Rotation 7 - General Medicine and Residency Interview Season

Posted by Jared at Thursday, February 16, 2017

Hello everyone! January and the first part of February have been a pretty busy time, but I'll update you with my latest rotation, along with my insights on residency interviews after going through the process!

Rotation 7: General Medicine

Like Millie, I was assigned to cover an adult internal medicine service for my general medicine rotation. During this rotation, you have the option of ranking between adult internal medicine, cardiology, surgery, pediatrics, or the NICU. Note that the NICU is typically an afternoon rotation, while the rest run from a normal 7-3:30 schedule. There are some blocks where the ED is an option for this rotation, but it wasn't during this block. Millie describes the rotation pretty well, but I'll quickly go over my time frame during the day.

6:00 - 7:00 AM: I would arrive at the hospital to work up patients for my service. On average, it would be about 10-12 patients a day.

7:00 - 8:15 AM: Talk over the patients with the resident I was on rotation with first, make
recommendations, then go over those recommendations with our main preceptor prior to rounds

8:15 - 11:00 AM: Round with the medical team

11:00 - 12:00 PM: Go over patients, discuss status/interventions, topic discussion

12:00 - 2:00 PM: Lunch, attend educational lectures (i.e. CE, resident on-call report), look up drug information questions, write warfarin/vancomycin notes, follow up on other medical issues for the team.
2:00 - 2:30 PM: Follow up with preceptor on issues, mini-topic discussion

2:30 - 3:30 PM: Student topic discussion. These consisted of either general topic discussions from preceptors, or student-led discussions that included new drug presentations, a topic discussion, journal club, and case presentation.

I enjoyed having internal medicine as my past rotations (ID and critical care), I felt I was only looking at certain aspects of the patient (i.e. antibiotics, renal dosing, etc.). However, on internal medicine, I could no longer ignore all the comorbidities a patient had. I really needed to make sure that a patient's medication was correct for not just the main problem, but even their home meds as well. It really taught me to look at the patient as a whole, and definitely helped solidify my knowledge. Also, my preceptor was great at going over a bunch of topics that helped me revisit a lot of areas from therapeutics. This definitely helped me out for residency interviews, which I'll go into next...

Residency Interviews

The month of December after Midyear is a frenzy. You're choosing where to apply, you're getting your letter of recommendations in order, and you're stressing out waiting to see the e-mail confirmation that they've been sent to PhORCAS, and that your transcripts are in. You spend days writing a letter of intent, and then you hit submit and play the waiting game.

Programs go about offering interviews very differently. There's no standard set of rules in terms of when they respond or how they will respond. Some programs will tell you when they'll get back to you by, others will just be silent until they send an interview offer or rejection. Some of my programs responded pretty quickly after the deadline, others took a few weeks. Some programs will either only give you one date to interview, some will have you fill out a list of preferences, or some will give you dates and you simply choose the one that works for your schedule. Finally, some programs will e-mail you, and some will call.

This process honestly requires you to both be extremely flexible and to have your calendar and phone at the ready. This is particularly true when some programs will call you and ask you to interview on a date, and you have to pick on the spot. Thankfully, I was able to have an hour or so to look at my calendar before responding back to them after the phone call, but I know of some students that weren't afforded that luxury for some of their programs. Sometimes, however, you will run into scheduling conflicts with interview dates if a program only offers certain dates or if you have rotation requirements. If you're unable to re-schedule the interview and can't accommodate it into your schedule for whatever reason, it's okay to decline as long you as explain your rationale and express your gratitude for being offered the interview in the first place. Programs would prefer you cancel prior to scheduling a spot. DO NOT schedule an interview and then cancel last minute. This causes bridges to be burned and looks extremely unprofessional on your part, and since pharmacy's a small world, you never know who they might tell...

