting the atmosphere was to an “outsider,” and I would highly recommend this site for an institutional rotation!

My next rotation brings me back home to the University of Michigan Health System. For the next six weeks I will be exploring the world of informatics and administration on my “non-traditional” rotation!

Anna in pajamas – a rotation at Lexi-Comp, Inc.

Posted by Anna at Tuesday, October 09, 2012

I just finished my fourth rotation: Drug Information with Lexi-Comp, Inc. As the title implies, this rotation has an open dress code as the bulk of the work occurs at home. It was great to take that white coat off for five weeks, but don’t let the cozy working situation fool you—this was a challenging rotation with high expectations.

I had the honor of reuniting on rotation with one of my colleagues, Katrina. Our preceptor, Dr. Dan Streetman, is one of the pharmacists responsible for the interaction database for Lexi-Comp (among his other responsibilities). This was the main focus of our rotation, which meant a lot of CYP interaction review! Essentially, Dr. Streetman makes sure the interactions reported by Lexi-Comp are up to date and accurate, and he also fields questions directed to the interactions team. For five weeks Katrina and I did our best to do the same!

A perk of this rotation is flexibility in your schedule. Your hours can be whatever you want them to be, as long as you get your projects done and make sure to get in (at least) 40 hours of work per week. Due to the nature of this rotation, my laptop became my new best friend. I would search for information, read the literature, come up with my own interpretation and recommendations, and type up a summary of what I found. This was a less traditional take on a drug information experience, as I never directly communicated with other health care providers regarding patient specific questions; however, I did have the chance to answer questions posed to the interactions team. Some of these questions included:

·         Is there any data regarding an interaction between digoxin and proton pump inhibitors—specifically long-term use of PPIs?

·         Should gadobenate have any QT interactions and/or be listed in one of the QT-prolonging groups? If yes, which risk-category? 

·         What interactions need to be added for Stribild, a newly approved drug?

Other basic daily tasks included creating new drug interaction monographs, updating old interaction monographs, journal club, and working on a longitudinal project that involved herbal-drug interactions.  We would also meet with Dr. Streetman twice a week to go over our pending projects and get grilled on our therapeutic knowledge.

Overall, I learned many things on this rotation. I had the opportunity to delve deeper into the mechanisms of drug interactions and the questions that pharmacists face when analyzing literature for true interactions. I gained confidence in my ability to evaluate the primary literature and make my own conclusions regarding the data. I also discovered that working from home is not my forte—although I loved my comfy clothes and short commute, the lack of direct human interaction was difficult, and I also felt that since I worked from home I never actually left work.

The fourth rotation was definitely a blur of activity, as I completed my Pharm.D. seminar on the last day of rotation. Already I am two days into my fifth (!!!) rotation—Advanced Institutional Pharmacy at Spectrum Health in Grand Rapids!

Canton Meijer Pharmacy = Counseling!!!

Posted by Anna at Tuesday, September 04, 2012

My third rotation was at Meijer Pharmacy in Canton, MI. Having had about two years of retail pharmacy experience, working in the community pharmacy setting for five weeks was definitely a nice break after two very unique rotations.

                            

The primary goal of this rotation was spelled out by my preceptor on the first day: maximize patient interaction. This meant that when on-site, I was the initial resource for any pharmacy-related questions from patients, any new medication counseling, and all over-the-counter medication recommendations. The site was a very busy pharmacy, functioning with one to two pharmacists and four to five technicians at any given time. I was not treated as “free labor,” and I was not expected to perform pharmacy technician activities. Essentially, I was a supplemental pharmacist, which provided the opportunity to review and reinforce much of my therapeutic and pharmacy law knowledge. This rotation also required little off-site preparation, leaving more time at home to work on other projects and deadlines.

Overall, I would highly recommend this community rotation site. The pharmacists were incredibly welcoming and gave me the freedom to step out and apply my knowledge. The pharmacy technicians were efficient and self-sufficient, and they were quick to call for me me whenever a patient had a question or needed additional counseling. It was a great work environment, and I could not have asked for a better community experience.

My next rotation will be quite a change from the hustle and bustle of a large retail setting: I will be working primarily from home for the next five weeks completing a drug information rotation with Lexicomp!

