Rotation 2 - Infectious Diseases at UMHS

Posted by James Shen at Monday, August 01, 2016

I finished up my second rotation with the infectious disease consult service at UMHS, and it was definitely quite the experience. We have an excellent team of infectious disease pharmacists at the University of Michigan, and you will undoubtedly learn more about antibiotics, antifungals, stewardship, and other infectious disease related topics than at any other rotation. Make sure you review your bug-drug list, brush up on your pharmacokinetics, and put on your stewardship hats – because you will be in for a very challenging, yet rewarding rotation!

 Infectious diseases functions primarily as a consult service at UMHS, which means that we have no specific unit to which we are assigned to. Any patients that have complicated infectious cases are referred to our team, where we will review their antimicrobial regimen and determine if any adjustments need to be made. Throughout my time on the service, I was able to see many unique cases, including patients with HIV, mucormycosis fungal infections, gangrenous toes and fingers, gunshot wounds, amputated limbs, and more. Sometimes the infectious causes were obvious, whereas other times I really had to dig deep to find out what the true source of a patient’s infection was.

Morning Routine
A typical day on rotation would start with me working up patients in the morning that were assigned to our particular consult service, which would usually amount to around 15-20 patients per day. Some patients would remain on the service for weeks, and I got to know their cases in-depth as I followed up with them each day, whereas other patients came on the service and were signed off within hours. Once I had a solid grasp on several patients on the service, I would meet up with my preceptor to discuss each of the cases. Sometimes, a topic would come up that would warrant a further topic discussion for the next day, such as the use of linezolid with SSRIs, or the use of carbapenems in patients with penicillin allergies. After going through the patients with my preceptor, we would discuss if any changes needed to be made to their regimen based on their clinical status, culture results, or any other relevant factors. We would then start our afternoon rounds, which typically lasted from 1 pm until 4 pm.

Rounding
Rounds were typically preceded by something called “Micro-rounds,” where the team would meet in the pathology lab and we would have a brief topic discussion about some microbiology topic. After that, we would head up to the floors to begin our actual patient rounds. The rounding team is large, and it typically consisted of at least one attending physician, an ID fellow, a medical resident, a medical intern, a fourth-year medical student, the fourth-year pharmacy student, and occasionally the ID pharmacist. Prior to entering the patient room, one of the team members would present the patient case to the attending, and we would then have a discussion about what we think needed to be done. Don’t be surprised if the team turns to you and asks for a dosing recommendation during this whole process - the team will take your dosing recommendations very seriously, so make sure you do the proper research beforehand about each of the patients on the service!

What else?
In addition to rounds, I attended various weekly meetings, which included stewardship meetings, weekly reports, and ID grand rounds. The weekly reports were my personal favorite. We would meet early in the morning, and one of the ID fellows or ID physicians would present 2-3 interesting, complex, or unsolved cases from the previous week. It was always interesting to hear the ID team’s thought process as they tried to narrow down a patient’s diagnosis, and discuss all the possible differentials that may be contributing to a patient’s clinical symptoms. I also attended various other meetings on and off throughout the rotation, including an infection control meeting (where we discussed environmental and non-pharmacological ways to reduce infection spread in the hospital), and a P&T committee meeting (where we discussed changing some of our ID guidelines).

Other student responsibilities during this rotation included monitoring patients on restricted antimicrobials (ex: fidaxomicin, meropenem, micafungin), and determining whether or not their use was appropriate. I also participated in ID stewardship, where I assessed patients that had S. aureus bacteremias, C. difficile infections, or HIV infections. Finally, I did a lot of reading of primary literature, and I gained a much better understanding of how to properly interpret, analyze, and critique the literature. I would often be assigned one or two landmark trials per week, and then I would meet up with my preceptor to discuss each of them in depth (ex: statistical analysis, inclusion/exclusion criteria, flaws in study designs, implications for practice, etc.)

 Overall, I learned a lot on this rotation about what it means to be an infectious disease specialist. This was a topic that I greatly enjoyed learning about in therapeutics, and I would highly recommend this for anyone that is interested in learning more about it. Even if you are not interested in pursuing a future career in ID, I think this rotation really gives you a solid foundation that will undoubtedly be useful for any future clinical rotations.