As for the interview process, I would say Michigan prepares us extremely well. Most questions weren't out of the ordinary in terms of questions you would expect (why residency, why our institution, situational questions, tell me about a time when..., etc). At this point in time, I have completed the majority of my interviews, with just one more between now and when our rank list is due for the Match. Some tips I have below based on my experience:

• Know your CV inside and out, forwards and backwards. I studied my CV prior to interviews and took notes on all my presentations in case I got asked about any of them. The rule of "if it's on your CV, it's fair game" is extremely prevalent during residency interviews. Looking back, I've been asked about the majority of my presentations/projects, or have at least referred to them at one point during the interview process. It doesn't look good if you can't speak to at least what the project/presentation was about and what you did. For Michigan students, this is EXTREMELY true for your PDI. PDI becomes a default answer to a lot of questions (tell me about what you're most proud of, a time when you had to manage multiple deadlines, etc). Know your PDI, what you did, and what it found. I know I have been asked about it on multiple interviews.
• Try to group interviews together that are geographically close, especially if you know their dates ahead of time. This particularly applies to applicants going out of state for interviews. For example, I had some interviews out in the Pacific Northwest that I was thankfully able to coordinate in the same week, so I didn't have to travel back and forth between Michigan and Portland/Seattle. Some programs do release their interview dates ahead of time, so you can try and be strategic about choosing dates.
• Be nice to everyone you meet, including your fellow interviewees! The adage "you're being evaluated the whole time" honestly holds true. I had heard that programs evaluated how social you were with the other candidates you interviewed with, so this is something you want to keep in mind. While you're all interviewing for the same spot, note that these people could potentially be your co-residents! You don't want to appear stand-offish or anti-social, as program directors and preceptors will notice. 
• Eat breakfast and drink coffee/water if you need it! Interviews are a long day, and there are a lot of people you're going to be talking to. Make sure you're fully energized for the day, so your brain is at its sharpest.
• Be prepared for clinical cases. A number of programs have parts of the interview where you have to work through/present a clinical case. From my personal experience, I've experienced a lot of ID/anticoag, but generally a lot of these cases are types of situations you might experience on an internal medicine rotation. The main thing interviewers are assessing here is your thought process. Don't stress too much if you don't remember the exact dose of azithromycin you'd give for a patient with CAP or how long you would treat them. One thing to mention always is where you might go to look up that information (i.e. IDSA guidelines, institutional guidelines, etc.)
• Write down your interventions/disagreements as you go through your APPEs. You'll almost always get asked about your most meaningful clinical intervention, or about a time a doctor disagreed with you. Writing these down will help you to refer to it later during interviews.
• Remember you're interviewing them, too. Just getting to the interview is an accomplishment, especially with how competitive residencies are now. Honestly, just be yourself and try to get to know them, along with showing off your personality. You really want to know if you'll "fit" at the program, as you'll be spending the next 1-2 years there, and you don't want to hate your time there and be miserable. As always, prepare a number of questions for the different people you might meet (i.e. residency program director, preceptors, coordinators, residents). Finally, don't feel bad asking multiple people the same question. It's good to get different perspectives to help you better assess if the program is a fit for you.

I will say doing most of my interviews during the general medicine rotation was mildly hectic, but I'm glad most of them happened during this block. I felt really prepared for the clinical cases I came across and had various things I could speak to when interviewers asked me about clinical interventions/disagreements. Thankfully, I had most of my interviews during this block, as I'm currently in DC doing a rotation at the FDA. However, note that there are a lot of interview dates that occur during block 8, where you don't have an extra 5-6 days built in to go on interviews. Thankfully, my preceptors during both rotations have been really accommodating with me and have allowed me to go on interviews.

Hope that helps with a picture of residency interviews or the general medicine rotation. Feel free to e-mail me (jpborlag@med.umich.edu) with any questions. Thanks!

Two Professions at Once: Surgery Generalist

Posted by Unknown at Wednesday, July 27, 2016

After my first rotation at a local community pharmacy I was finally due for my first clinical rotation--generalist. This rotation is required for all University of Michigan pharmacy students and (looking back) a great way to kick off my clinical experiences. A few weeks prior to my assigned block we got a survey asking us to rank which generalist sub-specialty we were most interested in. We could choose between Internal Medicine (pediatric and adult), Surgery, Cardiology, and the pediatric intensive care unit (PICU). Before long, I was assigned to Surgery.

I had no idea what to expect. Surgery (of any type) is not exactly something that we cover in school and while I find it fascinating I had zero practical knowledge about how to manage these people. To be honest, I knew very little about how to manage a 'regular' patient, let alone one that we've gone in to and moved a whole bunch of things around.

