Hometown Hospital

Posted by Eric Zhao at Monday, April 30, 2012

Last month, I was with Providence Park Hospital in Novi, MI. If you have the fortunate opportunity to do a rotation in your hometown and live with your parents, do it. Coming home to homecooked meals and some family loving is a nice relief from the Totino's pizza and shenanigans associated with the typical college lifestyle.

Providence Park Hospital, Novi, MI

This was no ordinary institutional rotation, however. Each week had a different theme to provide exposure to the varied aspects of a hospital pharmacist.

Week 1: Made IVs in the clean room, delivered controlled substances, dealt with medication shortages, assessed/restocked inventory, and packaged medications.

Providence's USP 797-compliant Cleanroom

Week 2: Dosed-adjusted for the pharmacokinetics/anticoagulation service. We monitored for aminoglycoside/vancomycin levels and initiated/adjusted heparin, warfarin, dabigatran, fondaparinux, and rivaroxaban doses.

Week 3: Assisted metabolic support services through ordering appropriate parenteral nutrition. Rounded in the intensive-care unit (ICU). This part of the rotation is like a mini critical care rotation!

 ICU Rounds

Week 4: Attended a Pharmacy and Therapeutics meeting at Providence Hospital in Southfield. Gave a journal club presentation on the potential use of rivaroxaban in the treatment of pulmonary embolism. Spent a day in the Operating Room and viewed implementation of a bone-assisted hearing aid, a laparoscopic cholecystectomy, and a hemicolectomy. 

 

Bone-assisted Hearing Aid

 

Hemicolectomy

(I will spare you the graphic photos, but feel free to google it)

All in all, a great rotation that far exceeded my expectations. Highly recommended. A+++! Would rotate again.

Eric Zhao

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

Midyear & Fellowships

Posted by Eric Zhao at Friday, February 24, 2012

Pharmaceutical Industry Fellowships
Since a majority of Michigan students pursue a post-graduate residency, I’ll post a bit about industry fellowships (there were only 3 of us who applied). Before I begin, please take a look at a previous blog post by Michigan alumnus, Jeffrey Huang, a clinical research fellow at GlaxoSmithKline. His advice and wisdom was instrumental in helping me succeed.

Midyear PPS
Where do I begin? The Rutgers Industry Fellowship program could be one of the most intense interview processes I have ever experienced (14 interviews and 6 receptions over 4 days; see schedule at end). Before you are allowed to sign up for interview slots, you have to watch a 30-minute crash course about the Rutgers program. You can bypass this and sign up for interviews immediately if you attended the Fellowship Information Day at Rutgers in New Jersey about a month before Midyear. I did not attend Fellowship Information Day, so despite being one of the first people in line, I was sent to the middle of the pack after watching the video onsite.

This line is silly

Get there early! I got there about 2 hours before opening and there was already a line forming. I guess it doesn’t really matter, but interview slots are given out on a first come, first serve basis.

Interview Tips
Mock interviews: Do at least one mock interview with another fellowship candidate and ask all the tough questions. You’ll thank yourself later.

Curriculum Vitaes: They say to bring 50 copies, but I only handed out 21. Future candidates can get away with only bringing 30 or so. If you can, print at least 10 (ideally all of them) on resume paper and paper clip them instead of stapling them.

Between interviews: Space your interviews out by 30 minutes, so you can take notes and breathe. Bring some snack foods because sometimes you won’t have time to go eat. There can also be a lot of sitting and waiting if you scheduled your interviews far enough apart.

Presentations: While this isn’t necessary, you can print off any past presentations or materials to show to interviewers if they ask for it. It really drives the point home when you’re talking about your past experience while they are actually viewing it. I brought my PharmD Project, seminar, and pharmaceutical industry presentations.

Research the companies: Be smart.

Interview Process
First round interview: These are with the current fellows and last about 15-30 minutes. They want to see if you have the qualifications and desire to be in the industry. Practice answering “tell me about yourself,” “why a fellowship?” and “why this company?” Sign up and get these out of the way early. If they like you, they’ll set you up for a second round.

Second round interview: These interviews can be either with a fellow or preceptor or both, depending on the company and can last anywhere between 30-60 minutes. The questions are more difficult and typically involve behavioral questions.

Tell me about a time when…

Third round interview: After passing second rounds, the third round is with the preceptors and directors of the departments (one company brought in a vice-president!). Again, the majority of questions are behavioral. If they like you, they will extend an invite to their reception.