Rotation 1: The Gospel According to Frame

Posted by Emily at Wednesday, June 17, 2015

My first rotation was something of a baptism by fire as I was assigned to the adult bone marrow transplant service at a large health center with Dr. David Frame.  As you can imagine, bone marrow transplant patients are a complicated population, so walking into the hospital on the first day was equal parts terrifying and exciting.  The first week was overwhelming as my two fellow rotation-mates and I learned to navigate the (abbreviation-filled) world of BMT.  For example, a typical progress note for a BMT patient might start something like this:

XY is a 40 yo male w/ AML in CR1 s/p 3+7 (idarubicin/ara-C) and s/p 3 cycles HiDAC followed by FluBu4 conditioning for MUD allo PBSCT on 5/1/15.  Admitted for intractable N/V/D with concern for GVHD.

Translation:  XY is a 40 year old male with acute myeloid leukemia in his first complete remission status post a chemotherapy course consisting of 3 days of idarubicin and 7 days of cytarabine, as well as three cycles of high-dose intermittent cytarabine, followed by four days of fludarabine and busulfan as preparatory conditioning for a matched unrelated donor allogenic peripheral blood stem cell transplant on 5/1/15.  Admitted for intractable nausea, vomiting, and diarrhea with concern for graft-versus-host disease.

Phew!  Fortunately, Dr. Frame gave us a high-level overview of the tenants of BMT on our first day.  There are two main types of bone marrow transplant: autologous and allogenic.

Autologous transplants are simply rescue therapy for patients who require incredibly high doses of chemotherapy to treat their blood cancer.  The patient's own hematopoietic stem cells are harvested and stored, the patient is given a course of high-dose chemotherapy that essentially wipes out their entire immune system because the regimens are so myelosuppressive, and then those stored stem cells are reinfused into the patient to save them from the toxicity of the chemo they received.

Allogenic transplants are a little bit more magical, as Dr. Frame put it.  In allogenic transplant, a patient's immune system is wiped out ("ablated") by high-dose chemotherapy, and then replaced with stem cells from a donor.  The idea is that the new immune system from the donor will recognize the patient's cancer cells as foreign and attack them, with the goal of getting rid of the cancer all together.  However, allogenic transplants are a careful balancing act because while we want the new cells to attack the cancer, we don't want them to attack the rest of the body.  Unfortunately, this is a relatively common occurrence in allogenic BMT referred to as "graft-versus-host disease" or GVHD.  Thus, allo patients are placed on immunosuppressive regimens including medications that are often used in solid organ transplant like tacrolimus or cyclosporine, mycophenolate, sirolimus, and/or steroids in order to prevent GVHD.

GVHD is a big concern for allo patients, but infection is a major issue for all BMT patients, especially immediately following transplant when patients' white blood cell and neutrophil counts essentially drop to zero.  Thus, all patients are placed prophylactically on an antibiotic, an antiviral, and an antifungal.     

The learning curve was steep, but I started to speak the language of BMT and feel more comfortable after those initial two weeks.  A typical day on this rotation looked something like this:

0630-0800 - work up patients at home 

I was never very clear on what it meant to "work up" patients before starting this rotation.  It's a phrase we hear thrown around a lot during pharmacy school, and it simply refers to following your patients' progress, monitoring their lab values, and most importantly, combing through their drug therapy to make sure all medications and doses are appropriate.  "Working up" a patient means developing a pharmacist care plan, complete with assessment of each issue and your plan to address and monitor the problem.  Patient work ups are the core of clinical pharmacy practice and are crucial if you want to meaningfully contribute to patient care during rounds.  I developed my own monitoring form specific for this rotation, since most BMT patients receive similar infectious disease prophylactic regimens, nausea and vomiting regimens, pain regimens, etc.  Having a service-specific form helped me to be more efficient as I increased my patient load.