Pediatric Emergency– A Generalist Approach

Posted by Anna at Friday, July 27, 2012

The end of the second rotation seems abrupt—how has it been 5 weeks already?! I had the privilege of working with the generalist pharmacists in the pediatric emergency department at U of M. I specifically requested a pediatric experience due to the lack of pediatric-focused care in my other rotations. It was an added bonus to be placed in the emergency setting, which is another area I would have had no experience in otherwise.

I was scheduled to be on rotation from 10am to 6pm but often went in from 1pm to 9pm in order to maximize my chances of being on-site when the ED was busy. Although there is no routine day in the ED, I did have some typical tasks I fit in throughout the day.

1.       Patient work-up. Upon arrival and throughout the day, I assessed the patients in the ED. When there were a good number of patients (>9 or so) or several patients with complicated conditions, I would spend time working up the patients and present them to my preceptor. The presentation included basic background information regarding the patient’s medical history and presenting complaint, with a more detailed discussion of what we have done so far regarding treatment, if that treatment was appropriate, and what else I anticipated the patient may require while in the ED. I found myself better able to anticipate the needs of the patient and make treatment choices as the rotation progressed. With the quick turnaround of patients speed was definitely a factor and is something I will continue to work on.

2.       Topic discussion. I was required to put together a brief (1-2 pages) handout for an ED topic discussion with my preceptor once to twice a week. These topics ranged from management of diabetic ketoacidosis to dealing with rabies or venomous bites. I also had the opportunity to meet with other P4 students on the pediatrics generalist rotation to participate in pharmacist-lead discussions about important topics in pediatrics.

3.       Journal clubs & case presentations. This activity also involved the other three fantastic P4 students on the pediatric generalist rotation. The topics were all pediatric-focused, and I learned a lot from my peers and the pharmacists in attendance. In case you’re dying to know, my journal club discussed the use of hypertonic saline in the ED in the management of acute wheezing in preschool children, and my case presentation pertained to a patient undergoing treatment for neutropenic fever in the ED.

4.       Discharge counseling & medication reconciliation. I was able to perform discharge counseling for patients being sent home with new medications—antibiotics being the most common. For patients requiring hospital admission I was responsible for obtaining a medication history and writing up a medication reconciliation note. Overall, these tasks granted me some face-to-face time with the patients and their caregivers and helped me to become more confident and comfortable in my knowledge and communication skills.

5.       Traumas. The pharmacist is responsible for responding to any traumas that come in—and that meant I got to tag along! I will 100% own up to the fact that I was very nervous about this aspect of the rotation due to my low tolerance for blood and such. However, I can happily report I had no fainting spells or other equally embarrassing reactions! This is likely due in part to the scarcity of traumas while I was on-site; I witnessed a trauma usually once to twice a week. Even so, I did have the chance to see the pharmacist in action and understand how her ability to accurately and quickly prepare medications for administration can impact patient care in this setting.

Overall, I believe this was a great rotation. Patients ranged from 2 days to 20 years old, which allowed me the chance to practice both pediatric and adult dosing. I learned a lot about pediatric-specific conditions and medications. I learned about emergency medicine and how to anticipate patient needs. I was forced to become faster at everything. I got to sleep in. I also worked with some fantastic pharmacists who really tried to maximize my learning experience.

Although I will miss the pediatric ED, I now must switch gears and prepare for my community rotation at Meijer!

BMT: a badge of honor

Posted by Anna at Wednesday, June 20, 2012

I can't believe my first rotation is coming to a close. Five weeks have really flown by, and I'm shocked by how much I have learned in such a short period of time. While I am thrilled to be coming out of this rotation only mildly battered, I am sad to leave the welcoming health care team that staffs 7W as well as the amazing patients.