Reception: If you want to succeed, you’d best go to these receptions, even if it’s just for 30 minutes. Most will have hors d’oeuvres (pronounced HORES DE' VORES*) and an open bar, but it’s not a time to party. Make connections and try to meet everyone at the company, as they may be potential supervisors and mentors. Here is where pharmacy student business cards might come in handy…but they are not necessary.

*not really, but I petition for an alternative pronunciation…Kudos to Bernie Marini, Andrew Wechter, and Brian Dekarske for this wonderful pronunciation.

Thank you cards: Send one to each interviewer. They had a basket at PPS for these, but I ended up mailing all of mine once I came back from New Orleans. I don’t think it matters either way, but if I had to do it again, I’d bring a set of blank cards to Midyear.

Sample Schedule
To give you a taste of what to expect, here was my schedule for PPS:

Saturday

• 12:00pm PPS Opens
• 4:00pm 1st round

Sunday

• 8:20am 1st round
• 9:30am 1st round
• 10:30am 1st round
• 11:30am 1st round
• 12:30pm 2nd round
• 3:30pm 2nd round
• 4:30pm 2nd round

Monday

• 10:15am 2nd round
• 11:30am 3rd round
• 1:00pm Residency Showcase
• 3:00pm 3rd round
• 4:00pm 3rd round
• 5:30pm Reception
• 6:00pm Reception
• 7:00pm Reception

Tuesday

• 8:30am 1st round (non-Rutgers)
  
• 9:00am Residency Showcase
• 1:00pm Residency Showcase
• 3:00pm 1st round (non-Rutgers)
  
• 6:00pm Reception
• 7:00pm Reception
• 8:00pm Reception

Wednesday

• 8:30am Breakfast Reception
• 11:00am Sleep until 4:00pm

I had a fantastic time at Midyear and had no regrets going through the process. I liken it to running a triathlon: the training and actual event is very tedious, but once you are finished, you feel a great sense of accomplishment. I will leave you with some words of wisdom for all you future candidates out there.

Clinical Pearls

• Get to PPS early.
• Go to Fellowship Information Day to skip the line at PPS to sign up for interviews. Plane tickets can be expensive, so perform a cost-benefit analysis. I didn’t think it was worth the cost and did just fine.
• Mock interview with a friend.
• Print CVs on resume paper and bring past presentations.
• Bring a set of business cards and about 30 blank Thank You cards.
• Snacks on snacks on snacks.
• Go to receptions.
• Get some sleep.
• Reward yourself and sight-see after it’s all done.

That’s all folks!

Sincerely,
Eric Zhao

Multidisciplinary Oncology

Posted by Eric Zhao at Thursday, December 22, 2011

St. Joseph Mercy Hospital has been my home for the past month, where I rotated with Dr. Carol Yarrington in Ambulatory Care Oncology.

New Oncology Infusion Centers in Canton, MI and Brighton, MI
Patient bays increase privacy and comfort

After brushing up my knowledge on the oncology drugs, therapeutic areas, and side-effect management strategies, I was charged with setting the groundwork for a pilot pharmacy intervention at the Multidisciplinary Oncology Clinic.

The Multidisciplinary Clinic (MDC)
The clinics are held on Monday (head/neck cancer), Tuesday (lung cancer and gastrointestinal cancer), and Friday (breast cancer). In one sitting, a patient can see a nurse navigator (explained below), nurse practitioner, palliative care nurse, physician assistant, medical oncologist, radiation oncologist, and surgeon. What's nice about this initiative is that the patients receive the full spectrum of care in a single trip. Each of the healthcare professionals will individually visit with the patients, rotating between patient rooms. Afterwards, they all convene to discuss their plan for each patient.

The Multidisciplinary Team in the Cancer Care Specialty Center
[Link to Brochure]

Nurse Navigator

The nurse navigator, a rising new concept, serves as the main contact and face of the multidisciplinary clinic. They make sure the patient is acquainted to the clinic by setting up appointments with the healthcare professionals and providing follow-up when needed. Because days can get hectic, these navigators help orient the patient during their treatment visits.

Pharmacy Intervention
Between visits from the healthcare providers, patients may have 30-120 minutes of downtime before the next visit. What a convenient time for pharmacy to step in, interview the patient, and review their medication list! The clinic is mainly focused on the oncology aspect, so there is a lot of room to manage their chronic health concerns. Oftentimes, patients with cancer will try complementary or alternative medications to improve their situation. However, these medications may interact with chemotherapy to reduce their efficacy; for example, some chemotherapy agents rely on creating free radicals to destroy tumor cells, so ingesting a large amount of antioxidants may cause more harm than good.