0900-1200 - rounding with the medical team

The team was made up of an attending physician, "physician extenders" like physicians assistants and nurse practitioners who took rotating ownership of a fraction of the patients, a discharge planner, a registered dietician, and of course - the pharmacist!  Rounds generally lasted anywhere from two to four hours depending on the attending physician and the number of patients on the floor on any given day.  We would visit each patient's room as a group, and after the NP or PA presented an update of the patient's condition and problems that needed to be addressed, we would all go in to speak with the patient in person.  Rounding was not as high pressure as I expected it to be.  While Dr. Frame (and everyone else on the team!) loved to quiz us, they were all very understanding of the fact that we are still students and this was only our first rotation.

It was also very cool to see Dr. Frame's genius in action.  The team - including the attending physicians - frequently turned to him for recommendations and explanations as to why a certain medication/regimen/dose was preferable to another.  BMT is a very guideline-driven service.  Because Dr. Frame helped to write/overhaul so many of the BMT treatment guidelines here based on the best available evidence, and because the medical team trusts his knowledge so much, one of the physicians referred to these protocols as "The Gospel According to Frame".  To me, this exemplified the pivotal role pharmacists play in providing patient care of the highest quality.  Even patients knew Dr. Frame as "the drug guy" or "that pharmacist I was telling you about", and this was because Dr. Frame treats every patient with as much care and attention to detail as if they were his own family member - and he encouraged us to do the same.  I hope to one day inspire that same level of confidence and appreciation from my patients as Dr. Frame does from his.

1300-1500 - patient and topic discussion with Dr. Frame and/or Dr. Benitez, the PGY1 resident who was on rotation with us this month

Topics included management of chemotherapy-induced nausea and vomiting, posterior reversible encephalopathy syndrome (or PRES, a serious side effect of the immunosuppressant tacrolimus), Clostridium difficile infections, pain management, graft-versus-host disease, cytomegalovirus, neutropenic fever, pharmacokinetics, management of fungal infections in immunocompromised patients, respiratory syncytial virus, engraftment syndrome, and more!

evening - read journal articles, prepare answers to questions that came up during topic discussion, work on nursing in-service project

My nursing in-service was on the anti-emetic drug dronabinol, a synthetic form of THC.

My favorite part of this rotation by far was the way Dr. Frame pushed us to really THINK.  He told us on the first day that he didn't care if we became bone marrow transplant experts; he was more interested in us learning how to think like pharmacists, to reason our way to appropriate recommendations, and to always ask WHY.  Every day on rotation was full of puzzles needing to be solved, and I had so much fun striving to really think every puzzle through mechanistically.  I used to think that Dr. Frame was some kind of pharmacy wizard who just magically knew everything.  But I quickly realized that he's not so much a pharmacy wizard as a pharmacy super sleuth who uses logic (and half-lives!) rather than magic to be so good at what he does.  (Even if allo transplants are a little bit magical.)

Overall, this was a fantastic, highly recommended rotation experience.  It solidified my interest in pursuing residency, and helped me to realize that I probably know more than I give myself credit for.  I'm looking forward to diving into my next rotation - pediatric generalist - ready to continue building my skills and my confidence!

Superman, Spiderman, and Captain American washing the windows at Mott

"Drug Information Service, How Can I Help You?”

Posted by Silu at Monday, January 06, 2014

Happy New Year, everyone! P4s, the mysterious year of graduation is upon us…2014! It has definitely been a busy two months with rotations, the Midyear meeting and residency applications. The past few weeks was a much-needed break. 

I was excited for this rotation at the Drug Information Service at U of M to learn about using resources to their full potential and answering questions from all parts of the health system. In the end, drug information taught me much more than just that.

The student’s responsibilities for this rotation include running the phone- and email-based drug information service, attending P&T and sub-committee meetings at the hospital, two major projects (a drug monograph and another writing project), a newsletter article, and other small assignments that may come up.

Answering questions was my favorite aspect of the rotation. A wide variety of questions came to us, from the outpatient clinics asking for antibiotic selection to UMHS pharmacies in search of compounding recipes and medication formulations to physicians inquiring about potential idiosyncratic drug reactions. UM Drug Information Service has a comprehensive collection of books, online databases, and internal resources…it was definitely a nice privilege having ease of access to these resources. The meetings we attended gave a unique insight into behind-the-scenes operations. It was empowering to see excellent pharmacy representation at both P&T and interdisciplinary committee meetings.