As promised in my last post, I wanted to briefly touch on how pharmacists (and student pharmacists!) make an impact on this service. Pharmacists are well recognized as experts on medications, and their wealth of knowledge is not lost upon the health care team running adult BMT. In order to keep this concise, below you’ll find just a small taste of the questions directed at pharmacy:

• A patient has consistently dropping cell counts, which is not altogether uncommon in this patient population. However, could any of the patient’s medications be contributing to this trend? If so, what change would you recommend?
• A patient is unable to keep anything down due to the chemotherapy regimen we conditioned her with. What do you recommend after standard anti-emetic therapy has been attempted?
• The patient is still throwing up. What else can you suggest?
• A patient has been admitted with severe graft-versus-host disease of the skin. What type of therapy would you recommend to control the disease? What literature is your recommendation based on?
• A patient is experiencing significant changes in mental status. Which drugs could be the culprits? Are there any specific tests or concentrations you need to assess? What about drug interactions?
• Your poor patient has been hiccuping non-stop for a day with no relief in sight. We've tried Thorazine, but what else could help him?
• A patient has end stage renal disease. Does this change your recommendation for chemotherapy doses? What is the basis of this decision?

Overall, this rotation was eye-opening. It truly helped me to determine my strengths and weaknesses, and it also allowed me to start developing important skills crucial to a successful career in pharmacy. I highly recommend this rotation for anyone who wants exposure to a unique and dynamic patient population. You also typically have at least a few other classmates on rotation with you, which honestly was pretty awesome!

The next time you hear from me I will be reporting from my rotation with a generalist pharmacist in the Pediatric Emergency Department!

BMT: and what's the half-life of that?

Posted by Anna at Saturday, June 02, 2012

Why the title? I am on rotation with Dr. Frame working with UMHS Adult Bone Marrow Transplant, and if you know only one thing about a drug, I recommend it be the half-life as you will undoubtedly be asked about it.

This is my first rotation, and I have now completed my 2^nd week. I will say that the first week was definitely busy, overwhelming, and consisted of many late nights trying to get up to speed on what was going on with the patients in this service (refer to Roxanne's post for more details!). I think the stress of this was definitely eased by the classmates also on this rotation: Roxanne, Katrina, and Philip. You’ll see blog posts from the first two as well, so you will definitely get a feel for BMT if you follow us!

This service is quite different from many others. We have had anywhere from 21 to 27 patients on the floor total, with the majority of patients being scheduled admits. The patients come in about one week prior to their transplant in order to undergo the appropriate preparatory regimens. After transplant, they remain on the floor until they have recovered enough to thrive again on their own—typically, this takes at least two weeks after successful transplant. As a result, we will follow patients over a very long period of time and try to keep them as healthy as possible. Due to the nature of the transplant, the patients are severely immunocompromised for an extended period of time, making infection prophylaxis and treatment a crucial component to this rotation. Additionally we encounter a lot of nausea/vomiting issues, graft-versus-host disease, and any other disease state or chronic condition you can imagine. In BMT you see it all!

I am always curious as to what an average day looks like for each rotation, and here we have a pretty standard schedule:

• I arrive around 7:30am to review patients for any issues that have come up overnight. I then modify or adjust recommendations as needed.
• Rounds start around 8:30-9:00am. In attendance: Pharmacist, Pharmacy Students, Attending Physician, Nurse Practitioner/Physician Assistant. During rounds we will typically be ready to make any recommendations regarding our patients, and we are usually quizzed and questioned by Dr. Frame or the Attending Physician.
• Rounds end anywhere from noon to 1:30pm. Then we grab a quick lunch!
•  After lunch we meet with Dr. Frame to review our patients and any new developments. We will discuss any number of topics we have been assigned and also address any questions we have. Here we will also briefly present our patient cases and discuss what we need to prepare for the next day.
•  Topic discussion with other oncology pharmacy students occurs at 3:00pm, where we meet with an Oncology Pharmacist to discuss pertinent topics to our patient population. This requires varying amounts of reading the night before.
• 4:30pm: go home! At home I will do assigned readings, review my patients again, review material I feel needs more attention, and prepare for the next day!

So far, I have really enjoyed this rotation. It requires a lot of work, a lot of preparation, and you have to deal with a decent amount of stress regarding what questions you might be asked at any moment (often regarding mechanism of action and/or drug kinetics/half-life…) Overall, I have found it to be challenging but incredibly interesting!

In my next post, I hope to describe in more detail what types of interventions pharmacists (and pharmacy students!) make and how the pharmacist is a crucial member of the BMT team.