Due to the way that preceptor schedules worked out, I spent three weeks with a general surgery unit and the remaining two weeks with a urology surgery unit. The units work a little differently:

A Day In the Life on General Surgery

Arrive at 7 AM to begin working up patients. I live on the south side of campus but the buses come every 10 minutes and there is virtually no traffic. For the general unit there are no formal rounds that pharmacy is a part of (they happen at 5 AM!). As a consequence, we meet with the Physician's Assistants that are doing most of the day-to-day clinical management around 11 AM to discuss our interventions. This meant that I would work up my patients until about 9 or 9:30 AM, then meet with my preceptor. We made a point of staying out in the conference room where the medical team worked to be accessible for drug related questions. We would walk through each patient, each problem, and discuss what information we needed (usually the people who knew were right behind us!) and why, then make recommendations accordingly.

Surgery patients are challenging in that every third word is a strange surgical term or acronym. Down the literature rabbit hole I would go to find out what is going on and determine how their medications might be affected. Regardless of the procedure, the four main areas we focus above and beyond the typical dosing, safety, and interactions are home medications, nutrition (pharmacy owns IV nutrition like TPN and PPN), anti-infectives, and anti-coagulation.

By the time that process was finished it would be 11 AM or so and I would have a dozen things to follow-up with patients and nurses, disease states to look up and apply guidelines or literature to, drug-information questions to research, as well as counseling and education to complete.

Somewhere in there, I would take 20 minutes for lunch before meeting back in the pharmacy for a quick follow-up with my preceptor and discuss our plans before jumping into a one-on-one topic discussions with one of the surgery pharmacists. We covered a wide range of topics from toxicology to common procedures for X, Y, or Z disease state, infectious disease and much, much more.

This would be immediately followed by a student led topic discussion, case presentation, or journal club (we each had an assigned afternoon for each of those three things spread out over the five weeks) that wrapped up the day around 3:30 PM.

A Day in the Life of Urology

Urology works a little differently. They also have general rounds that pharmacy does not participate in directly, but instead have interdisciplinary rounds led by the urology intern/fellow around 8 to 8:30 AM. I would quickly look over my patients beforehand (not a full workup) to see if there were any major, urgent issues to review before briefly meeting with my preceptor to discuss things before heading upstairs to rounds. These are primarily an information gathering session--notes in the electronic medical record can often be a day behind so these allowed us to get up-to-date on the plan and goings-on for each patient in our service. Any major questions we have are answered (and we get a fair number of questions ourselves!) before heading back down to report out. A full workup of each patient follows, along with the same walk-through-each-patient as before, go talk to the team as before, and a dozen things to look up and follow-up on as before.

There is still room for lunch before the afternoon progresses just like before with topic discussions, case presentations, and journal clubs.

In each case, there are usually a handful of things to finish during the evening hours, but never so many that you can't hit the gym, relax a little, get some other work done, and make dinner before getting some rest and doing it again the next day!

--

Now on my last few days, I can safely say that I have learned an enormous amount and that this is a fantastic springboard for my next rotation: infectious disease! See you again soon!

Pediatric General Medicine: A Whole New World

Posted by Silu at Wednesday, October 09, 2013

Hi everyone. Rotation 4 has ended and so has 50% of P4 year. Siri tells me there are 199 days from today until graduation! Ah!

For this rotation, I was at UMHS Mott Children’s Hospital for pediatric general medicine. This is considered the “Inpatient A – Generalist” rotation that all UM students have to complete at a UM hospital, having the choice of either adult (University Hospital) or peds (Mott Hospital). I had no prior interest in pediatrics, and, up until a few weeks before the rotation started, I had no intention to choose peds. After some consideration, I changed my mind for the following reasons: 1) several of my rotations were adult internal medicine/general medicine-related, and I wanted to add some variety 2) quite a few residencies programs I looked at had mandatory pediatric rotations, 3) this was my last chance to learn about a special population of patients as a student!

