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 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.
For this BPMH, this was an unfortunate 64 year old woman who previously had tried propafenone pill-in-the-pocket and sotalol up to 120 mg PO BID for a rhythm control strategy in atrial fibrillation, with concurrent metoprolol for rate control (had symptomatic recurrences up to 1-2x a week). She was recently switched to flecainide 75 mg BID + diltiazem 120 mg BID a week ago. She felt extremely unwell, nauseous, and faint and went into Emergency, where she was found to be in Afib with RVR. She had an overnight stay in hospital and was discharged on different medications. She reported to the A-fib clinic the following week for an expedited follow-up. On Pharmanet it showed all 3 antiarrhythmic medications she has tried, plus a couple of rate control agents. I took a BPMH from her in person and gathered that she was taking:
– Apixaban 5 mg BID for stroke prophylaxis (she was almost 65, shared decision between care provider and patient to anticoagulate)
– Metoprolol 50 mg BID for rate control
– Levothyroxine 75 mcg daily for post-thyroidectomy hypothyroidism
– Estrogel 1 pump applied every other day + Prometrium 100 mg QHS for menopausal symptoms
– Avamys nasal spray 1 spray daily PRN into each nostril
I garnered from patient interview that she had tolerated the sotalol best, and had the least recurrences (1-2x a month) while on it. She had tried metoprolol alone in the past for rate control which was ineffective. Her ECG in clinic showed she was in sinus rhythm and her ventricular rate was 82, and her BP was 146/73 (higher than usual measurements at home). From this information I presented my recommendation to the electrophysiologist to restart her on sotalol 80 mg BID and discontinue metoprolol (as sotalol at lower doses displays more beta-blocking activity – higher doses >80 mg BID is where class III antiarrhythmic activity kicks in). The patient was amenable to this plan as well as she wanted to avoid side effects at the expense of experiencing AFib episodes 1-2x a month.
This was a 61 yo male from out of Vancouver, followed by the A-fib clinic, whom I was following up with regarding refills for his spironolactone and candesartan. Past medical history significant for persistent AF (CHADS2 = 1), CHFrEF, mitral valve replacement (2006), current smoker (2-3 cigs/day), and obstructive sleep apnea.
From Pharmanet —-> verified with patient over the phone:
Warfarin 5 mg tabs filled —————-> taking 5 mg daily for stroke prophylaxis
Bisoprolol 10 mg daily —> taking 10 mg daily for rate control and HFrEF
Carvedilol 25 mg BID x 14 emergency supply filled 30 days ago ——-> no longer taking, was taking both bisoprolol and carvedilol. Counselled he was correct in taking only bisoprolol as it proved superior for his rate control over carvedilol (from chart).
Candesartan 16 mg AM + 8 mg PM ——-> taking 24 mg PO QAM for HFrEF
Spironolactone 25 mg daily ——–> taking 25 mg daily for HFrEF
Amiodarone 200 mg tabs last filled in Nov 2017 ——–> no longer taking.
No OTCs/NHPs were taken by the patient. Home BP 120-130/80, HR 75-90 (rate controlled), no dizzy spells, shortness of breath. Able to carry out ADLs on his farm. Refills were provided for candesartan 24 mg PO daily and spironolactone 25 mg PO daily for 3 months from the clinic and faxed to his pharmacy. Conversation was documented on AF clinic records in patient’s chart.
My patient was a 43 year old male, after a prolonged stay first at another hospital for CHF exacerbation (from his CHFrEF secondary to failure of previous TAVI implant), who got transferred to St Paul’s for a repeat TAVI (transcatheter aortic valve implantation). A TAVI is unique from other valve replacement procedures in that traditional methods involve surgically cutting out the old valve before sewing in the new one. A TAVI is a bioprosthetic valve that is implanted, while pushing the old and damaged valve aside.
As I learned, it is quite a controversial area of cardiology practice as to how to provide prophylaxis against thromboembolic events after this type of surgery, as it is quite a new procedure and the evidence for all the therapeutic options is poor. It is practitioner-dependent whether to opt for ASA alone, ASA + clopidogrel, or ASA + rivaroxaban 10 mg PO daily. For this gentleman, the team decided for ASA + rivaroxaban 10 mg PO daily because of his unique situation being a TAVI within another TAVI – which puts him at higher risk for cardioembolic events versus a TAVI-naïve patient undergoing TAVI.
I provided continuity of care to the outpatient setting by applying successfully for Special Authority for rivaroxaban, which at the dose of 10 mg PO daily is reserved for post-hip or knee replacement. I emphasized that in the “TAVI in a TAVI” clinical situation, pathophysiologically, warrants rivaroxaban. Moreover, warfarin had never been studied post-TAVI, and that the upcoming GALILEO study (https://clinicaltrials.gov/ct2/show/NCT02556203) is exploring this therapeutic option versus ASA + clopidogrel.