Commitment is a word that can be applied to various concepts. Commitment to a job. A relationship. A promise to a friend. A contract to pay. When we took a pledge of professionalism way back (wayyy back) in first year, we knew somewhat what we were getting ourselves into. I’d like to think that I have a better understanding now of what commitment to a profession is, especially one in health care.
A commonality that I’ve observed is that no matter what you do with your pharmacy degree, whether it is making bedside interventions, or formulating policy for an entire region, there is a commitment to benefit the patient. It may sound hokey, but it’s been reinforced during this rotation that although we all go into Pharmacy with some sort of idea of how we are going to make an impact, one has to be open minded as to how that impact looks like.
So, I’d like to think that commitment is versatile but consistent, and I’d like to remind myself now and then what it will look like in that moment (sometime in the future), from time to time.
For one of the mini projects I did on this rotation, this was a budget exercise whereby within certain constraints (some aspects were simplified for the purposes of the exercise), I was to allocate 18 million dollars to fund 5 pharmacy departments at sites in a fictional “mini health authority”.
This exercise reinforced the notion that policy makers have difficult decisions to make every day and sometimes creative solutions are required, with sometimes suboptimal outcomes in order to make the best of what you have. In the setting of our publicly funded health care system, every penny truly counts and whether every penny is working to its full potential must be questioned.
“All managers are leaders, but not all leaders are managers”. I’ve been fortunate enough to have had exposure to aspects of leadership from previous educators. Such aspects of leadership, or good characteristics of a leader and how they are different from good characteristics of managers can too easily be described abstractly. Instead, I found myself reflecting on good and not so good leaders I have come across in the past. Here are some differences I distilled from my readings and experience.
Leaders make you feel engaged and “buy in”, managers enforce policy.
Leaders meet human needs of their team, managers meet the needs of their organization.
Leaders have their hands on the pulse of their team, managers are the pacemakers.
I’m sure I’ll come across many more examples of managers and leaders, but it was good to reflect on these overarching concepts.
In general, these are the overarching goals I hope to achieve on this rotation:
– Gain a better understanding of the role of regional coordinators, pharmacy directors, and the executive director for LMPS
– Open my mind to other roles pharmacists may play in health systems management
– Understand implications for region-wide change as it relates to initiatives, and downstream impact on clinical coordinators and pharmacy staff.
I hope that through shadowing my mentor and gaining exposure to the inner workings of the LMPS offices, I gain a better understanding of the above.
Overall throughout this rotation, I felt more like a fish out of water than other rotations. I think it is because there was a lot more grey and uncertainty in regards to recommendations, for the most part. We are taught to embrace the grey in pharmacy right from 1st year… by the end, I felt that I was getting the hang of it, but I feel that it is a career-long journey to be comfortable with that uncertainty.
Goal #1: Become more competent with history taking and information gathering from the psychiatric patient: I believe that I am more competent in this regard now, compared to when I started the rotation. Establishing rapport is very important in this setting – I hope to use the experiences I have acquired in order to better take care of patients with psychiatric illnesses in the future.
Goal #2: Be able to recognize and adequately treat extrapyramidal symptoms in the psychiatric patient and be able to rationalize it as pharmacotherapy-caused, rather than from other etiologies: I had the opportunity to perform two movement assessments this rotation, in addition to just observing my patients for possible EPS during their hospital stay. I also had one patient with possible bladder dystonia secondary to aripiprazole, which was managed by decreasing the dose of the antipsychotic.
Goal #3: Be aware of non-psychiatric considerations for the psychiatric patient receiving pharmacotherapy, and be vigilant of those in the non-psychiatric setting: The thing about psychiatry is that it is so specialized. That is why, when we had a peritoneal dialysis patient on the ward, pharmacy could step in with a bigger role in liaising with other services and suggesting modifications to drug therapy for non-psychiatric condition patients. In this case, the patient was non-compliant to PD because of her psychiatric illness – hopefully, by managing her psychiatric illness, she will experience better outcomes from a renal perspective.
