Rotation 3: Infectious Diseases

Posted by Andrea at Monday, September 17, 2018

This rotation was a bit more busy for me, because I had my P4 seminar presentation. P4s are required to put together a 30-40 minute presentation for our class about our PharmD Investigations (longitudinal research project) or a pharmacy topic. The topic I presented about was the controversy of using steroids in septic shock. While this rotation did not require much outside work, most of my days after rotation were spent working on my slide deck or practicing my presentation. I was so glad to have finished this!

Rotation 3: Infectious Diseases
My third rotation was Infectious Diseases. This was my first clinical rotation and ID was a difficult topic for me in P3 Therapeutics, so I was nervous before starting this rotation. I had a variety of experiences on this rotation, including rounding with the ID team and antimicrobial stewardship. A typical day of rounding would start with working up patients (8AM-10:30AM), meeting with my preceptor to discuss patients (10:30AM-12PM), and end with rounding with the ID team which consisted of an attending, a fellow, a resident, and two med students (1PM-4 or 5PM). Rounds take a long time, because ID is a consult service so their patients are scattered all over the hospital. Days on antimicrobial stewardship were much different. The ID pharmacists share these responsibilities. There is disease-based stewardship, where antimicrobial therapy is reviewed and optimized for patients based on targeted disease states (e.g. HIV). There is also drug-based stewardship, where restricted drugs are reviewed for appropriateness (e.g. linezolid, daptomycin). These days were spent reviewing patient charts on the computer, followed by discussions with my preceptor. I also attended antimicrobial stewardship committee meetings (pharmacists and physicians discussed initiatives to optimize antimicrobial therapy), presented a topic discussion, and journal clubs. My preceptor would often send studies to read and discuss the next day.

Something I learned from this rotation was how to “work up” patients. We focused primarily on the ID problem. For each patient, we had to assess if the antimicrobial therapy was appropriate including drug, dose, frequency. To follow up, we assessed vanco and aminoglycoside drug levels and monitoring parameters.

Some questions I encountered on rounds were: Does this drug require renal/hepatic adjustment? Anyone know the patient’s creatinine clearance today? How do I dose this if the patient is getting dialysis? I also liked seeing how there was opportunity for pharmacists to develop wide-reaching initiatives through policy and guideline development. For example, they were trialing a pilot program for penicillin skin testing, creating guidelines for community acquired pneumonia treatment, and pediatric animal bite treatment guidelines. I really enjoyed this rotation!

Rotations 1-3: A Triad of Non-Clinical Rotations

Posted by Unknown at Monday, September 17, 2018

Hello fellow COP students 😃  Thanks for visiting our P4 blog!  Before I go into my first post, here is a little bit about me (feel free to skip the rest of this paragraph if you're just interested in the riveting rotation details).  I am originally from Pittsburgh, PA, and I came to U of M for undergrad in 2012.  I joined the COP in 2015 after completing 2.5 years of undergraduate prerequisites (shout out to the non-degree-ers).  I have a long history with working in community pharmacy at CVS, a job which I truly LOVE.  In pharmacy school, I have been an active member in SMPA, PSA, and MPSO, and have enjoyed taking advantage of the opportunities that those and other student organizations have offered me throughout the past 3 years.  I am always willing to talk about my extracurricular experiences, so feel free to contact me with any questions about that stuff!  This summer I have been balancing starting rotations with buying my first house and taking care of two children (cats), so if anyone is looking for advice on home-buying or parenting, I'm pretty much an expert (ha).

Our first house.  Goodbye Ann Arbor rent prices!

Buffalo Yoda Green

Lady Macbeth Green

As for my rotations so far:  my first, second, and third blocks were all very non-clinical based, which has turned out to have both positive and negative impacts on my rotation experience...on one hand, they provided a fairly smooth start to P4 life; I wasn't inundated with intense responsibilities, pharmacokinetics, or rare disease states to learn about.  I didn't do any topic discussions or any outside projects and I worked fairly consistent hours.  Each rotation had it's challenges, of course, but overall they were straightforward and stress-free.  However, it was very, VERY easy for me to fall off the clinical skills wagon.  Because I didn't really keep up with studying or reviewing notes during the first 15 weeks (even though I told myself I was going to...), it was difficult for me to switch gears back into analyzing doses and writing SOAP notes for my 4th block (more to come in my next blog post).  Looking back, my advice to myself (and to anyone reading this preparing for rotations) would be to listen to our Deans and be a life long learner!  Remember that if you don't use it, you will lose it, and that just a few minutes a day of review and staying up to date will really pay off when you need it.

