Rotation 7: Lexicomp and Work From Home

Posted by Unknown at Tuesday, January 24, 2017

I was very thankful that I received not only Lexicomp, but also with Steven Stout, someone with a technical background and someone immersed in the database management aspect of keeping this enormous drug information resource online.

Unlike most rotations, Lexicomp is a work-from-home. Typically, I met with my preceptor 2-3 times per week in various coffee shops in the Ann Arbor area for discussion of the work done so far, where to go from here, and do mini "topic-discussions" on topics related to the collection and organization of drug information resources. This includes statistics, study design, database design, information sources, how to vet information sources, searching (search terms, structure, narrowing results), and many, many more.

Work centers around the searching, collection, organization, and drafting of drug interaction monographs for inclusion in the Lexicomp Interactions database, as well as taking part in a number of longitudinal projects that his team is involved with. This includes migration to a new content management system and the thousands of tasks involved in that process, developing a tool that creates graphical summaries of queries to the OpenFDA API, among others.

This has been a very flexible rotation--work does not need to be done in an eight hour block so long as it gets done and during interview season (onsites for fellowships) this has been an incredible benefit as I can do work on the plane or in an airport or in a hotel in Seattle. That said, you will be tested on your time management skills as there is no external forces making you do anything! Self-motivation is a big plus!

One of the biggest benefits (as pointed out by other commentators) is the incredibly refinement of your literature search abilities. I had been doing this in a managed care setting for two years and still made leaps and bounds in my ability to careful craft queries (MeSH terms are the best) and iteratively refine my searches to maximize my relevant results. There have been many "mind-blown" moments when using PubMed, EMBASE, and other databases with these techniques, particularly when comparing how I used to construct a term versus my current method.

What has been incredibly cool is seeing the nuts and bolts of Lexicomp Interactions—how everything fits together and the methods that they use to keep their enormous quantity of data organized and maintained. My preceptor is truly a master of the craft and he has been an incredible mentor in developing some of my own skills in this area as well.

A typical day is what you make it, and there is tremendous flexibility in pursuing projects relevant to your interests! Highly recommended!

Michael Harrison (mhar)

Rotations 4-6: Working from Home, the MICU, and the Off-Rotation/Midyear

Posted by Jared at Thursday, December 29, 2016

Hello everyone! Apologies for the delayed post, but the last couple months have been quite a busy time! I'll summarize my last few rotation experiences below. Heads up, it's quite long!

Rotation 4: Drug Information

My fourth rotation was actually a work-from-home rotation! I worked for a drug company database alongside a fellow P4 student. The projects we were typically responsible for involved various inquiries from customers of the database (typically healthcare professionals) or drug companies asking us to clarify a statement about their drug that was listed in the database. Other times, we would have to look into evidence because a drug company was trying to prove that what we had in the database was false. We also typically looked into drug interactions that might not be present in the database, and wrote up drug monographs for these based on the research we found.

A typical day involved us meeting our preceptor a few times a week at an off-site location to discuss our assignments, what we found, and to discuss new things that came up. Afterwards, we were free to do as we pleased with our schedule, as long as we finished up the tasks given to us and e-mailed our preceptor with updates. This rotation really tests your time-management skills, as you really could slack off given the lack of normal structure. I tended to do many of my projects at night, as it's easier for me to work on projects like that at that time frame due to years of undergrad and pharmacy school studying. However, I really enjoyed this rotation as it helped to beef up my research skills and further interpretation of drug literature and drug labels. I got better experience understanding pharmacokinetic (PK) data and using PubMed, as often my preceptor would find things that neither me or the other student on rotation would find about our respective assignments. We also got the chance to read through foreign drug labels to help write our monographs, and they're quite different in the data that they provide compared to those here in the US!

I also appreciated this rotation, as it gave me time to finish up my PDI. If you're interested in seeing a different side of pharmacy and believe you can handle managing the time on your own, I would highly recommend this rotation! I really learned a lot more about searching strategies and drug interactions. 

Rotation 5: Critical Care - MICU

My fifth rotation brought me back to the hospital for another inpatient rotation, this time in the medical ICU at UMHS. This was actually my first rotation at UMHS, so I was both nervous and excited at the same time. However, this time I had another student with me on rotation, which was a welcome change from my infectious diseases rotation where I was the lone student.

