Rotation 2: Non-traditional - Food and Drug Administration (FDA)

Posted by Polly at Tuesday, August 27, 2019

My second rotation was at the FDA in Silver Spring, Maryland. I was looking forward to this rotation since I first heard about it in my P1 year. I have always been interested in non-traditional pharmacy and most of my internship and extracurriculars are geared towards the non-traditional roles of pharmacy. I lived on the University of Maryland (UMD) campus. This was at most a 20-minute drive to the FDA if there was traffic. I was lucky because my rotation was during the summer where many students were looking for subleasers! Unlike some of my peers, I had better luck finding cheaper housing options.

My first day was a whirl wind of meetings, badging appointments, security checks, and trying to figure out what all the acronyms were for each department. I was the only Michigan student onsite during this rotation, so it was definitely a scary experience being alone in a new city. The APPE students there besides me came from all over the country and it was a great networking experience.

My preceptor is the Deputy Director of FDA's Center for Drug Evaluation and Research's Office of Compliance. She deals with securing our supply chain for pharmaceutical products and was a helpful mentor. She took the time out of her busy schedule to have one on one meetings with me almost each day to see how I was doing and to see if I was interested in attending meetings with her. It was nerve wracking to be in the same meeting as some of these officers and oversea agencies. Aside from my preceptor I worked on projects from many other departments.

My schedule was not as clear cut as my first rotation. A lot of my time went into networking with people from the FDA and lectures given to us by PharmDs from different departments. The rest of my time was projects from a variety of departments. My projects varied from data analysis for MedWatch, reviewing 501k submissions for medical devices, a variety of written work, and a presentation on FDA's Medical Devices Regulatory Process.

Here are some tips when you go on the road to Maryland for those of you who get chosen:

1. If you choose to drive, it is a 9 hour car ride and you need to bring at at least $40 dollars for the toll roads. I drove alone and it was very boring so either bring fun music or listen to a podcast.
2. Silver Spring is on the edge of DC and I highly suggest visiting! Get a SmarTrip Card and just google your way around. I wouldn’t suggest looking at the maps on pamphlets they have because it can get annoying really quickly. Google maps is your best friend and you get alerts for when the train is delayed or if the stop gets switched to a different area. The trains are very well kept and is not as confusing as I thought they would be.
3. BRING REUSUABLE BAGS. They charge money per bag you use and it can add up especially if you are grocery shopping.
4.  I went in July. It was hot. It was sunny. It was humid. Even when it rains, the humidity and heat does not let up. It was disgusting weather and I never thought I would experience heat on par with southern Asia in the United States. Find an Airbnb or apartment with AC and don’t even bother packing a hoodie or a long sleeve shirt. That will only take up room. The fall is nice though from what I heard.

Overall, the rotation gave me an understanding of the work the FDA does and has solidified my intent to pursue a fellowship after graduation.

Rotation 1: Community pharmacy

Posted by Polly at Tuesday, August 27, 2019

My community pharmacy rotation was completed at Grass Lake Community Pharmacy in Grass Lake, MI. This was a good rotation to ease me into APPE. This pharmacy was an independent pharmacy with a big presence in the community. I have never worked in an independent pharmacy before, so I did not know what to expect! My past IPPE rotation was at Kroger and it was by far the busiest rotation I was at before APPE. My expectation of the rotation was quite low because of my past experience in a chain community pharmacy. However, my preceptor went above and beyond what he had to do to make me feel comfortable and to experience what a pharmacist does. My first week, much of the time was technician work and becoming familiar with the pharmacy. This included answering the phone, understanding how to document opioid access, becoming comfortable with the computer system, and knowing what products we had on the shelves.

The next four weeks, I was eased into the work of a practicing pharmacist. I was able to have consultations on my own, take blood pressures when requested, check filled prescriptions, and take prescriptions over the phone. A majority of my counseling was on probiotics and it was not something I learned at school. A lot of research had to be done for me to become familiar with the products the pharmacy had. I had plenty of time to complete the projects the school gave me as well as complete a project of the pharmacy on the side. My overall experience was better than I expected!