Rotation 1: Non-traditional (Managed Care)

My first rotation provided a nice easy transition from P3 to P4 life.  My primary responsibilities at my Managed Care rotation were to call members to complete comprehensive medication reviews (CMRs), then to complete a write up that included important counseling points from our conversation and an updated medication list, which I would then mail out to the patients for them to use for their records and share with their families and doctors.  On the surface, these daily tasks were simple and straightforward.  However, they involved unique opportunities to provide individualized patient care in order to empower our members to improve their health.  For example, I would often get questions and comments from members about how they did not agree with a medication prescribed by their doctor, or about what medications were for and why they had to take them.  As a future pharmacist, this is where I felt my expertise in pharmaceutical knowledge and patient counseling came into play.  I was able to provide the information that the patients needed to become educated about their medications and health, and even if the patient didn't always agree with my input, they at least gained the knowledge necessary to make more educated health decisions.  Additionally, through our conversations and the write-ups that I would send, patients would receive references and information that they could use to empower themselves to start conversations with their doctors about their health an become a more active participant in their health care.  

These patient care aspects of the rotation were rewarding to me as a student because I felt that I was able to make a true impact on the members' health, either by simply sending them an organized medication list or being able to answer their health questions that they felt were previously unexplained by other health care providers.  Another special patient-care responsibility was that of sending targeted medication reviews to prescribers; if I identified the potential for medication optimization (such as duplicate therapies, target dose optimization, and finding lower-cost medication alternatives), I would send a notice to the prescriber.  On several occasions, the prescriber accepted my recommendation or would respond back that he/she had reviewed the patient's health profile as a result of my intervention.  To me, this was an unprecedented example of interdisciplinary health care and the impact it could have on a patient.

In addition to the CMRs, I also took part in several meetings and teachings about the workings of a managed care setting.  This included aspects such as formulary management, specifics of different insurance plan options and the details of payment, and STAR criteria, among others.  Overall, it was an all-inclusive rotation with a good balance of patient care and operational work that allowed me to refine my written and verbal communication within a specialized population.

Rotation 2: Community

As I mentioned, I have a long background working in community pharmacy, so this rotation was pretty ordinary for me.  However, although I was generally familiar with the everyday flow of the pharmacy, my experience here taught me to never discount the potential for new learning opportunities, even in familiar settings.  From picking up clinical pearls from different pharmacists, to being in charge of managing the a Shingrix shortage, to learning new ways that individual pharmacies operate, there was always an opportunity to broaden my community experience and knowledge.  Most importantly, this rotation taught me to always approach my pharmacy experiences with lots of questions, an open mind, and a willingness to learn.

Rotation 3: Health Systems/Hospital

My third rotation was where I really started to feel comfortable with the P4 rotation experience.  Initially, I was apprehensive about this one;  it was my first out of area rotation, which was intimidating in itself, let alone the fact that my preceptor happened to be the senior director of pharmacy AKA knows everyone AKA could have a real influence in me getting a job/residency in the future 😉.  The rotation was set up to be very independently driven; I was given a schedule of shadows and events to attend, but my preceptor made it clear to me that I could make the rotation what I wanted.  I could follow the schedule, or I could skip all of the events and do research in the library every day for 5 weeks.  For me, this was a refreshing approach to precepting, because it meant that I could build my rotation around what I personally valued and what I knew would be the most beneficial to me.

It turned out to be somewhat of a career-defining rotation.  Throughout my time, I saw just about every aspect of how a health system runs: operational, financial, inpatient pharmacy, pediatric pharmacy, purchasing and inventory, and business management.  Additionally, because my preceptor was a director, I had a lot of exposure to the administrative side of the hospital, which is where I really felt in my element.  Prior to this, I had suspected that I might have an interest in pharmacy administration, and when I finally got to work in that setting, my interest was confirmed.  Because of my preceptor's willingness to let me forge my own rotation path, I was able to tailor my experiences to the administrative side of things, and in doing so I rubbed elbows with several higher-ups and worked on hospital-wide projects, including a shortage management project and one on reducing hospital readmissions for acute kidney injury.

While each of my experiences on this rotation were valuable to both my education and personal growth, the biggest message I took away from it all was to be fearless.  While it's definitely a cliché, it's a valid one.  Although I was a bit intimidated by the environment an the people with whom I was interacting, I tried to approach each situation with confidence and motivation to succeed, and it couldn't have been more beneficial.  I met a lot of successful people who were very encouraging and willing to share their knowledge and experiences, which was invaluable.  I can definitely see myself pursuing a career in this setting, which is such an exciting thing to be able to say!

