Rotation 4: Ambulatory Care Like You've Never Seen Before

Posted by Unknown at Monday, October 31, 2016

I spent block four at the Cancer Center at St. Joseph Mercy Hospital (SJMHS).

My preceptor is piloting a new program at SJMHS where each person that is receiving any oral medication to treat cancer is required to speak to a pharmacist about that medication. Oral chemotherapies—while often much more tolerable than the usual intravenous option—are not benign by any stretch of the imagination. More importantly, unlike the IV chemotherapy where the patient is surrounded by healthcare professionals for the duration of their infusion, the pills go home with them. For many of them, there are very real risks associated with exposing other people to the drug and other considerations like what you should/not eat or drink, warning signs for side effects and other complications, and drug-drug interactions that could compromise their treatment.

All of the same items apply for patients new to IV chemotherapy, but the majority of the side effects and management have significant overlap so that is done in a classroom setting. However, there are always little things that a nurse practitioner and I would team up to address afterwards.

These sessions would typically take about an hour (and sometimes much longer!) and after three or four in a day I would try to avoid talking for a while so I wouldn’t lose my voice!

Typical Day

I would typically arrive at SJMHS between 7 and 8 AM. First things first: check in ARIA (the infusion center electronic medical record system) to see if there were any new patients for the day. While most of these were scheduled days or weeks in advance which would give us plenty of time to prepare, there was the occasional last minute addition. The morning was usually project work or counseling, depending on the day, and afternoons were the same dependent on the IV chemotherapy teaching class schedule. Generally, I would be in my car headed home between 4 and 5PM with a smile on my face.

The Work

Working up a patient is less focused on their specific disease and more focused on the drug and the logistics of getting it to the patient on time. A lot of things need to click in to place before the drug is sent to them by the (usually specialty) pharmacy, and a big portion of what I was responsible for was, on top of the usual pharmacist duties, ensuring that our office had all of the information we needed and that all necessary testing was done or scheduled. Based on the drug or drugs they were receiving additional screening (such as hepatitis B, HIV viral load, or an echocardiogram) might be required.

Next would be actually going to meet the patient and their family. I often had groups as large as eight or nine people—and spend the hour or more discussing the information that I had, answering their questions, and if they wanted to continue, collecting their consent form. Most days these counseling sessions would take 3-5 hours on 2-3 days a week.

These sessions have been some of the most fulfilling work that I have done as a student pharmacist. Most of the people I was seeing have only known that they have had cancer for one or two weeks. There is a lot of apprehension and a lot of things are changing very fast—suddenly they need to reevaluate their entire life plan and here I am talking about all the bad things that could happen if they take this medication. I could relate to what this was like—my father was diagnosed with cancer when I was in high-school—and those experiences went a long way towards helping me understand what these people were going through. The relief that each person experienced when they were done speaking with me was something to behold. Many underestimate the power of knowledge and what that can do when you have been preoccupied with so many fear-filled unknowns. Pharmacists make this possible.

Projects

My preceptor more-or-less owns the responsibility for the back-end management of ARIA and as such, we had access to a ton of data and reporting tools for process improvement. I used my programming background to streamline several reporting processes for each of the five clinic sites that will probably save an analyst a full week of work each year (30-45 minutes per report à 10 seconds per report). This is on top of literature searches for various questions like “should we use cryotherapy with doxorubicin infusions” or “is glucarpidase over dialysis cost-effective in managing methotrexate-induced acute kidney injury?”

A major component of these counseling sessions is a set of informational packets built for each drug. The Michigan Oncology Quality Consortium (MOQC) has built a ton of these for the oral chemotherapies that we enhanced for use in our clinic. Part of my job was building these for new drugs and updating old drugs with new data.

Overall Thoughts

Year to date, this has been a blast of a rotation. I sincerely left each day with a smile on my face and an excitement about the next morning. I found the work fascinating, challenging (but manageable), and I made a sincere, visible difference in the lives of so many people. Not to mention, I got to program and use a bit of my technical background as well! You can peer in to the world of specialty pharmacy billing, learn a whole lot about various cancers and their treatments, and a ton of other interesting work besides. I highly recommend this rotation!

Rotation 2: Health Systems, Day +25

Posted by Millie at Saturday, July 30, 2016

Hi again! 

My second rotation was health systems/hospital at a cancer research and treatment center affiliated with a medical campus full of other hospitals. I came into this rotation not really knowing what to expect, and I’m leaving it with such a good understanding of pharmacy operations, pharmacy services, and more about bone marrow transplant and hematology/oncology than I could have ever thought possible from only 5 weeks!