Surgery Generalist (Gen Med) - Rotation 2

Posted by Makenzie at Sunday, August 18, 2019

For general medicine, I preferenced completing the rotation in surgery.  Surgical medicine isn’t well-covered in class so I was looking forward to exploring it.  A large part of what I learned in the beginning was what medications should be stopped prior to surgery (if at all) & how to restart patients back on their home regimens when appropriate.  This was particularly salient for patients on chronic anticoagulation regimens.  Also covered were certain drugs specific to postoperative patients (e.g. Entereg) and how to treat acute surgical pain. Patients were scheduled for surgery (day zero) & then stayed until well enough to be discharged, which ranged from 2 days to 30 days (typically 3-7 days) where I was placed.

A typical day included taking the first bus out of my neighborhood to arrive at the hospital at 6:45am.  I usually started looking at patients the afternoon before (while they were still in the operating room), making note of their scheduled procedures & going through their preop physical.  I spent my early morning reading over surgical & overnight notes for each patient.  During the first week, I covered about 6 patients/day, by the end I was covering the service which which usually included 17-26 patients, all of varying complexity.  I would meet with my preceptor 8am-8:30am to pre-round on patients.  From 8:30-9am were the interdisciplinary rounds with PAs, social workers, interns, and dietitians.  These rounds were very fast & took place in a conference room.  Thus I had to prioritize interventions that would be most acute to each patient & the team.  

After rounds I would update my preceptor & follow up with any requests from the team (e.g. coming up with an oral opioid pain regimen to get a patient off of PCA).  Mornings varied widely depending on team needs.  This also included covering the pager for service.  Around lunchtime I would attempt to look over patients entering the OR who would be admitted for postop management.

Afternoons were set aside for presentations, usually starting at 2pm.  Each general medicine student need to give one journal club, one topic discussion, and one case presentation.  With six students in the adult services, there was a presentation to attend every day.  Afterwards, I was free to return home.  In the evenings, I would work on my future presentations or go over patients for the next day.

Overall, this rotation block was busy but rewarding.  I also gave my PharmD seminar on the last day of this rotation.  Despite how busy I was throughout this block, it solidified my desire to pursue hospital pharmacy post-graduation.  My preceptor also emphasized the importance of writing weekly reflections & making note of meaningful interventions & observations.  The time I set aside for writing these reflections allowed me to keep my goals and mind & to make conscious steps towards them.

Rotation 1 Nontraditional and Rotation 2 Psychiatric Pharmacy

Posted by Sarah Choi at Wednesday, July 31, 2019

School is hard, and pharmacy school is even harder. We’re constantly studying for the next quiz or exam. We don’t absolutely love every subject we learn about in Therapeutics. It is so easy to lose sight of why we wanted to become pharmacists, but I can honestly say that P4 APPE rotations are different (though I’ve only completed 2 rotations). It’s equally as difficult, but now you’re experiencing new things every day and learning from real-life examples. You get to apply all the knowledge you’ve built up in the past three years, and it’s far easier to remember why you decided to become a pharmacist in the first place.

Rotation 1: Nontraditional Pharmacy

            My nontraditional rotation was at a specialty pharmacy. This was a great rotation to have after my P3 school year ended, largely because it required a lot of self-directed learning and projects. Specialty pharmacy is unique because there are so many high-cost and high-touch medications that require more time investment from every party involved, such as insurance companies, pharmacists, patients. Specialty medications weren’t covered in depth during class, so this rotation really gave me a chance to delve into different disease states (like cystic fibrosis, multiple sclerosis, and plaque psoriasis) and their unique treatments. I also completed two journal clubs during this rotation about newer specialty medications like Risankizumab and Tafamidis. The most valuable part of this rotation was that I was allowed to be curious and look up disease states and drugs that I was interested in; this was a breath of fresh air after three years of school where the curriculum was set. It reminded me of one of the main reasons I decided to pursue pharmacy: I love researching and learning about different diseases and treatment options.