The Mott General Medicine rotation has three main components: 1) rounding with a pediatric general medical team, 2) monitoring total parental nutrition (TPN), and 3) medication reconciliation. A typical day began between 7 and 7:30am, when I would arrive before rounds to work up my patients. This was followed by rounds (usually 1.5-2 hours) and TPN monitoring. In the afternoon, we often had topic discussions with the preceptor or would meet with the other Mott pharmacists and P4 students for presentations and discussions. In between, we would follow up with tasks and questions from rounds and complete med recs for newly admitted patients.

In the beginning, I felt like I entered another world. I Googled and Up-to-Dated every other disease state and wrote down everything I didn’t have time to look up to research later…which was always more than I expected. In the end, I enjoyed this rotation much more than I thought and learned a great deal, not only in terms of therapeutic knowledge, but also of unique challenges in pediatrics for which pharmacists can intervene. For example, since most young children cannot swallow pills, their medications must be in liquid form. It is up to the pharmacist to ensure the patient is able to obtain the liquid medication after discharge by confirming its commercial availability or notifying the team if certain medications need to be specially compounded.

Overall, I enjoyed this rotation for the continuity of seeing patients day-to-day, being a valued part of an interdisciplinary team and the challenge of using creativity and critical thinking to resolve special issues related to pediatrics. The hardest part of the rotation was balancing a full patient load with several other responsibilities, but it was a good learning experience in time management and productivity. In the end, I am glad I chose to experience pediatric pharmacy and feel more confident in working with kids. I’d recommend choosing Mott for the generalist rotation to anyone who is remotely thinking about it…you won’t regret it!  (Bonus? Beautiful view of Ann Arbor from the 12^th floor every day!) 

From Clinical Pharmacy Generalist to HIV Community Specialist

Posted by Rachel Lebovic at Wednesday, August 28, 2013

Rotation 1: Clinical Pharmacy Generalist

                  Entering the hospital for the first day of P4 rotations was energizing. I have walked through the University of Michigan hospital’s doors countless times as an undergraduate volunteer and P1-P3 student for shadow experiences and IPPEs, but this time was different. I knew that I would be playing an important role in caring for patients. No more watching other practitioners, this time it was my turn. Plus, I knew that I would be returning every day for five weeks instead of my previous once weekly routine.

After orientation the first day I was asked to work up eight patients. It took me several hours. I was motivated and tried to complete a thorough work-up for each patient. It was extremely rewarding when I was able to see these patients on rounds with the team the next morning. My preceptor joined me on rounds for the first few days, then I progressed to rounding by myself. Over time, I began to feel more comfortable and increased my patient load from eight patients to as many as 16.

Throughout most of the rotation my schedule usually involved arriving to the student computers in the basement pharmacy by 6:30am, working up the patients on my service until 7:40am, running upstairs to the fifth floor pharmacy to discuss any recommendations I wanted to make while on rounds, then meeting the healthcare team for rounds at 8am. Rounds lasted anywhere from 1.5-3 hours depending on the number of patients and the complexity of the cases. Then, I would return to the fifth floor pharmacy and discuss each patient with my preceptor in more detail. If there was more time, I would then work up patients on one of the non-rounding services (an attending only), discuss those patients with my preceptor, then discuss my recommendations with the attending from 1:30-2pm. Other afternoon activities included counseling any patient on my service who was on a blood thinner and looking up any patient-specific questions.

In my opinion, having the clinical pharmacy generalist rotation for block one was excellent scheduling. This rotation was a great review of pharmacokinetics and dosing for antibiotics including vancomycin and aminoglycosides, and I reviewed/learned a lot about several different anticoagulants. Furthermore, this rotation was a great balance of boosting my confidence and reminding me that there will always be more to learn.

Rotation 2: HIV/AIDS Community Pharmacy

                  Fortunate to have a great internship experience in Henry Ford Health System’s outpatient pharmacies, I found myself looking for something different for my P4 community rotation. I definitely found that “something different” with my HIV/AIDS community pharmacy rotation in Chicago! Considering we only had about three lectures on HIV in the P1-P3 curriculum, I had a lot to learn to be able to optimally treat patients with HIV. To prepare for the first day, Caitlin (the other U of M P4 on rotation with me) and I were told to learn all of the brand names, generic names, and abbreviations for the HIV medications currently on the market. It seemed like just memorizing the drug names was a lot to learn at the time, but little did we know that we would understand and apply most of the 240 pages of HIV treatment guidelines over the course of the next five weeks.