Of all of the duties we were assigned, the projects ended up being the most challenging aspect for me. I felt confident about my ability to complete these assignments well. However, both my projects turned out to be larger in scope than I (or my preceptors) had imagined. My first writing project regarding IV acetaminophen for post-operative pain was complex and had a much sooner deadline than anticipated along with several points of follow-up based on changing circumstances. My monograph of an ophthalmic preparation of an antiviral drug used for a very specific disease also included a cross-country search for an ophthalmic recipe and writing an informed consent. At first, I was surprised by the scope and constantly changing demands of these projects, but realized in the end that this was, after all, real life. For my preceptors, new situations and different opinions can change the direction of their work, just as it did with mine. This challenged my ability to prioritize and manage my time around meetings, assignments, and an unpredictable volume of phone questions. In the end, I appreciated that I was immersed in real work of a drug information pharmacist rather than simplified student work.  

Overall, I am thankful for all I have learned at Drug Information and for the opportunities to make a difference to improve patient care on a different level through the work I accomplished.

Stayed tuned for the next rotation …o wait…I am off! See you in February for community pharmacy.  

-Silu

"New patient resus charlie"

Posted by mariarx at Wednesday, November 28, 2012

Rotation 5 is in the bag! Hard to believe we have now crossed over the halfway point. For 5 weeks, I was in the emergency department pharmacy with Dr. Pam Walker (no relation to Dr. Paul Walker) and her amazing ED team at UMHS. The ED pharmacist has a unique role in that they are staffing the ED satellite by themselves (checking orders, making all the IVs, answering questions) as well as responding and working first line with all traumas/codes that come through the resuscitation bays. By the end of the rotation I was confident in my ability to jump in and do (mostly) all of their tasks, with supervision of course.

To paint a picture for all the readers - the adult ED is MASSIVE. 90+ beds split into 5 areas, and 3 trauma bays for critical patients, plus a psych wing. ED satellite pharmacy? Approximately 1.5 times bigger than my closet. Super tiny. The skills these pharmacists are not lacking are efficiency, space management, and time management.

The rotation started out with me working in the satellite, observing the workflow and getting comfortable being in that setting. The ED is definitely different than being on the floors - always lots of movement and energy. On the first day I got to respond to a trauma code in a resus bay. Pam and I helped the team with a patient that needed to be intubated. The first thing Pam does - leave me alone with the RSI (rapid sequence intubation) box while she runs back to grab etomidate from the satellite. Drawing up a neuromuscular blocker on the fly via shouted out directions was the moment I knew that I had to be on my feet and ready to go for the remainder of my time down there. I LOVED it. Over the course of the rotation I got familiar with antibiotic dosing, checking orders, how to use EPIC and Carelink and Worx simultaneously, and all that is needed in running a satellite by yourself. I also volunteered myself for 2 midnight shifts during the rotation to get a feel for the types of patients that are coming into the ED at 3am versus 3pm. It was not as difficult as I anticipated to be up all night. The 2 red bulls and bowl of candy helped as well. :)

Throughout the rotation I definitely got more comfortable with resus patients, and building up the ED pharmacist mindset of "what will they need next? What is the worst case scenario for this patient and what drugs will they need?" Those are key skills for an ED pharmacist, along with on-the-fly dosing, estimating a patients weight and height for said on-the-fly dosing, and the order to give them in (etomidate BEFORE neuromuscular blocker).  I practiced this by looking at patients who were "expected to arrive" to the ED, looking at the 1 sentence blurb that usually accompanied them, and coming up with a (fake) plan.

Projects for the rotation included topic discussions a few times a week, both one on one with Pam, joining the Cardiac ICU students for their critical care discussions, and leading the topic discussion about ACLS for the ICU P4s. I also worked on automated dispensing machine optimization for the multiple omnicells throughout the ED. Looking for administrative type projects seems to be my M.O. for P4 year.

In the end I really enjoyed the ED pharmacy rotation and would highly recommend it to any future P4s.  A++ would rotate again! For rotation 6, I'm at Meijer pharmacy for my community rotation. If you shop in Ypsilanti come on by and say hello! 

Rotation 1: Cardiology with Dr. Dorsch

Posted by Alison Van Kampen at Saturday, June 16, 2012

Hello Everyone!