Rotation 3: Specialty Ambulatory Care

Posted by Unknown at Sunday, September 09, 2018

This was my first experience dealing specifically with specialty drugs, which are commonly referred to as "high cost, high touch" drugs. The high cost part makes sense, but what was not immediately apparent to me was the concept of high touch. I soon learned that high touch simply meant that these drugs needed more hands-on management in the forms of baseline evaluations and follow-up calls with the patients, which is not like what a regular community pharmacy would do. I liked this aspect, since it gave me a sense of how patients progressed through a short-term treatment plan. In particular, I gained some familiarity with hepatitis C treatment, which was usually treated for a duration of 8 - 12 weeks. Having previously done the HIV community rotation and now this, I also developed an appreciation for how far we have come in terms of improving medications. Compared to the antiviral options we have today, the early drugs just seemed much more burdensome in every way possible, not to mention that their efficacy was also not as good. The problems with side effects, frequency of administration, and other administration considerations (e.g. with or without food) are mostly not an issue with today's options.

Another aspect of therapy that I understand a little more of after this rotation was the prior authorization process. While the majority of submissions from our service to insurance companies do get approved, occasionally we had to submit appeals after receiving the denial verdict. While writing appeals to insurance companies did not sound appealing at first, this exercise actually proved very insightful. I was forced to delve deeper into the primary literature and use the data to demonstrate that my patient truly would benefit from getting this drug approved. Depending on the insurance, I also may have needed to collect lab results to illustrate the severity of the patient's condition, and it was not just limited to the Child-Pugh score that we learned in class.

Aside from my main priority in doing baseline and follow up calls with patients mostly for hepatitis C medications, I also had the opportunity to contribute to some quality improvement projects. Specifically, I collected the data to show that compared to the national average, our specialty pharmacy financial coordinators did a great job in terms of PA and appeal approval rate. Furthermore, I also looked into the average turnaround time for prescriptions filled by Michigan Medicine versus those filled by outside pharmacies. These small side projects allowed me to look at the bigger picture of healthcare, and see that there is clearly much more to treatment than just the drugs themselves.

Although I prefer more in-person consultations as opposed to telephonic ones, this was still a valuable learning experience. I learned how to manage my time and juggle multiple responsibilities, but I also now understand that taking extra time to be meticulous about your work is important to. In other words, try to avoid speeding through tasks just to get them done, and really spend some time to think about what you're doing. All good things to take with me as I head into my next rotation (and first inpatient) at the neuro ICU here at Michigan Medicine!

Rotation 1 and 2: Community and Nontraditional Informatics

Posted by Andrea at Thursday, August 30, 2018


Hi everyone! My name is Andrea Duong and I will be one of the P4s blogging about their APPEs this year. I’m excited to give you a glimpse into the life of P4. Hope you enjoy!

Rotation 1: Community Pharmacy

I was looking forward to this rotation, since I only had experience working in a big chain pharmacy. This rotation was at an independent pharmacy in a small town in Michigan. Typical hours for this rotation were 9am-5pm. My days were spent filling prescriptions, taking phone calls from patients and providers, and counseling patients. Later in the rotation, I became responsible for checking prescriptions (with preceptor supervision). I felt like a real pharmacist with this autonomy! When checking, this new responsibility changed my perspective- I realized that I would soon be working as an independent practitioner and no longer as an intern under the safety net of a preceptor or supervisor. I appreciated that my preceptor also did an extensive review of law with me, which reinforced what I had just learned in the P3 law class. Other activities included reviewing calculations, compounding some simple creams and solutions, reviewing OTC products, and doing one journal club per week.

The staff and patients were so welcoming here. I could tell that my preceptor was very passionate about community pharmacy and learning in a low volume store was the ideal setting for me.

Rotation 2: Nontraditional Pharmacy- Informatics
I was very excited for this rotation, since I am interested in pharmacy informatics. My rotation was at a community hospital in Michigan and my preceptor was responsible for managing the oncology electronic medical record (EMR) system. Oncology is a complex field with numerous types of cancers and constantly evolving drug therapies, so you can imagine keeping the EMR system up to date can be quite challenging! Managing the EMR system includes updating treatment regimens and building new ones, based on clinical studies and guidelines. Treatment regimens typically consist of multiple chemotherapy drugs and supportive care (e.g. antihistamines, anti-emetics, IV fluids, etc). Patients are on a certain number of “cycles”, which include days with drugs and days without. For example, one cycle can be 14 days, with only one day of chemotherapy and 13 days without. These were just some of the variables we had to keep in mind when building regimens in the EMR.