Most of the time we were in a miniature Walgreens pharmacy inside the Howard Brown Health Center on the north side of Chicago. This health center is focused on treating lesbian, gay, bisexual, transgender, and queer patients. Additionally, two afternoons per week we were in a multidisciplinary HIV primary care clinic at Mercy Hospital on the south side of Chicago.

A typical day in the Walgreens pharmacy consisted of:

1.     New to therapy calls – calling patients who recently picked up a new medication to see how it was going

2.     ADAP (AIDS Drug Assistance Program) calls – contacting patients whose HIV medications are shipped from a CVS-Caremark specialty pharmacy in Pennsylvania to let them know their medications arrived

3.     Typing, filling, and verifying prescriptions (with the pharmacist’s oversight, of course), along with patient counseling at the pick-up window

4.     “The Queue” – the list of patients whose HIV medications are due to be refilled or patients who are nonadherent to their HIV therapy. We filled these patients’ HIV medications, accessed their HIV regimens for appropriateness, and contacted patients to ask if they wanted their medications delivered to their home

5.     Discussions with our preceptor, Mr. Halbur RPh (Drew) – Drew would often say something to the effect of “let’s discuss nucs” or “tomorrow we’re discussing child pugh scoring.” What this really meant was review everything we knew about anything related to the subject and be prepared to discuss it in great detail! While preparing for these discussions was often a lot of work, they were a tremendous tool for learning about the HIV medications (side effects, drug interactions, patient counseling, etc.) and reviewing other topics.

A typical clinic day at Mercy Hospital consisted mostly of performing readiness counseling and adherence counseling with patients. Readiness counseling sessions are used to explore if a patient wants to start taking HIV medications. This is important because patients who do not take their medications reliably are subject to medication resistance, and their treatment options can become incredibly limited. Adherence counseling sessions try to determine the barriers causing patients to miss doses of their medications and help them figure out strategies to overcome those barriers. Often, we would set up pillboxes for patients to aid them in adhering to their medication regimens. Although more rare, one of my favorite types of counseling sessions was initiation counseling during which we would discuss the four first-line HIV regimens with a patient, discuss the patient’s lifestyle, disease state, comorbid conditions, and other medications, then work with the patient to determine which of the four regimens would be best for the patient to start.

Other projects we worked on during this rotation included:

1.     Teaching a transgender patient how to administer his own intramuscular testosterone injections

2.     Writing a newsletter article for the Howard Brown Health Center

3.     Giving a presentation titled “HIV 101” to the new PsyD (Doctor of Psychology) externs at Mercy Hospital

Even though this blog is mostly about my rotation experience, I have to mention that exploring Chicago with Caitlin was definitely an added bonus on this rotation! In the free time we scrounged up, we managed to check out some local eateries, go the Art Institute, hang out with Sue the T-rex at the Field Museum, and see lots of fun critters and creatures at the Lincoln Park Zoo (which is free, by the way).

Overall, my experience in Chicago was a whirlwind. I’m happy to say that I learned a TON about HIV, enjoyed working with unique patient populations at both clinics, and had fun exploring Chicago in the process!

Adventures in Babysitting -errr, Pediatrics!

Posted by mariarx at Tuesday, September 04, 2012

Oh man, I can't believe it's already rotation 4! The quiet summers of empty Ann Arbor are gone... soon we'll be entrenched in computer turf wars with the P3s on their direct care IPPEs. Before we get too far into rotation 4, I wanted to look back at my adventures in peds.

Our PY team. I like to think I'm the girl with the gold viking helmet hanging on for dear life.

The generalist rotation, new and required this year, gives you the option of working on the adult (UH) side or the pediatric (Mott) side. I decided to take the plunge and go with peds. Who doesn't love kids? Me. But I did like working with their meds. My mom would be so proud. 

My day on the generalist rotation started with rounds prep. On any given day we had between 2-6 patients admitted to the PY (pediatric gold) team. That isn't a lot of patients... until you realize the work that goes into peds dosing, indications, etc. For each patient I tried to get a good idea of their problems and what all their diagnoses meant (helloooo Google), their dosing regimens, weight based dosing, daily maxes for the medications, indications, and any alternatives that I may be asked about. Safe to say my monitoring form looked like a rainbow in trying to keep all the info divided. My preceptor, Jenny Hlubocky, was really good at giving pointers for keeping everything straight and reminding me to focus on the drugs and not get lost in the world of googling mowat-wilson disease.