After reading a few of my classmate's previous posts, I now realized I am woefully under-qualified to write entertaining, catchy blogs.  So I would like to apologized in advance for any future writings that are so dry you feel as though you are reading an extensive "Statistical Analysis" section in a research article.  That being said, all that follows are my experiences from my Cardiology rotation at UMHS with Dr. Dorsch.


Since beginning this rotation, I have had several anxious classmates ask me about the experience (most likely anxious because many have heard that Dr. Dorsch has changed his rotation format, and they will have this rotation in the near future).  If you fall into that category, do not fret, it really is not bad and I have really enjoyed myself.


Here is basically how the set up has been operating


Week 1:

• One day orientation to Dr. Dorsch's expectations and our responsibilities
• Got a pager, you know you have arrived when you have a pager :)
• We would be following the Medicine Coronary Service in the hospital which is composed of 3 teams
• I am on this rotation with another student, Victor Truong, and we split up the teams so we would each follow one team and we split the other. This meant that we follow approximately 8-15 patients at a time.
• Arrive at 7:30 ish in the morning to collect data on the each patient on the team, perform medication reconciliation on patients that have been admitted in the last day, and perform discharge counseling on any new medications for the patient. 
• The teams rotate days on which they admit new patients, so each team only gets new patients every 3 days.  This means lots of work on the days that my team admits new patients, moderate amounts of work on the days that the team we split admits patients, and very little work/catching up on days that the third team admits patients.
• We are also responsible for looking at antibiotic doses to see if they need altering, checking if the patient's insurance covers particular medications, and a few other things.
• All of these interventions are recorded in notes on Careweb.
• In the afternoon we meet with Dr. Dorsch and his resident, Jen Lose.  Here we went over the notes we had written in the morning and discussed why they had certain therapies.
• We were generally able to leave by 3:00-4:00.

Overall Impression:  This week required a lot of work at rotation and outside of rotation, this was primarily because I was still figuring out the best way for me to collect the data and where to find the data one the patient's profile.  I learned a lot about the hospital system.  Both Dr. Dorsch and Jen were really great to learn from.  They ask you questions to make you think but also inform a lot about things that were kind of glossed over or not covered in class. Things like aortic stenosis and the studies that are used in diagnosis.

Week 2 and 3:

• All of week 1's activities plus afternoon topic discussions.
• Arrived at 7:30 ish in the morning
• In addition to the basic med rec, we were expected to start looking more at the patients medications in terms of their medical needs (does each medication have an indication, is each medical condition adequately treated, appropriate doses, interactions, is dose adjustment needed based on lab values, etc). 
• Often answered
• Topic Discussions:  
• We held topic discussions after discussing our patients in the afternoon.
• There were 7 topics (ACS, HTN, Arrhythmias, HF(1 and 2), Pulmonary HTN, and Stable Vascular Disease) that Victor and I split up between the two of us.
• I took 4 (2 average length and 2 short topics) and he took 3 (2 average length and 1 long topic).  
• For these topic discussions we were expected to write a background and summarized about 4-14 research articles and present these informally in a 45 ish minute presentation.
• These presentations actually ended up lasting around one and a half hours.  Often Dr. Dorsch or Jen would interject to add clarification to certain points, discuss a study more in depth, or deviate to a new topic entirely.
• Topic discussions were often pretty fun.  It was a really great way to learn about optimal therapy for a particular condition and Dr. Dorsch and his residents often went off on really entertaining tangets that frequently had nothing to do with the topic at hand.
• The purpose of the topic discussions was to give us a good knowledge base before starting rounds.
• We usually left around 4:00-5:00 on topic discussion days.

Overall Impression:  These weeks I really learned a lot about treatments in cardiology and became more comfortable with suggesting treatments. Topic discussions were very helpful, but required A LOT of work outside of rotation, I talking dedicate your weekends to this kind of  work.  This was primarily because I did 2 topics each week and I am kind of a slow worker, so maybe it will not take others in the future so long.

Good Advice from Jen: Know all the little things about the drugs (half life, route of elimination, which might be a little better at one thing over another).  The physicians know which classes are needed but they rely on the pharmacists to know which drug in a class will be best in an individual patient. Ex.) A patient needing a beta blocker but has poor compliance and poor renal function should avoid atenolol (renally eliminated) and carvedilol (BID) so could get Metoprolol succinate.