One major project I worked on was building treatment regimens for Rituxan Hycela (rituximab and hyaluronidase human), a subcutaneous formulation that could be used after the first dose of rituximab IV infusion. This would save the patient lots of time, since they would not need to be in the infusion chair for as long. I also evaluated and presented a comparison of the respiratory interleukin agents, wrote a case report, updated patient education for chemotherapy regimens, created an herbal supplement/vitamin reference sheet, and answered drug information questions. Every day was different, which was thrilling for me. It was a mix of meetings, project time, and discussions with my preceptor. Typical hours for this rotation were 8am-4pm. Most of my time was spent at my desk, but I worked in the cubicle next to my preceptor, so we were able to easily bounce ideas off each other.

In this rotation, I further developed written communication skills and analyzed primary literature. We often referred to the National Comprehensive Cancer Network (NCCN) guidelines and analyzed the clinical studies that were referenced. It’s free to make an account on the NCCN website, I recommend checking it out! Oncology was not an interest of mine prior to this rotation, but now I think it’s such an innovative field with a lot of opportunity for pharmacists to help physicians and patients understand the drugs.

Rotation 2/3: Ambulatory Care in the Community

Posted by Unknown at Thursday, August 30, 2018

Hi everyone! My name is Laura Hayes and I am one of this year's P4 bloggers. I am excited to write about my experiences during fourth year and hope my reflections can help you in your pharmacy journey!

A little about me before I jump into my first reflection: 
I grew up in Rochester, MI and went to the University of Michigan for undergrad where I majored in Biomolecular Science and minored in Anthropology. I got married last summer and love being with friends/family and being outside. 

We just celebrated our one year wedding anniversary this August!

 My husband and I went to Europe for 2 weeks after P3 exams ended. This is me at the Cliffs of Moher. 

 We also had the opportunity to go to Denver, CO this summer and went hiking in the Rocky Mountains! It was so majestic!!

This is me on my birthday at Dom's Bakery in Ypsilanti. These apple fritters had just been taken out of the oven and were the BEST I've ever had! I would definitely recommend you check it out.

Now that you know a little about me, let me tell you about my last two rotations; Rotation 2 was Ambulatory Care and Rotation 3 was Community Pharmacy.

Ambulatory Care
For Ambulatory Care I had the privilege of being in two family medicine clinics 2.5 days a week and mostly managed diabetes, but also saw a lot of hypertension and hyperlipidemia. I met with patients in person for 40 minutes or talked to them on the phone for 20 minutes and discussed how their diet, exercise and medication regimens were going. I was able to build relationships and really connect with people to help them help themselves. While I absolutely loved this rotation, it was extremely busy. I worked up patients before clinic, finished notes after clinic and had to complete all the rotation requirements set for this rotation. This included a journal club, topic discussion, case presentation and Anticoagulation discussion. I learned a lot about time management and making sure I took time to relax in the midst of being very busy.
Of the three rotations I have completed, this one has been my favorite. I loved connecting with the patients and helping them with such important aspects of their lives. This experience was very encouraging as I had been interested in ambulatory care for about 1.5 years prior and after this rotation, I feel quite confident and excited to work in the ambulatory care setting.

Community Pharmacy
Community pharmacy was not a rotation I was very excited about. I had never worked in community pharmacy (I had an internship at UofM in the Cardiovascular Center inpatient pharmacy) and have heard a lot of horror stories about chain pharmacies. Needless to say, I was a little worried about how it would go.
I was placed in a grocery store/big box store pharmacy for this rotation. It was a slower store and had what I feel an independent pharmacy may feel like (based on what others have told me). The pharmacist has worked there for over 15 year and the patients deeply trust and respect him. Because we weren't running around crazily filling scripts, I had lots of time to engage in clinical services with patients. I did over 10 blood pressure screenings and made recommendations, counseled countless people on their medications and over the counter drugs, completed comprehensive medication reviews and had the opportunity to build relationships with patients who came back multiple times during my 5 weeks. These aspects felt so similar to my ambulatory care rotation and I was pleasantly surprised.
This experience helped break down some strongly held assumptions I had about community pharmacy,  has helped me realize just how important community pharmacist are and what roles they can play in patient's healthcare. Even though I do not plan on going into community pharmacy, it has become my 'Plan B', which feels like a big step from not even wanting to consider it before this rotation.

My advice to you, take every opportunity to learn and grow. Go into it with an open mind and learn all you can. I never thought I would enjoy being in the community pharmacy as much as I did, and I am so thankful I went in with a desire to learn and experience new things.