One aspect of peds drugs and dosing that I didn't really think about before this rotation was the taste of oral meds. Unfortunately, tiny mouths and esophagi are not made for swallowing tablets - which is where solutions come into play. Doing the taste test with Dr. Streetman and the medical students was really fun, even if I did get a headache from all the random drugs we tasted. Note to the public: linezolid, clindamycin, MVIs, and iron taste GROSS; and chocolate syrup is Dr. Streetman's gift to little kids everywhere. 

After rounds my partner-in-crime Vince and I would go over our patients with Jenny, maybe work on orders for our services, and then have the afternoon to do individual work. Besides our general PY patients, we also worked up the rehab patients in Mott. These patients are usually in the hospital for a really long time (and have a really long MAR), so we would make sure that doses were appropriate and make recommendations for cleaning up the med list - such as getting rid of PRN meds that hadn't been used in a while. 

Our final patient interaction component was med reconciliation. I feel like I spent the majority of my afternoon work hours trying to find parents to speak with about their kids medications... the laws of not speaking to minors alone make medrecing quite the difficult task. 

Besides patient interactions and monitoring, we also had some mini-projects and 2 bigger presentations. Mini-projects consisted of topic discussions about things that may have come up in our talks about patients or just interesting topics in the world of peds. In the effort to bring my own interests into the pediatric world, I ended up presenting my journal club and larger topic discussion about pharmacy administration and its role in the inpatient stay and discharge. Dr. Brummond and Dr. Kelley would be proud (I think). 

Overall, I'm really glad I picked the pediatric side of the generalist rotation. I don't have any other peds rotations on the horizon so this was a good adventure to have. My 4th rotation is ambulatory care in oncology... you'll hear about that soon enough if I make it out alive. Till next time, keep saving lives fellow P4s! 

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!

GeNeRaLiSt RoTaTiOn - WeeK OnE

Posted by Melanie at Sunday, August 07, 2011

I am the FIRST EVER student to partake in this (anticoagulation) rotation. It is brand new (still has that new car smell) and I am the only one taking it -- so that makes me the Eve of this rotation.

Eventually, this rotation will go on the REQUIRED ROTATION list and everyone will have to take it.

As a reminder: I am at UMHHC and my preceptor is Dr. Lizzie Engle (yeah, we rock the last name).

Pre-rotation: Complete required materials on CTools course site. This included pharmacokinetic practice, watching anticoagulation videos, and completing the anticoagulation MLearning.

Day 1: Orientation with Drs. Brummond and Kraft. They gave me a basic overview of what I would be doing – rounding with medical teams, managing anticoagulation and kinetics, patient education, daily readings, topic discussions on Tuesdays and Thursdays, leading a journal club, giving a patient case presentation, and giving a topic discussion.
When this was over, I caught up Dr. Engle on rounds. I was given three patients to work up for the rest of the afternoon.

Day 2: I got to rotation two hours before rounds started (rounds start at 8) to work up patients for the team that Dr. Engle had assigned me (she manages 4 teams, each with about ten patients, so she typically oversees 40 patients). My team had 10 people so I looked at labs, medications, and admission/progress notes to get a better understanding of each patient. I look for anticoagulation and vanco/aminoglycoside antibiotics because they require more management from the pharmacist. I am also looking to see whether there are any drug interactions, if the dose is appropriate for kidney function, and if there are any glaring problems (there is not time to do a full workup for each patient, so you are checking to see if there are any safety problems).

I discussed any issues I had spotted with Dr. Engle and then we went on rounds with the team. During rounds, you can find out what is going on with the patient and what the medical teams plans for treatment. You can find out if they plan on continuing antibiotic therapy, if they plan on restarting any medications that were on hold, or if they plan on discharging the patient.

After rounds, I did a more in-depth workup on the patients. I did medication reconciliation to ensure that patients were receiving in-house what they were taking as an outpatient. I looked in treatment guidelines to make sure that patients were on appropriate medications for their condition. And, I followed up on labs (such as INR, aPTT) and made recommendations to preceptor based on these results.

