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 + 2^nd/3^rd 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 (jsphntan@med.umich.edu)! 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!

Infectious Diseases - The Big Guns Come to Life

Posted by Jared at Monday, August 01, 2016

After my first rotation in ambulatory care managing patients with mostly hypertension and diabetes, I was doing a bit of a 180 in the clinical sense and jumping into the world of infectious diseases (ID). ID was by far my favorite section in therapeutics during pharmacy school, and I was both excited and nervous for this rotation, as I knew it was going to be a challenging rotation. I had the opportunity to do this at a hospital in Detroit, so I was interested to see how the patient population would affect the type of infections we would see and how these patients would be managed.

A Typical Day
I generally would get into the hospital at around 6:30 AM to work up the patients I was planning on presenting to my preceptor, along with following up on patients I was still following and finishing up my topic discussions. At around 9 AM most days, I would meet with my preceptor and present the two new patients I picked up on our service, do a topic overview of their disease state, present my assessment/plans, and then discuss patients I was still following. Afterwards, I would typically go on rounds for a variable amount of time, which was dependent on the schedule of the attending physician and fellows, as they had different commitments (clinics, didactic, meetings, etc.). Generally, we would round for about a few hours in the morning, then break for either ID Grand Rounds, a lecture, or journal club, and then re-convene in the afternoon and finish rounding, which usually got out anywhere from 5-6 PM.

Of note, ID services are typically consult services, so we would see patients on a number of floors, ranging from the internal medicine floors to ICU, Burn, Neuro ICU, and Surgery. Due to the nature of our service, which typically consisted of the attending physician, two fellows, two to three residents, the clinical pharmacist, and me, we would often get new consults during the day that we would need to address. On average, our service had around 12-15 patients, but could go up to 20-23 patients.

Expectations, Challenges, and Overall Thoughts
As I mentioned earlier, my preceptor required two new patient presentations a day, along with a topic discussion for each patient's disease state.  I also needed to follow all my patients that were previously presented that our service was still following, along with keeping an updated patient list that included the patient's infection, their antibiotic therapy and duration, along with notes about their treatment. Also, if any patients I was following were on aminoglycosides or vancomycin, I was responsible for doing the pharmacokinetic calculations by hand and showing it to my preceptor that morning when discussing dose recommendations. I also had to write a review paper on a topic of interest that could only utilize primary literature as sources (no review articles or textbooks).

Without a doubt, this rotation was a huge challenge on my time management skills. I would initially spend a lot of time both at home and in the hospital working up patients and putting the topic discussions together. My preceptor in particular challenged me to use only primary literature, rather than relying on class notes or textbooks to put these together. This was difficult for me at first, as not every disease state has a nice review or guidelines to go over and synthesize into a succinct presentation. After I ran through most of the common ID disease states (i.e. pneumonia, skin and soft tissue infections, bacteremia), I essentially picked what might be interesting to me or things my preceptor recommended to go over (i.e. tuberculosis, malaria). Often, I was in a time crunch in the morning, but as the rotation went on, I got much more efficient at putting together these topic discussions and working up my patients.

Also, while the topic discussions were time intensive in terms of preparation, it really helped to solidify my therapeutic knowledge. My preceptor was great at asking probing questions and really helping me to understand the reasons behind various concepts (i.e. why is IV drug abuse a risk factor for endocarditis?). Furthermore, the institution I rotated at doses vancomycin differently than what we were taught at UM. Rather than using a nomogram, they targeted AUC (area under the curve). This required me to essentially re-learn vanco PK, but it helped a lot with practicing those equations and solidifying my skills. Due to the nature of Detroit's patient population, I got to see a lot of patients with either MRSA infections or multi-drug resistant infections that required either those big gun agents Dr. Carver has us avoid using in therapeutics (i.e. daptomycin, linezolid) or unconventional combinations. Finally, the questions I got from both my preceptor and the clinical pharmacist that went on rounds daily helped me to understand why we spent so much time learning physiology and med chem by really "connecting the dots" between concepts I didn't think could relate to ID in the first place.

All in all, this was an extremely rewarding experience. I was constantly challenged and pushed to my limits, but I came out of it with a much more solidified therapeutic knowledge base of ID and a greater appreciation for the discipline. A PGY-2 in ID still isn't out of the question for me, but we will see what the rest of the year holds! For now, it's on to community and rotation 3!