In the same afternoon with my Trimentorship student, we had a patient who was to be started on paliperidone long-acting injectable. I thought this would be a good opportunity for my student to practice counselling on medications in the hospital setting, as this patient was back to baseline and was being prepared for discharge.
I structured it such that I sent a couple of short pre-readings on long-acting injectable medications, and reviewing overall side effects for atypical antipsychotics. Then, during that afternoon, we had a “dry-run” where I role-played the patient and had my student counsel me on the medication. Afterwards, I provided overall feedback and tips to express some concepts in more patient-friendly language.
Unfortunately when we went onto the ward (where I would observe my student counsel the patient) the patient went on a pass 30 minutes early so we were unable to interact with the patient. However, I believe that I coached my student through what an interaction with the patient would be like.
I had my Trimentorship student with me on rotation for an afternoon during Psychiatry. It was the day that Medication Group was to be conducted, so I thought it would be a good opportunity for my student to see the role of the pharmacist in providing medication education to patients in a unique setting. In Medication Group, patients who have a bit more insight into their illness can play a board game and learn more about the conditions and medications that they have. With the assistance of my preceptor (who know some of the patients better than I do), I modeled the skills of eliciting understanding from the patients, establishing rapport, and reminding patients to always check for interactions when starting something over the counter.
I delivered a presentation (2 sessions x 30 mins each) to nursing staff on a novel antipsychotic recently approved by Health Canada in 2017 – brexpiprazole (Rexulti). I tailored the presentation to be more in tune with nursing considerations for the drug and also to provide some background on pharmacology of antipsychotics.
I thought that my presentation as a whole was good, and my pace was appropriate. I think I could have elicited baseline understanding a bit better, and I could have explained complex pharmacology concepts in more easily digestable chunks. However, it was a good experience and I would not mind conducting in-services for nursing staff in future if given the opportunity.
For this drug level, this was a lithium level for a 25 year old non-certified female patient who came in with a manic episode. She was supposed to be on aripiprazole in community but was non-compliant. In the past, the combination of lithium and aripiprazole had cleared symptoms of psychosis (grandiose delusions) rather quickly in hospital so the decision was made to start her on lithium carbonate 450 mg PO QHS + aripiprazole 10 mg PO daily. A level was ordered for her 4 days post admission.
The level came back at 0.5 mmol/L and was appropriately drawn (approx 10 hours post-ingestion). By this time the patient’s elated mood and pressured/intrusive speech had mostly resolved, albeit with some flight of ideas still intact. However, the level was subtherapeutic for usual maintenance therapy (0.6-0.8 mmol/L). I recommended the dose be increased to 600 mg PO QHS. At the time I left rotation, it was being contemplated whether she would do better on aripiprazole depot as she had tolerated aripiprazole on previous admissions and she was a high risk for non-compliance.
I remember on the third week of Clinical Orientation, one of my patients came in and was HIV-positive. There was an order in the chart. “Pharmacy to assess HIV therapy and restart if appropriate.” I panicked. I didn’t know what to do. Luckily, I had my preceptor to give me a crash course in how to assess appropriateness of HIV therapy (and who had access to the CfE’s labwork and database – this was at St Paul’s). So, I really appreciated this session’s practical approach to evaluating HIV medications. Lots of resources were introduced. The take-home points I got:
– Although I have heard this before, it still is amazing to think that HIV is now treated as a chronic medical condition, and not the life-ending illness it was.
– Always, always, always check drug interactions when encountering a patient who is HIV positive and on HAART
– Do NOT assume anyone knows about their diagnosis.
– Always err on the side of continuity of care. If you have the opportunity to initiate HIV therapy but the patient is leaving in a day or two (and there is no opportunity to liaise with CfE before they are discharged), refer them to CfE for a complete assessment.
– Half-lives of medications play a role into clinical decision making, and whether to abandon a treatment regimen, or alter a regimen slightly in order to ensure continuity of care