Rotation 2: Psychiatric Pharmacy

            My second rotation was completely different from my first. While the first showed me how much I loved learning about different disease states and unique drugs, the second showed me how much impact a pharmacist can have on a patient’s treatment course. I worked with a team to manage the psychiatric care of about 9 to 11 patients a day. My mornings on this rotation included working up new patients (focusing on their psychiatric problems), attending table rounds with the interprofessional team, and visiting patients daily with the medical residents and students. Having the opportunity to go to rounds and discuss patients with other health professionals was so valuable. After the first week, I had built up enough confidence to speak up during rounds and advocate for my patients. Seeing patients day after day really showed much how much he or she can improve, and this is magnified when you know that you made a recommendation that contributed to the patient’s improvement.

Overall my first two rotations only have me excited for the rest of my rotations. I’m ready to learn and experience more. Thanks for reading and coming along the journey with me! I’ll be back after my third rotation (infectious diseases) is done!

Health System/Hospital - Rotation 1

Posted by Makenzie at Wednesday, July 10, 2019

For my first rotation I was back to where it all started.  I was able to go back to my hometown and complete my first APPE at the hospital I was born.  I work at a different hospital in the same city but I was surprised at how many common connections there were with pharmacists & techs across institutions (pharmacy is indeed a “small world”).

I also wasn’t lonely at this rotation - I was joined by 12 P4s from Ferris State who were completing all of their APPEs at this one institution.  Many of us would have lunch together, go to each other’s seminars, and bounce ideas off of each other.  For my first APPE, it was nice to have the safety net of a large group of students.

The rotation itself was great.  My preceptor took into account my previous work experience and personalized the rotation to my interests and gaps of knowledge.  For example, I am already experienced at sterile compounding but haven’t done TPNs before, so I was able to modify my schedule to spend more time on TPN verification and compounding.

This particular APPE also had the option of attending an open heart surgery with an anesthesiologist.  The procedure was a quadruple bypass & over 6.5 hours long.  The anesthesiologist placed me standing on a stool at the head of bed, with the heart only an arm’s reach away.  I was prepared for what it would look like but the smells (cauterization) and sounds (cartilage breaking) was not something I was prepared for.  Throughout the anesthesiologist taught me about what meds were put on cont IV vs bolus and how he monitors the patient while the surgeon explained the pathophysiology of the patient’s a-fib.

The next morning I followed the patient on CCU rounds & was astounded that he was already sitting in a chair & eating after such major surgery.  Attending the surgery helped me understand a patient’s cardiac journey and what role health care providers & medication management play throughout.

As amazing as open heart surgery is, it wasn’t apart of a “typical day”.  A typical day was divided into 2 parts.  The mornings were always scheduled.  I spent half of the mornings of the rotation doing staff pharmacist work.  Dosing, front counter, IV, med safety, etc.  The other half of the mornings I would do rounding in the PICU, ICU, or CCU and was able to spend additional days rounding in units based on my interests.

Afternoons were spent doing projects.  Daily, I did patient educations on post-AMI medications or anticoagulation teaching and had weekly audits for titratable medications.  The afternoons were also when students would do topic discussions, clinical questions, or present patient cases as final projects.  I found it helpful to attend these sessions as it kept ambulatory care, general medicine, ID, etc topics at the forefront of my mind.

For rotation 2 I am back in Ann Arbor for my gen med rotation in adult surgery & to present my PharmD seminar at the end of July.

Rotation 7, 8, 9: Farewell, and Be Kind

Posted by Michael Tsai at Saturday, April 27, 2019

Hospital/Health-system

In a large academic medical center, I was specifically assigned to the operating room pharmacies in the main hospital, eye center, and children’s hospital throughout the week. In addition, I got to see the satellite pharmacy, the general infusion center, and the cancer infusion center pharmacies. Once a week, I attended meetings and worked on projects with a pharmacist working on the management side.