It all seems so obvious now, lol

Weeks 4 and 5:

• Same as weeks 1-3 but we have finished our topic discussions except for Victor's last one which he did on week 4.
• Started rounding with the team, which means getting to the hospital at 6:30 ish in the morning to collect all the latest information on the patients and identifying any ways to improve therapy in order to be ready for rounds at 8:00.
• Rounding is interesting because it gave me a better idea of what was going on with the patient and helped me to better understand the best way to treat the patient.
• Also it was easier to understand what exactly was going on when I could be a part of the discussion rather than just read a note on Careweb.
• We discussed our patients in the afternoon and found any other possible areas for therapy improvement to either bring up to the team the next morning or pager a team member about that afternoon.
• Afternoon discussions were primarily held with Jen on week 4 and will be with Dr. Dorsch on week 5.
• We generally left around 5:00

Overall Impressions: I was glad to start rounding because it felt more like real clinical pharmacy practice but it does take up an unpredictable amount of time (mine lasted between 50 min and 4 hours).  The rotation is very time consuming but rewarding.  Working with Dr. Dorsch and Jen has been awesome because they are so knowledgeable and try to test your knowledge but do it in a way that does not make you feel like you are a failure as a human being.  They will often have you look up an answer and then provide further clarification. 

I have really enjoyed the rotation and for all of you that have the rotation in the future, Good Luck!

Avoiding the Dogma House: Rotating with Dr. Regal

Posted by David Plumley at Tuesday, May 29, 2012

I have been looking forward to my Internal Medicine rotation since the day we found out our rotation schedules.  I had ranked Dr. Regal number 1, 3, and 5 for rotation preferences hoping I would get him.  I had heard many good things about his rotation and knew how hilarious he was from previous classes (I think he is the only professor to ever use a picture of Flavor Flav on one of his lecture slides).

One the first day of rotation Dr. Regal gave me and Chuck (my rotation buddy) a syllabus of what a normal day would be like for us, what the major focuses would be, and revealed a somewhat unexpected "bench test" that would be given at the end of the rotation to test the knowledge we would be accumulating over the next 5 weeks.

As far as what we would be doing on a day to day basis, each of us would be assigned to one medical team who we would round with and be responsible for all of the patients on that service.  My service is Med Dock; the team consists of an attending, a senior medical resident, 2 interns (1st year residents), and two med students.  Each morning rounds start at 8am and by that time I should have worked up all the patients and have a general idea of what issues may come up on rounds.  My major focuses are antibiotics (choice and dosing), anticoag (dosing, monitoring, education), overuse/misuse of PPIs (a Dr. Regal pet peeve), and other chronic condition therapies that are not being maximized.  Each morning after rounds we meet with Dr. Regal and discuss briefly questions that came up on rounds and recommendations we should make, we then follow up with our teams and make sure these recommendations are relied to them and either taken or have a reason why they are not.  After that we have some time for lunch and time to work up any new admits (each team is on call 2 days a week) or read any articles that were given to us.  Then in the afternoon we meet up with Dr. Regal to do some topic discussions about articles we have read or common themes that he has seen come up on rounds.

The most interesting this so far about this rotation has been the wide variety of cases I see on a day to day basis.  So far in my first 5 days I have seen your more common infections like pneumonia, cellulitis, many UTIs, and  several heart failure exacerbations, but I have also seen some rare conditions only seen in case studies like POTS (Postural orthostatic tachycardia syndrome), plastic bronchitis, and cardiogenic autonomic neuropathy.  These are conditions that most health care providers will never see; but because of this rotation I get to see these conditions and hear the medical team discuss their treatment.

I hope you enjoyed my first entry.  I will try to keep you up to date with some of the more interesting cases I see and give you an idea of what I do on a day to day basis over the next 4 weeks. 

 

"I don't know"

Posted by Bernie Marini at Tuesday, November 22, 2011

To remind myself to post a blog this rotation, I simply put "I don't know" in the subject heading, and I bookmarked it. I didn't have a great idea or theme for a post at that point in the rotation. Nothing great came to mind. But then, I realized "I don't know" is actually a perfect theme.