Typical Day:

6 AM: arrive at the hospital to work-up patients.

7:30 AM: table rounds. This is when the night team would typically hand over new admits to the day teams. Also at this time, the attending doctors would typically go over various topics for the residents (i.e. sepsis, sedatives, etc.)

8:30 AM - 11 AM : Rounds. The MICU at UMHS is divided into two teams: Maize and Blue. For students on this rotation, typically one P4 will take each service and pick up all the patients for that service. There's about 20 beds or so (forgot the exact number) on the unit, so typically you'll have 8-12 patients at a time that you have to follow. For most of the time, we would each round with a pharmacist (either my preceptor or the resident on our rotation at the time). 

11 AM - 1 PM: lunch/preparation. Usually after rounds, we would have lunch, prepare for discussing our patients with our preceptor, or look up questions we were asked.

1 PM - 3 PM: At this point, we would meet with our preceptor and the resident to discuss our patients. We would typically go over our patients, discuss their status, and the changes the team made to their drug therapy. Often here, or during rounds, we would get asked what we thought about their changes. We would also discuss a certain topic that was relevant to critical care, such as sedatives, electrolytes/fluids, sepsis, etc. 

In terms of drug therapy, antibiotics were huge in terms of the pharmacist role. In the MICU, the general trend is to just throw a very broad-spectrum regimen as the patients are extremely sick (vancomycin and Zosyn are huge workhorses). We often had to remind the residents or the team that after 3 days, they needed to get ID approval to continue using vancomycin. Also, we would often recommend adjusting the antibiotics based on culture data and whether the patient was getting better/worse. The other big thing we looked for was renal dosing. Often, many of these patients developed AKIs that sometimes required them to go on dialysis or CRRT temporarily. I would always get asked if drugs were adjusted correctly given the renal function, along with when would be best to order levels for vancomycin or aminoglycosides if they were on one.

  

The MICU was challenging to me because the most common problems we saw were of a respiratory nature (i.e. respiratory failure, ARDS, etc). Beyond pneumonia, the presentation and therapies to treat these type of patients were completely foreign. Often, ventilator settings would be the common route for the team to adjust, and I generally had no idea what it meant. After the rotation, I have a better understanding of it, but I would definitely need more exposure to that and another review of the basic concepts. I also got a great refresher of topics we had learned in therapeutics that I personally wasn't great at, such as electrolytes, metabolic acidosis/alkalosis, vasopressors, and sedatives. Sedation strategy was another thing that often came up in the ICU, and I never really thought to think about it until this rotation.

Ultimately, I think a critical care rotation is a terrific experience, and one I would highly recommend. While it's not my favorite area of practice, I think it offers valuable lessons that would be useful in any setting of practice. You really get exposed to a lot of different clinical areas as these patients present as very complex cases, and you learn to prioritize what really needs to be solved now vs. what could be dealt with at a later time. Finally, it also really hits a number of gaps that our curriculum is unable to cover, particularly on the respiratory side of things.

Rotation 6: Off-Rotation / Midyear

Initially, I chose rotation 6 as my off rotation as I wanted to have time to attend Midyear and work on residency applications/letters of intent, as well as go on one last trip before graduation. However, this worked out for me really well for another reason. 

I had the opportunity to represent the College of Pharmacy at the 2016 International Forum of Pharmacy Students in Nanjing, China. This conference was sponsored and held by China Pharmaceutical University, which is one of the schools in China our College of Pharmacy has a partnership with. Here, I was asked to present a project that provided some insight into clinical pharmacy practice in the United States. In this case, I presented my PDI project as a glimpse into the roles of an infectious disease pharmacist in the US. I thought I was only going to be presenting my project in a small sub-forum, but I ended up being selected to present during the opening session in front of the entire conference, which had hundreds of attendees. Undoubtedly, I was nervous as I had just flown in from the US a couple days prior, but it ended up being a really great experience! I also got to meet other great student pharmacists from around the world, many of whom were there due to their connections with the International Pharmaceutical Student Federation (IPSF). Learning the differences in education and pharmacy practice between our respective countries was really interesting. After graduation, I'd like to get involved with the International Pharmaceutical Federation (FIP). After the conference, I had a chance to visit New Zealand, Australia, and Singapore. Needless to say, it was awesome and a perfect way to relax and clear my head before Midyear. Pictures below:

Some of the great student pharmacists I met at the conference in China

Skydiving in Queenstown, New Zealand

 Hiking the Ben Lomond Track: Queenstown, New Zealand

Mrs. Macquarie's Point at Sunset: Sydney, NSW, Australia

The famous Merlion in Singapore

Midyear

For those that don't know, the ASHP Midyear Clinical Meeting is the largest gathering of pharmacists and pharmacy students worldwide each year. It typically happens around the first weekend of December. This year, it happened in Las Vegas. I will quickly mention that I'd recommend not getting back from a trip on the other side of the world and then flying to Vegas a couple days later. I had the worst jetlag I have ever experienced, which caused me to not to sleep well during my time in Vegas, and also took me quite a while to recover from.