If a patient is being discharged on anticoagulation therapy, it is policy to provide education. Therefore, it was important during rounds to pay attention to what patients were being discharged and if they were going home on anticoags.

Day 3: I rounded with the same team again, so my prerounds consisted of following up on the progress notes and new labs from the patients.

At UMHS a pharmacist is in charge of carry the code pager. We received a code page, and had to respond. There is a drug box that Dr. Engle grabbed and took with us. Inside of it, there are different drugs that may be needed in such a situation (epinephrine, norepinephrine, atropine, vasopressin, etc). A whole team responds and the pharmacist is in charge of assembling the drugs that are necessary. This includes putting together the epinephrine syringes, drawing up the norepinephrine, and making a vasopressin drip. This was a nerve-wracking experience. It takes a lot of discipline to put your nerves to the side and focus on what you are doing to try to perform your tasks quickly and accurately.

Day 4: I took on a new team today. When I got there in the morning, I looked up my new patients and reviewed the patients from the previous day (this meant I was following 19 patients). Dr. Engle started rounds with me, and then she allowed me to finish by myself. At first I was very nervous, but the medical team has been very supportive of letting me round with them, and the attending physician seems just as interested in helping me learn as much as his residents.

There was a topic discussion around noon on diabetes. In order to prepare for this, I had to read three articles and review my therapeutics notes.

Day 5: I rounded with the same team I had on Thursday. Dr. Engle let me round by myself. It wasn’t as bad as I had expected. I just wrote down my concerns/questions prior to rounds, shared them with Dr. Engle, and then addressed them with the team during rounding.

During the afternoon, I picked up a third team that Dr. Engle was managing and started working up the patients.

Week Summary: I learned how to enter notes for anticoagulation, educate patients, answer questions for the team, order INRs, aPTTs, and Vanco troughs, and adjust anticoag dosing based on protocols.

I was also managing a patient with hemophilia A who was on Factor VIII (helixate). In order to manage this patient, Factor VIII levels had to be drawn and monitored so that the dose could be adjusted properly.

Key Points:

1 – During the first couple of days of rotation I was so nervous about getting asked questions. I would get myself so worked up that you could have asked me what my medications were and I wouldn’t have been able to tell you.

Then I realized – you aren’t going to/can't know everything. My preceptor will keep asking me questions until we get to one I don’t know the answer to. There is no point in being on rotation if you don’t learn things you don’t already know. I have learned a lot of information by looking up answers to questions I have gotten this week.

2- Don’t be afraid to ask the medical teams pertinent questions.

Okay, so the medical team can be intimidating; you have the attending who is very knowledgeable and has been practicing for a long time and you have a senior resident who has been out of medical school for a few year, junior residents, and sometimes a medical student. At first, I felt this pressure that I must know everything under the sun about every single drug on the planet so that they wouldn’t think of pharmacy as an inferior field. But, what I have found in this short week of my life, is that they value you as part of the team. So here is what I do:

a) I always introduce myself and make sure it is okay to round with them.
b) I listen to them when they are presenting the patient to see if any of my questions get answered.
c) I carry my computer tablet with me so that I can look up quick answers on the spot. (For example, I have access to labs and sometimes labs come in while we are rounding and I have been able to update the team; I have been able to look up common side effects; and I have been able to look up the generic name of an uncommon drug.)
d) If my questions were not answered, I will ask the team.
e) When we are done rounding, or if I have to leave rounds early, I thank the team for letting me round with them and tell them I will follow up with them if there was a question I could not answer.

A Question I got from the Medical Resident that may be of use to you in the future:

The patient was having fevers of unknown origin and wanted to know if any of his medications could be the cause. This was one I had to get back to her on.

Different articles publish slightly different lists, but here is one that I found (note: I looked at four articles before formulating an answer, ran it by my preceptor, and then got back with the resident):

http://www.mdconsult.com.proxy.lib.umich.edu/das/article/body/271291532-2/jorg=journal&source=&sp=811057&sid=0/N/51761/1.html?issn=0891-5520

If the link doesn’t work for you, you can always look up drug fever and find a list from a journal article.