"I don't know."

Those are the three very powerful words. To me, they evoke a wide range of emotions - fear, frustration, embarrassment, curiosity. As P4's, we dread having to utter these words on rotation. However, the best rotations are those in which those three words are the most frequent...

For example, I have just finished my rotation on the infectious disease (ID) service at U of M, and for once, I went into this rotation very confident. My rotation with Dr. Frame on the BMT unit gave me extensive practice in ID; I followed patients with a diverse array of infections - BK cystitis, fusariosis, invasive aspergillosis, etc.. So, armed with my white coat pockets stuffed with my trusty bug/drug list, my "blue book", and various fungal charts, I was ready to tackle ID head on...and it hit me, hard (like a Michigan linebacker!).

There was so much in ID that I didn't know, and having a challenging and extremely knowledgeable preceptor like Dr. Carver made that apparent quickly. Sure, I had a little knowledge of basic things like the adverse effects and drug interactions with azole antifungals, pharmacokinetic dosing of vanco and aminoglycosides, but I was quickly getting questions like:

• Should colistin be dosed on ideal body weight or total body weight?
• If we MUST to use bactrim in renal failure (although the package insert says not to), how should we dose it?
• Can we use tigecycline in a cystic fibrosis patient? If so, how much should we give?

Having difficult questions such as these thrown out on a consistent basis pushes you to the next level. I worked hard each day to search the literature for answers to my difficult questions, all the while following and assessing the drug therapy of a large number of patients. This is how the best rotations go. At the start, things are a bit overwhelming. You're clearly not an expert in the subject. But then you adapt. You start to think ahead. Anticipate. Think, "what questions will I get?" "If I was the attending or preceptor, what else would I need to know?" You start thinking like a pharmacist.

Unless you're a genius, we've all had "I don't know" moments on rotations. And although we dread the feeling of unknown and the embarrassment of ignorance, it's these experiences that make us better pharmacists and better people. Sure it's corny, but it's true: unless we know that we don't know, we can't know...anything. Wait, what? You get the point.

Like Father, Like Son

Posted by Jim Stevenson at Thursday, August 19, 2010

I may have gone to “Take your son/daughter to work day” once during elementary school, but I don’t recall it too well. I’d like to think that my understanding of and appreciation for my father’s job has progressed a bit since second grade. Really though, entering P4 year, I still didn’t have a good idea of what my father, or the rest of the large pharmacy administrative staff, did on a day-to-day basis. Are their roles something I could see myself doing? Are administrative skills genetically heritable? These are the questions I set out to answer during my first rotation.

Aside from honing my clinical skills and preparing myself for a potential residency, one of my main objectives of my P4 year was to get a better idea of how I might best apply myself in the field of pharmacy. I also considered administration to be one of the practice areas that you experience “now or never”. After speaking to the administrators at the hospital, I’ve learned that I was wrong about this “now or never” mentality, as many of them started out in other areas and didn’t even initially consider management. But that’s the spirit of P4 year – being wrong and then learning the truth.

My preceptor is Dr. Paul Walker, the Assistant Director of Pharmacy Clinical Services at UMHS. To my surprise, his meetings and projects to not overlap very much with my father’s (my father has his own P4 student this month, Doug Ritchie). I spend about half of my time each day attending meetings with Dr. Walker and about half of my time working on independent projects that I later relay to Dr. Walker.

One of the expectations for students on the administrative rotations is to meet with each of the Assistant Directors. We then find out what they do, how they got there, and how their role interplays with the other administrators. That’s been an interesting aspect of this rotation, as I now know who is in charge of what and the career paths they took to get there.

Another aspect of the rotation I have enjoyed is information on quality improvement in our hospital pharmacy. I’ve always enjoyed research and interpreting numbers, and administrative quality improvement takes those concepts and uses them to improve patient care and the financial efficiency of our services. In the Information Age, we have a lot of numbers at our fingertips, and this will only grow as our health system continues to advance Computerized Physician Order Entry and our software systems.

One Jim Stevenson has already chosen the administrative path. Will there be another? That remains to be seen – I’m barely half way through my first rotation!