My first two weeks were spent in pharmacy operations, where I observed and participated in unit dose, narcotic control, order verification, and making IVs for non-chemotherapy and chemotherapy products. I learned about the inventory process, which was especially interesting considering the pharmacy at this site is responsible for ordering and managing thousands of dollars’ worth of oncology products. I also spent some time with the Investigational Drug Services and was able to witness pharmacists’ role in managing medications for patients participating in a drug study. Being one of the largest sites for phase 1 studies, you can imagine the IDS pharmacists were very busy.

Starting with week 3, I transitioned from pharmacy operations to participating in our pharmacy clinical services. I was so excited that this site was a mix of both inpatient (floor) and outpatient services (clinics) because I wanted to get exposure to a variety of patients. I spent some days with the pharmacist in the bone marrow transplant clinic, where I was able to see a few patient education or “chemotherapy teach” sessions. Before patients begin their transplants, they come to the clinic and are counseled by a pharmacist who goes over the medications, the transplant process, and answer any questions they may have. It’s a very collaborative process between everyone in the room, and it was so great to see how the patients really appreciated a pharmacist spending the time to go over each step with them. I also watched how pharmacists, physicians, and nurse practitioners work together to write and review chemotherapy orders. I was also able to round with the infusion center nurses, watch how they administered chemotherapy, and ask them questions. I gained a good appreciation for how nurses manage to juggle everything, and the importance of effective and constant communication between all staff on the floor. I even got the chance to sit down with a patient and explain to her how her pain regimen worked!

I spent a few days with each of the inpatient pharmacy clinical specialists in bone marrow transplant, oncology, and critical care. During these days, I was given some patients to work up, create an assessment and plan, and present the case to the pharmacist. The pharmacists would ask me questions and we would discuss things to consider when assessing patients. We went on rounds together, where I had the opportunity to interact with medical and nursing staff. I was impressed at the collaboration between all of the members on the team, and it was fascinating to see the thought process behind clinical decisions.

Towards the end of my rotation I gave an in-service presentation to the pharmacy staff on Graft-versus-Host Disease in Hematopoietic Stem Cell Transplant. GVHD is a very complex topic, and I spent a lot of time diving into the immunology and pathology of the condition, as well as reading about the background of HSCT and how it pertained to my site. From this presentation, I was able to gain more experience in ways to effectively present complex topics and scientific data. Over the 5 weeks, I even got to participate in some important events, including a pharmacy and therapeutics meeting, medication safety meeting, and an emergency preparedness exercise. 

Overall, I was fortunate to learn from patients with such complicated cases and understand the pharmacy department’s role in the hospital, and it was a great way to get ready for my future inpatient rotations! 

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

TT whaaa??

Posted by Christine Rabah at Friday, September 09, 2011

So before we know it, rotation #1 one is over, and we're 2 weeks into rotation #2. I really enjoyed my Drug Information rotation at Beaumont and will miss all of the people I met there.

I am currently on rotation at Mott in Pediatric Hematology/Oncology with Dr. Erika Howle. I'm not gonna lie, I was terrified going into this rotation. I know next to nothing about peds, let alone pediatric oncology. It was also a big change to just complete a Drug Information rotation that had zero patient interaction to the complete opposite of the spectrum.

My typical day starts off by getting to the hospital around 7-7:30am to check on my patients before rounds at 9. Rounds last about 1.5-2 hours depending on how many patients we have on our service at the moment. Rounds include an attending, 2 interns (1st year residents), 1 senior resident, a fellow, a couple of med students, sometimes a dietician, and us. It's typical to see patients discharged for a few days then come back for chemo, so we follow the same patients throughout the month whenever they are readmitted. Each of our cancer patients are on a certain chemo protocol (as Melanie described a few posts down) which we have to follow. We also have to be very conscious of their supportive therapy (for pain, nausea/vomiting, neutropenic fever, etc) and make sure it's appropriate.

After rounds, my preceptor, fellow pharmacy student, PGY-2 Oncology resident, and myself discuss our patients. We then get some time for lunch, and lastly, attend boot camp. All 5 of the pharmacy students on oncology rotations (whether they are adult or peds) attend "boot camp" topic discussions about different things that can affect cancer patients. As Melanie described below, the first week consisted of topics on pain, nausea/vomiting, and neutropenic fever. During the second week, we talked about anemia, colony stimulating factors, and tumor lysis syndrome.

We also have smaller topic discussion as a peds heme/onc group on common pediatric cancers/heme disorders such as acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), sickle cell disease, the 3 sarcomas (osteosarcoma, rhabdomyosarcoma, Ewing sarcoma), and neuroblastoma. Dr. Howle was sure to give each of us a wide range of patients so we could learn about their diseases. Currently I have a patient with pre-B cell ALL, one with osteosarcoma, and one with TTP. Now, day 1 of this rotation when the team kept throwing around this acronym "TTP", all I could think was "what the heck are they talking about??" Of course, I had to LOOK IT UP!