Green tea, an antioxidant, may negate chemotherapy agents that depend on producing free radicals to destroy the tumor

Future Direction
The multidisciplinary clinic shows a lot of promise, and I hope the clinic continues to pilot the program with the next student. It's a great way for pharmacists to get involved in the multidisciplinary care of oncology patients through a review of not only their chemotherapy regimen, but their maintenance medications too.

Eric Zhao

Drug Information: Lexi-Comp

Posted by Eric Zhao at Sunday, November 13, 2011

This month, I'm excited to help write for a drug information program known for both its online and mobile platforms:

I'm looking at you, Lexi-Comp

Working with a previous University of Michigan College of Pharmacy alumnus as my preceptor, I help write and update drug-drug interactions for the program. Some examples of the interactions are those between carbamazepine/non-dihydropyridine calcium channel blockers, levodopa/iron salts, and oxcarbazepine/phenytoin, among others.

The Process
1. Initial Search: The initial search involves a very broad query in PubMed for the interacting drugs, and if there are a reasonable number of hits (around 200 or less), we begin screening abstracts for possibly pertinent articles. Sometimes the query produces over several thousand results, so we employ alternative search strategies (e.g., using limits, excluding "review" articles, etc.).

Some sort of national database

2. Screening: After combing the abstracts, I can usually narrow the article list down to about a quarter of the original number. Here's where I access and skim the articles to see if they will be useful for the write-up. This narrows the list down even further.

3. Write-up/Update: Once I determine which articles will be useful for an evidence-based write-up, I determine a strategy. Ideally, my final list involves articles that provide many different viewpoints of the drug interaction, which include primary literature and case reports. After thoroughly analyzing the articles, I begin writing the drug interaction monograph.

4. Upload: Prior to uploading, I review my drafted monograph with my preceptor for his opinion and expertise. If all goes well, my preceptor will remotely log-in to the database and upload our monograph. It's pretty neat to see the immediate changes on my phone's Lexi-Comp application after uploading.

This rotation allows me to practice my literature searching skills while providing a lot of autonomy. My preceptor gave me several projects that he wants finished before the end of rotation and it's up to me to prioritize and deliver (i.e., I set my own schedule). During our meetings, I inform him of what I have been working on, and he lets me know my progress. That said, I'm going to get back to my projects.

-Eric Zhao

ECT: Not Like the Movies

Posted by Eric Zhao at Sunday, October 23, 2011

Electroconvulsive Therapy
The media has given electroconvulsive therapy (ECT or "shock therapy") a bad rap. If you were like me and the general public, the only exposure of ECT came from the silver screen.

Clockwise from left: A Beautiful Mind, One Flew Over the Cuckoo's Nest, and Requiem for a Dream (all great movies, mind you)

ECT Reality (Content from the University of Michigan ECT Program)
What an honor to view a live ECT treatment during my psychiatry rotation. The whole procedure took only 15 minutes and looked nothing like the film scenes above.

The medical team (psychiatrist, anesthesiology, and nursing) typically reserves ECT for patients refractory to first-line interventions or for those with severe psychiatric episodes. We don't know exactly how it works but some theories suggest alterations in neurotransmitters or stress hormone regulation. The aim of ECT is to induce a seizure using a brief electrical pulse, so patients are tapered off adjunctive anticonvulsants (e.g., lamotrigine, valproic acid).

EEG showing seizure activity (top) and seizure termination (bottom)

Anesthesia
The anesthesia team administers anesthetics, neuromuscular blockers (typically succinylcholine), and oxygen for both safety and comfort. A blood pressure cuff around the arm monitors blood pressure and a second cuff around the lower leg prevents neuromuscular blockers from traveling to the foot, allowing psychiatrists to monitor for motor seizures. That's right folks, the ankle/foot area is the only part of the body that showcases "classic" symptoms of convulsing.

Patient receiving ECT. Notice the blood pressure cuff around the lower leg to prevent neuromuscular blockers from traveling to the foot.

Unilateral vs. Bilateral
A full course of ECT typically ranges from six to twelve total ECT treatments. Bilateral treatment involves electrodes at both temples, and patients undergoing bilateral treatment typically respond quicker (i.e., less total treatments) than those who receive unilateral treatment. However, bilateral treatment is associated with more memory side effects.