Anyway, this meeting is very important for those of you that are pursuing fellowships or residencies. As I plan to go the residency direction after graduation, I don't know too much about the process with pursuing fellowships. All I can say is that it requires scheduling interviews ahead of time through the Personnel Placement Service (PPS) with the companies/fellowships you're interested in. In terms of residencies, Midyear is great because every residency in the country is present in one location for you to ask questions to their residents, preceptors, or program directors, and determine whether or not you want to apply to a program. So, for those of you that are looking for residencies all across the country (like myself), this helps to put faces to programs and answer some questions that weren't possible via simply e-mailing them. However, if you're only interested in Michigan residencies, Midyear might not be necessary for you. The SMSHP Residency Showcase that occurs in October has all of the Michigan residency programs present and allows you to meet the residents / program directors and ask questions there. Anyway, here's some tips from my experiences:

• BE PREPARED. This really can't be overstated. You will hear this all the time in Dr. Kraft's Opportunities class and from anyone you ask about Midyear. Have updated CVs, business cards, etc. While you won't be handing out CVs to most programs, they sometimes will ask for it or provide a place for you to drop it off. I often heard that if they ask for a CV, it's typically a bad thing as there's so many people at Midyear most programs likely won't remember who you are. But, in my case, I went to a couple programs that did take them to help remember who stopped by their booth, and even got asked for one from a residency program director that I had a good conversation with. Also, many programs took business cards as well, possibly another way for them to keep track of who stopped by. 
• Do your program research ahead of time. Prior to Midyear, go to the ASHP Residency Directory. It lists all the accredited ASHP programs by location and program type, along with giving a summary of the program and the links to the program's website for more information. Prior to Midyear, ASHP provides a schedule of when each program is available during the Residency Showcase, along with a map of where their booth is. The Residency Showcase is divided into three sessions: Monday, Tuesday AM, and Tuesday PM. Each program is only present during one of these times, so it's imperative you know which programs you want to talk to, where they're located, and when they're available.
• Prepare questions for each program you want to talk to. From my experience, it didn't seem like you could just walk up to a program and ask them to give you a general overview of the residency. The residency showcase is like a zoo, with a bunch of frantic P4s trying to figure out their futures and many residents would be talking with multiple P4s at a time. With the limited time frame, you really want to get the questions that will make or break a program for you asked and answered. You could certainly listen to other people's questions and then ask something if you think of it on the fly, but it's easier to be prepared. I personally created a general list of questions I could ask most programs, along with specific questions that pertained to the programs I was visiting. 
• Reach out to preceptors, professors, and alumni! Prior to Midyear, I reached out to a lot of people with help in terms of editing my CV, looking at my program list, asking questions about residencies, etc. Everyone at Michigan or those who have graduated from the program are extremely helpful and really want you to succeed. Your preceptors as well can give useful insight, especially if they're at a system you're interested in possibly obtaining a residency at. 

Finally, my last tip in terms of the application process: Ask for transcripts and letters of recommendation ahead of time. Fall grades will come out way too late for them to be sent to programs on time, so I would recommend immediately sending your transcript to PhORCAS once it comes out in November. Also, I would ask for letters of recommendation ahead of Midyear as well. Many preceptors and professors will understand that you may not have your program list finalized until after Midyear. However, it is good to ask them how they would like the references generated. With PhORCAS, you generate a request to your letter writers and can provide extra directions. For most programs, one general reference will suffice. But, if your writer knows someone at the program, sending another request that's more personalized to that program can be beneficial. When submitting the app, you can designate which specific request you want to assign to a program. This might not make much sense now, but it will when you go through the process.

Wow, sorry again for the long post! Hopefully there's helpful advice in there for you, and enjoy the rest of the holidays!

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

Posted by Anna at Tuesday, October 09, 2012

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

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

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

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

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

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

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

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

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

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