Rotation 4: Nontraditional - Amb Care Administration

Posted by Josephine at Saturday, November 18, 2017

Block 4: Non-traditional - Ambulatory Care Administration

This rotation was truly a whirlwind rotation for me, meaning that everyday was different and I often had to shift gears fairly quickly. The hours were generally 8 AM - 5 PM, but in the world of admin, that time constraint means very little (some days I would leave early or stay later, and occasionally stay up really late to finish spontaneous rotation work).

Despite this, I was very fortunate because my preceptor strongly believes in bringing the P4 student along in everything that she is already doing. This means that I got to attend various meetings and that my schedule ended up being very fluid (some days I would have chunks of project time, while other days I would have back-back meetings the entire day). This rotation also required me to think on my feet and shift gears quickly, which were skills I hadn't really practiced before this rotation, so I was grateful to have this experience.

Unfortunately, I can't really talk about the specifics of the projects that I did (my preceptor likes to call it "admin HIPAA" due to the sensitive nature of the meeting discussions and project content). However, I can say that I did a profound amount of data collection on MiChart, a lot of data analysis using Excel, and made/edited several presentations to Michigan Medicine leadership. I also learned my fair share about the following: team dynamics/interpersonal interactions, conflict navigation, utilizing connections, giving feedback to employees, how to run a meeting (utilizing time, moving agenda items forward), how to overcome pushback from collaborators, practice change management, initiating a clinical service, project management (reporting results, informing stakeholders, process improvement, etc), value proposition, and billing.

Unlike in my previous rotation (where I mainly had context with 3 other P4s), during this rotation I was, for the most part, attached to my preceptor's side. This was a huge benefit to me because this preceptor is a pretty dynamic, forward-thinking, vision-casting type of person, with multiple connections and projects happening around the state. In a different administration rotation I might have been mainly based in a hospital, attending meetings within that institution. But during this rotation, I was able to see things happening across institutions. Consequently, I felt that I got a taste of the "progressiveness" that characterizes the Amb Care space.

Rotation 3: Health System/Hospital

Posted by Josephine at Saturday, November 18, 2017

Hi Everyone,

I's been very busy recently (with the secondary projects of P4 year - finishing up the PharmD Investigations Project with a polished manuscript, and completing the P4 Seminar). It truly feels good to be done. But as a result of being busy I haven't been able to post about rotations, so I'll start with 3 now.

Block 3: Institutional/Health System/Hospital Rotation @ a local community-based teaching hospital
During this rotation, I was very fortunate to have a variety of responsibilities. The preceptor is very organized and open to feedback. I rotated through the various duties on a 4-day schedule with three other P4 students (2 from Michigan including myself, 1 from the University of Toledo, 1 from Midwestern):

• Verification duties:
• Unverified Orders Monitor (UVOM) - sitting in the central pharmacy and helping them clear the orders that have either already been given or have been discontinued
• Anesthesia Trays
• Pyxis Cart Refills
• ACS Boxes and A-Packs
• Patient Counseling:
• Discharge counseling on Orthopedic Surgery patients
• Anticcoagulation counseling on new-starts (rivaroxaban, apixaban, dabigatran)
• Miscellaneous:
• Constantly checking MedMined (the pharmacy's surveillance system) to assess the clinical significance of each alert and determine potential interventions (renal dose adjustments, duplicate medications, adverse effects)
• Answering random DI questions

In addition to the above duties, I also was able to shadow several times (Emergency Department, Nursing, SICU, MICU, IV room). The preceptor is curious about your interests and works very hard to set up opportunities in that area. I also was required to present a journal club with all of the other P4 students rotating at this hospital (so there were about 10 students in the room). In addition, ther were miscellaneous other presentations to attend: student presentations, pharmacy presentations to nursing, as well as noon conferences for doctors (free food!)

Overall, this rotation was rather relaxing (compared to what I imagine an inpatient rotation would be like). The day was generally 7:30 AM - 4 PM (with 30 minutes for lunch). I never took work home and was not able to access the medical record from home anyway. The preceptors at this institution are very friendly and eager to teach. 

Besides all of this, the rotation was made the most enjoyable by the people! (ie: the other pharmacy students). As I said there were 3 other P4's with me (as well as a P3 from Toledo completing a 2-week IPPE). Honestly, the 5 of us had a lot of fun together, going through all the responsibilities and learning about each others' respective pharmacy schools and various interests. We would eat lunch together everyday and sometimes even hang out after rotation (I'm still in touch with one of the Toledo students even now). I think it could have been easy to simply go through all of our responsibilties without exchanging a word. But this rotation shows me that it's this camaderie-building relationship that truly makes work enjoyable (also, best way to network!). 

(See next post for Rotation 4 details)