Bilateral Treatment


Right Unilateral Treatment

Side Effects - Possible Short-term Memory Loss
Sometimes patients experience headache and nausea after the treatment. One of the greatest concerns of ECT patients is short-term memory loss during the period of ECT treatments (e.g., forgetting lunch or previous interactions). In some cases, patients may lose memory of past events, especially those 2-6 weeks before treatment.

Patient Response
It's hard to imagine patients responding well to ECT given its stigma and unknown mechanism of action. It's one of those things where you have to see it to believe it. I remember a patient with severe depression who no longer desired to live and was not responding to any conventional therapy (e.g., SSRIs, SNRIs, TCAs, etc.). A full course of ECT later, this patient was completely reborn: smiling, joking, and poking fun at the medical team. Forget electroconvulsive therapy; this was an electroconvulsive transformation.

-Eric Zhao

Early Impressions of the Top Floor

Posted by Eric Zhao at Sunday, October 09, 2011

I'm on the top floor of UMHS where you need a keycard to access to the unit. Two weeks into my psychiatry rotation, I feel safe in saying that I doubt I will ever experience a patient population more interesting or empathy-inducing.

A Day in the Life
7:45 am: Patient workup prior to team meeting

8:30 am: Team meeting with attending physician, medical residents/students, nurse practitioners, physician assistants, and social workers. During this meeting, we talk about the patients, their progress overnight, and our therapeutic plan. If you see any pharmacy interventions, speak up here.

10:00 am: Rounding with the medical team. Now's the time to see the patients and view how they're doing. Pharmacists make sure that the medications are working as intended while minimizing any side effects. For example, in an obese patient or an athlete, recommend an antipsychotic that minimizes weight gain and other metabolic complications; aripiprazole and ziprasidone are good choices, while clozapine and olanzapine are not. As always, consider the patient profile as a whole, but you knew that.

12:00 pm: Patients are usually at lunch or group therapy, so we spend time chatting with our preceptor about our patients, giving journal clubs, and attending grand rounds.

1:00-4:00pm: Follow-up with patients and ask any questions. This is a good time to write up pharmacy notes, visit patients again with the team, and provide therapy recommendations.

Variety is the Spice of Life
As you can guess, no two days are the same. Diagnoses may be similar, but no two hallucinations, delusions, or psychotic episodes are alike. Also, there are few things more inspiring than seeing a patient's mood improve as their medications take effect. One of the strategies used to manage severe, drug-resistent forms of acute metal illness is called electroconvulsive therapy (ECT). Tune in next time as we explore the clinical dimensions of ECT.

-Eric Zhao

Oncologic Drugs Advisory Committee

Posted by Eric Zhao at Wednesday, September 14, 2011

SILVER SPRING, Maryland - Oncology experts from around the nation gather in the FDA's White Oak Conference Center to evaluate the new drug application for Ferriprox (deferiprone) and to discuss trial design for the development of products to treat patients with non-metastatic prostate cancer. It's 8 o'clock in the morning and the Chair of the Oncologic Drugs Advisory Committee (ODAC) meeting begins the Call to Order for this all-day meeting. The ODAC consists of 13 voting members to review and evaluate safety and efficacy data for oncology drugs and makes recommendations to the Commissioner of Food and Drugs, CDER, and CBER.

Their view:

The Great Room in the White Oak Conference Center
FDA White Oak Campus, Building 31

Meanwhile, in Indianapolis, I park myself in my desk chair, log on to the Lilly corporate system, and break out my headphones. Inside my bag, I pack two caffeinated beverages with my lunch to prepare for today's 8:00 a.m. to 5:00 p.m. meeting. My assignment today consists of analyzing and interpreting how the FDA thinks. Think of it like the industry playing chess against the FDA.

My view:

The closed captioning didn't make sense all day.

Ferriprox (deferiprone) [8:00 a.m. - 12:00 p.m.]

Iron Man's Kryptonite

Submitted by ApoPharma, Inc., deferiprone is proposed for the treatment of patients with transfusional iron overload, when current chelation therapy is inadequate. During the meeting, ApoPharma, Inc. presents their case, and then afterwards, the FDA presents their case (are we in court??). Following this, the public delivers their testimonials and opinions about the magic of deferiprone. Finally, the ODAC answers questions, discusses any issues, and casts a final vote. In this case, they voted 10-2 to support an application for accelerated approval.