Infectious Disease at UCMC

Posted by Eric Zhao at Sunday, March 25, 2012

How fitting. I've caught an infectious disease on my infectious disease rotation at the University of Chicago Medical Center. My remedy? Lots of water and lots of sleep. Unfortunately, this is not the case with the patients on this service.

University of Chicago Medical Center

Infectious Disease (ID) Consult Team
The team I'm on consists of an 1) attending physician, 2) ID Fellow, 3) medical residents, 4) medical students, 5) ID pharmacist, 6) pharmacy resident, and 7) and yours truly, the pharmacy student. Without fail, other healthcare professionals comment on the size of our team. As a consult team, we cover the entire hospital with answers (hopefully) to anything related to ID. Some examples include what antibiotic to recommend, how to address a bloodstream infection, or how to narrow therapy to specific cultured/suspected bacteria.

Typical Day
8am - 10am Work up patients prior to discussing with my preceptor. Sometimes the list can consists of many patients (high score of 28 in one day!), so you mainly focus on what pertains to ID:

• Reason for consult
• History of Present Illness
• Allergies
• Complete Blood Count (mainly white blood cell count and platelets)
• BUN/Serum Creatinine/Creatinine Clearance
• Antibiotics
• Drug Monitoring (e.g., levels for Vancomycin and aminoglycosides
• Microbe cultures and sensitivities
• Assessment and Plan

Selling this template for $5 to future students on an ID rotation

10am-12pm Discuss patients with preceptor with any concerns or suggestions. Typically, she'll ask how you would narrow therapy or how the vancomycin/aminoglycoside levels look.

12pm-1pm Follow-up with patients and clarify any questions (and lunch)

1pm-3pm Discuss patients with full medical team

3pm-5pm Medical team visits any patients that we want to see, especially new consults.

Mix this schedule in with intermittent topic discussions, ID conferences, and Pharmacy Grand Rounds for a taste of what ID can offer. Now, to get rid of this nagging cough...

-Eric Zhao

Staff pharmacist

Posted by Matthew Lewis at Thursday, October 06, 2011

This rotation is all about figuring out what it would be like to be a general staff pharmacist, and it's at the VA (veteran's affairs) if you haven't read my previous post. The first thing that stuck me was where this VA is, which is right next to a college (Wayne State) and several other hospitals (Detroit Medical Center and Karmanos Cancer Institute to name a few) so it's at the heart of a medical complex. I've already done quite a few different things. The life of a staff pharmacist can pretty much be what you want to make it. You could be asked to take charge of the anticoagulation clinic, or make decisions about non-formulary medications. Your job might be to check physician orders and medication fills mostly.

Speaking of checking medications, the hospital inpatient setting employs a tech-check-tech system where properly trained and trusted pharmacy technicians check each other's work for accuracy. You might think it unsafe, but literature has shown that this system is just as accurate as a pharmacist check. tech-check-tech is an up and coming practice which allows pharmacists to get out onto the floor more often and help the medication ordering and administration process, which is where most medication errors occur.

Making IVs was fun, and interesting. You have to scrub in and gown up according to our fairly new industry practice of USP 797 guidelines which dictates how sterile IVs should be made. The actual mixing of the standard IVs isn't hard since most medications aren't toxic to any degree. I did not get the special chemo drug training though, since that is so dangerous even to people who follow the guidelines and have the two pairs of gloves on, the sterile disposable jacket, hair covering, mask, eye protection, mixing hoods with particular airflow and filters put in place among other things (As you can see, there are a lot of things to consider when implimenting USP 797.).

Now I'm just going on rounds and offering suggestions to the team to best manage the medications. Part of the job the pharmacist I round with is to make sure the vancomycin troughs are appropriate, and all the anticoagulation pharmacy follows is done by this pharmacist as well. I've learned quite a bit from that pharmacist as to the real-life application of medications which have narrow therapeutic ranges. In school, we learn with the impression that we can get patients' drug concentrations to the exact middle of our precise desired range, but in real practice there are mistakes as to when patients get lab draws, physicians of varying experience might not take your recommendations, or the patient might not "fit the mold" and metabolize the medication in some super fast or slow manner just to name a few things fighting against a pharmacist trying to get that perfect concentration.

That's what this rotation is all about for now, I'll keep you updated as things change.