It was insightful to see how operating room pharmacies manage controlled substances and dispense kits for the anesthesia team. They also verify and dispense certain orders for patients before their operation. In the infusion center pharmacies, I saw the workflow of how pharmacists verified orders, how pharmacy technicians prepared medications, and how pharmacist checked preparations and noted stability of the medications. On the management side, I saw how space and workflow could impact delivery of patient medications throughout the hospital.

Since there were several pharmacists and pharmacy technicians on this rotation, I worked with different teams and had to adapt to different preferences and teaching styles. Also, while I was on this rotation, I was also interviewing for residency positions. Traveling was intense and time-consuming, but I’m grateful my preceptor was understanding and allowed me to make up days missed through additional hours or projects. Overall, it was a busy season for me, balancing rotations and interviews, but I am glad to have the experience as it allowed me to see the bigger picture of how pharmacies operate within the health-system.

Managed Care

I was placed at a large health plan for this rotation and worked under a pharmacist who was a manager on the medical benefit, where drugs managed needed to be administered by a healthcare professional. This was different from my previous managed care rotation, which was a prescription drug plan and focused on pharmacy benefits, where drugs managed were usually self-administered medications.

This rotation was project- and office-based. My main assignments included updating medical policies with support from literature and clinical guidelines, providing summaries of therapeutic agents for hemophilia, and analyzing medical oncology data to complete a report with charts and graphs. During the rotation, I also had informational interviews with pharmacists working in different departments of the company, including drug pipeline, formulary and rebates, legislation and policy, operations, regulatory oversight, and sales and marketing. These pharmacists played very interesting roles, bringing insight to the variety of positions available within managed care pharmacy. I hope to learn more and experience these different positions as I start a managed care pharmacy residency in the coming months after graduation.

My preceptor during this rotation was working on a medical oncology program, so I sat in on several internal meetings regarding the logistics of implementation and external meetings with the vendor to ensure responsibilities were carried out on both sides. Other meetings I attended involved a quarterly drug pipeline update and internal sales and marketing meetings and consultations. While I had previous experiences in managed care through student organization involvement, internships, and a rotation, this experience added on to that, exposing me to the medical benefit, different pharmacist roles, and vendor relations. I am excited that there is still much more to learn about managed care pharmacy.

General Medicine/Pediatrics

My final rotation was in a children’s’ hospital on the mid-day shift. Here, I got to work under a pediatric generalist pharmacist, and my role was to assist in verification of total parenteral nutrition (TPN) orders and pharmacokinetic service of antibiotics. It was interesting to learn about pediatrics and nutrition, since these topics are not widely covered in the pharmacy curriculum. Pediatric patients should not be considered as smaller adults since they differ greatly in distribution and clearance of medication compared to adults. To verify nutrition orders, I navigated through a patient’s chart, collecting weight, fluid goals, recent lab values, urine output, relevant medications, and the order put in by the dietician. I would make sure that the volume of the TPN was calculated correctly and that changes to macronutrients and electrolytes within the TPN made sense. For the pharmacokinetic service, I was responsible for interpreting vancomycin or aminoglycoside levels that resulted during my shift. From these levels, I would make recommendations on whether to continue therapy or change therapy, noting the dose and interval of the drug regimen, and on when to check levels again.

The mid-day shift itself was different, but exposed me to the endless work that pharmacists put in at the hospital. Additionally, as my last pharmacy school practice experience, this rotation showed me that the learning never stops. I was constantly looking up answers to my preceptor’s questions and diving into the field of pediatrics. Even though my plans after graduation have been set, I still very much appreciated seeing and experiencing yet another perspective of pharmacy.

Now that my time at the University of Michigan College of Pharmacy has come to an end, I hope that you have enjoyed following the journey of my final year and gained insight into the practice experiences of a pharmacy student.

 

“For today, goodbye. For tomorrow, good luck. And forever, Go Blue!" 

– Mary Sue Coleman