Non-Metastatic Prostate Cancer Study Design [1:00 p.m. - 5:00 p.m.]
Currently, there are no products approved for the following indications:

1. Non-metastatic, PSA-only recurrent prostate cancer who have not received androgen deprivation therapy (ADT)
2. Non-metastatic castration resistant prostate cancer (NM-CRPC) who have a rising serum level of prostate-specific antigen (PSA) despite currently receiving ADT

The afternoon session of the ODAC meeting discusses possible patient populations, trial designs, and suitable clinical endpoints for studies intended to support a product for these unmet medical needs. The session begins with an FDA presentation and two speaker presentations for background, and I feel like I'm in lecture again. For the next 3 hours, however, the committee argues about the pros and cons of trial endpoints until they finally hit 5:00 p.m.--with a split conclusion. I'm sure my preceptor is going to loooove this result.

The Food and Drug Administration

FDA stands for Full Day Agenda

Today was definitely a test of endurance, but a great experience nonetheless. I wish I requested a clerkship rotation with the FDA, because after attending this meeting, I realize how valuable that experience would have been. If you're interested in the industry, having been at the FDA will truly give you a leg up. Write that down...

-Eric Zhao

Caught Up In The Regulations

Posted by Eric Zhao at Friday, September 02, 2011

Once again, I find myself in the pharmaceutical industry (surprise!). This time, however, I am with Eli Lilly and Company...in the Regulatory Affairs Department, no less.

Eli Lilly and Company, Indianapolis, IN

If you remember from my previous adventures, I spent a summer in regulatory affairs at Abbott in Advertising and Promotion. You're probably thinking, what's the point of doing two regulatory affairs positions? I had the same thought, believe me.

What I didn't know was that I would be working on the complete opposite spectrum of the drug development process. At Abbott, I dealt with the regulations after the FDA approved a drug. At Lilly, I deal with the regulations before and during FDA approval. Yup, I'm working with Investigational New Drug (IND) applications and New Drug Applications (NDA).

I'm currently wrapping up a journal club presentation for this upcoming Tuesday on a competitor's newly approved biologic drug and will finish the rest of the clerkship gathering intelligence on a project that's under Double Secret Probation. I wish I could say more, but these industry folk like to keep to themselves.

I'm sure I'll come up with interesting topics to blog about that won't compromise my employment status, but for now, enjoy a picture of Lilly's entrance fountain.

Best,
Eric

Community Service

Posted by Eric Zhao at Friday, August 12, 2011

Ahh yes, the community rotation. Many of you already know the rigors of a retail pharmacy, so I will spare you the redundancy. FYI, I am rotating at a medium-volume pharmacy that I won't name (due to their corporate policies; again, I know...). Ask me in person if you want details.

Immediately after walking in, I knew why many patients decide to stay loyal to this pharmacy. The team here prides itself on efficiency and rapport. The pharmacists and techs all know the patients by name and have an all-around jolly good time joking around and causing all sorts of shenanigans. This is, of course, while maintaining patient safety and filling scripts accurately.

In this post, I will go over an awesome prescription software feature and the monthly health fair.

The Four-Point Check
In the workflow, this pharmacy software includes a "four-point check" where the pharmacy checks the 1) patient name, 2) drug, 3) strength, and 4) directions, because these are where errors can have the most impact. Then it goes into technician filling and another final check by the pharmacist before being verified.

Four-Point Verification before Filling

I've worked at three different retail pharmacies before and this procedure is new to me. If the other chains aren't doing this, then I suggest they man up before someone gets hurt.

Health Fair
It's a Saturday morning and I graciously volunteered to help out at the monthly health fair. The topics vary each month and this health fair tested for blood pressure, blood glucose, and vision.

Blood Pressure Testing Machine


Blood Glucose Monitor

Snellen Chart for Vision


Amsler Grid
(Normal Vision)


Amsler Grid
(As seen by a person with age-related macular degeneration)

We spent a good four hours utilizing our pharmacy knowledge to analyze results and encourage people to make lifestyle changes. And, because I know you care, here are my results:

Blood Pressure: 133/89
Blood Glucose (post-prandial): 110
Vision: 20/30 with glasses
Amsler Grid: No macular degeneration!

My BP is a bit high for my liking, but I'm still at goal (<140/90). I blame the economy. I'm happy with a glucose of 110 (post-prandial! AKA "After eating" for the lay person). Looks like I need to upgrade my glasses though...but I don't have macular degeneration! I'll wait until I'm over 50 y/o for that one, thanks.

Until next time, cheers!
-Eric Zhao