TTP stands for thrombotic thrombocytopenic purpura. It is a blood disorder that occurs when the body is deficient or lacking (this is rare) a certain enzyme called ADAMST-13, or if the body has developed antibodies to this enzyme. This enzyme breaks down a protein called von Willebrand factor which clumps together with platelets to form blood clots. When you are deficient in this enzyme, all of your platelets are getting stuck to the von Willebrand factor causing tiny blood clots all over your body (and shows up as tiny purple spots under your skin, called purpura), and are not free elsewhere in the body to do their job. This is why patients with this disorder have a very very low platelet count. To fix this, patients get a treatment called plasma exchange where blood is removed, the plasma is separated and the antibodies against the enzyme are removed. More plasma with the enzyme is added and it goes back into the patient's body.

So far, my favorite part of this rotation is getting to see the kids. A couple of them have already stolen my heart. I have also learned more than I ever thought I would about pediatric cancers in just 2 weeks, and am looking forward to learning much more. Previous to this rotation, anything having to do with pediatrics was not on my radar but now it just might be :)

The Ups and Downs of Chemo

Posted by Shannon Hough at Tuesday, February 02, 2010

In therapeutics, we learned that we can treat cancers with chemotherapeutic agents. However, they are accompanied by toxic side effects. This month, I had a chance to see first-hand how these drugs affect our patients. This was a lesson in side-effect profiles I will never forget.

Lesson 1: Myelosuppression (decreased blood counts)
Many of the patients that we saw this month were receiving some form of 3+7 (3 days of an anthracycline and 7 days of cytarabine) for a leukemia diagnosis. These patients often became neutropenic (low white blood cells), anemic (low red blood cells), and/or thrombocytopenic (low platelets). Patients who are neutropenic can be at risk for infection, and were monitored very closely for fevers or other symptoms. Patients who have low red blood cells often had very low energy levels that improved when we gave them a blood transfusion. And patients with low platelets often experienced more bruising or bleeding, including nosebleeds. Many times, these effects can be delayed, and the patient can feel great during chemo, and even a few days afterward. It was almost predictive, that when we saw the patient’s blood counts decreasing, their spunk would decline as well. One of my favorite times to see patients was when their counts were recovering and they were excited at the prospect that they had had a successful treatment and would soon be able to go home.

Lesson 2: Cold-Induced Neuropathy
In this case, a patient with colorectal cancer was receiving FOLFOX, a chemotherapy regimen containing oxaliplatin. Certain patients can experience sudden pain when exposed to cold temperatures when receiving oxaliplatin. This can even be triggered by drinking a cold beverage or holding something cold. This is an important side effect to discuss with our patients as this pain can certainly be avoided with adequate education.

Sometimes studying drug side effects can be difficult. There are so many drugs and so many side effects. But as we continue to work as students, we can collect experiences to help our memories along the way.

The Next Step

Posted by Shannon Hough at Saturday, January 16, 2010

January already.

December came and went with the ASHP Midyear Meeting, the holidays

and residency applications. This year's ASHP Midyear Meeting was held in Las Vegas, NV. I attended the meeting in order to learn more about first year (PGY1) residency programs. I could not believe how many people were at the meeting, including the number of pharmacy students looking for residencies. The photo at the right was taken at a student poster session. The majority of people in the room were students! It was a great experience to be at such an impressive meeting.

After weighing all of my options, I decided where I wanted to apply. So I polished up my applications and sent them off. I requested letters of recommendation and transcripts. Most pharmacy residency programs stopped accepting applications in early January. Over the next few months, I hope to receive invitations to interview for a PGY1 placement, and keep my fingers crossed for a good match.

This month, I also started my rotation in inpatient hematology and oncology at the University of Michigan. This rotation is unique in that there are two hematology/oncology teams, each of which sees both types of patients. Each team spends half of the morning rounding with an oncology attending physician, and the other half with a hematology attending physician. I am on one of the teams, and follow all of the patients that one of the physicians on the team sees. So far, I can see a huge role for a pharmacist with these patients. Cancer can change how the liver, kidneys and bone marrow function. Chemotherapy regimens alone have complex, highly individualized toxicities requiring patient-specific therapy. I have had to consider all of these factors in learning about the care of this patient population.

The team that I round with is quite pharmacy friendly. My fellow P-4-parter-in-crime and I reply to many "Hey Pharmacy..." questions from our residents and medical students. The residents often times make changes to the patient medication profiles as we make our recommendations. (Just one more reason we need to be very accurate in our recommendations!) I'm looking forward to learning more about the pharmaceutical care of hematology/oncology patients as the month continues.