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.
Goal #1: Hone my history-taking skills in a clinic-type environment where access to the paper chart may be limited or non-existent – I think I achieved this. I tried my best to obtain information from previous admissions and clinic visits, but sometimes, a robust symptom and medication history proved to be helpful in deciding further drug therapy. Such as in the case of the patient I had for my 2nd BPMH – a history helped determine that a re-trial of an old medication was the best way forward for her.
Goal #2: Gain a better understanding of practice differences between the acute care setting and the ambulatory care setting. – I think I was kind of surprised as to how, despite the collaborative environment, one has to be self-sufficient in this setting. In terms of info gathering and history taking, it was a different approach. I had to go in and gather pertinent information that, in that moment, could direct future drug therapy.
Goal #3: Be focused on providing patient-specific recommendations and alternatives, in situations where the available evidence is unclear – I was surprised in this setting that there is a LOT of grey. Sometimes what will determine what is the “evidence-based” recommendation is what the patient has tried – an “n = 1” of sorts. Anticoagulation peri-ablation was also a controversial area of practice. Now that the ablation has taken care of the afib (hopefully)…does the patient still need Eliquis for life?
I could talk about how I met or didn’t meet my goals that I outlined before the rotation…but I feel that this rotation taught me a lot both in the sense of developing one’s knowledge base and also growing as a clinician in general.
What I’m referring to is applying the evidence that you have, even when it’s not the best evidence. Towards the 3rd and 4th week of rotation (it’s always near the end, isn’t it?), I found myself realizing that no matter how many placebo-controlled, n = 10,000, published-in-the-NEJM trials you have – there will always be the daily clinical situation which will make you stop in your tracks and force you to extrapolate to your patient….even when the evidence can’t answer the question you want answered. As pharmacists, I feel like we always want to fit our patients into boxes. “Would he be a HOPE-type patient”, “do we want to COPERNICUS him”, “does PIONEER-AF PCI apply to her”… when it’s really about taking the years and years of context in which the study was done, integrating the new findings, and then making a decision based on the weight of evidence. I felt that at least for the first couple of weeks, I may have strayed away from that. I was so determined to know the trials, know the NNTs, know the inclusion and exclusion criteria, that I lost sight of treating the patient in front of me sometimes.
But that’s okay. I realize it’s all part of clinical development. And I think I’m better off now realizing this and learning from it. Off to the A-fib clinic next week!
Goal #1: Gain a better understanding of the role of the pharmacist in the Emergency Department beyond medication reconciliation: I think I got to see the EM slant of a pharmacist here. Getting involved with RSIs and procedural sedation, and observing how a pharmacist may contribute to helping in a trauma opened my eyes to the full extent of a practicing pharmacist in the ED setting.
Goal #2: Become proficient in condensing information for patient handover from Emergency to ward pharmacist: There were a few instances where I had to provide handover to the evening pharmacist covering Emergency, or to the ward pharmacist covering CTU.
Goal #3: Be able to provide recommendations on workup and pharmacotherapy for the most common conditions/procedures in the ED, e.g. acute pain, stroke, seizure, ACS, arrhythmias, tox overdoses, sedation: I was very fortunate to encounter a variety of cases during this rotation, but strangely there weren’t many hot NSTEMIs or STEMIs… mostly unstable anginas. However, I got to brush up on emergency management of A-fib in the ED, provide seamless discharge when we discharged a patient home on rivaroxaban for newly diagnosed A-fib, and got to see seizures of varying etiologies, from withdrawal to EtOH, to unclear diagnosis, to TBI, to possibly progression of brain mets.
One of the things that a residency should equip one with is a baseline competency to precept, or at least a framework to become a preceptor. This online course is intended to accompany the upcoming ADS on precepting on January 12th.
Overall, throughout the course I felt that it was aimed towards individuals who were established in their practice, but I felt that as a resident (a learner), it was interesting to see how our preceptors may have been trained. I found myself going through the modules and doing some self-evaluation in regards to how I am progressing as a learner, and also in how I would precept a student. During this year, I have taken on a TMP-SMX student, and although it is part of our procedure logs to demonstrate skills to a student, and coach a student to perform a skill, it’s inevitable that all of us will become preceptors at some point in the future, so it is beneficial to acquire these useful skills. Before residency, I have had some experience teaching and mentoring mostly through opportunities through music, but pharmacy is unique in that you are supposed to impart a schema to the learner to forge a thought process…very different!
I feel that after completing the course, I do not know how to be a preceptor, yet I know what it takes to be a good one. I also got the sense that being a good preceptor requires being mindful of what a student is looking for in a good preceptor. It is too easy to forget what it was like to be a student (and years from now, what it was like to be a resident!) and with that lose sense of what a thought process would look like for a student/resident who is still honing their process. I got a glimpse into the questions that preceptors must ask themselves every day when working with learners.
Goal #1: Develop a robust process for evaluating the quality of an RCT and whether to proceed with further critical appraisal. Not sure if I developed a process, but I certainly got a detailed overview in what to look out for in critically appraising an RCT, amongst other types of publications such as meta-analyses. We went through an exercise where we were to explain complicated concepts such as composite outcomes or non-inferiority trials in language that a member of the lay public would be able to understand, or the Feynman technique. I found it helped me quite a bit in solidifying the concepts that I reviewed.
Goal #2: Become familiar with various methods by which study authors present statistics and data to influence the reader to come to the same conclusion as the authors. Through attending a couple of Therapeutics Initiative meetings, a didactic session on meta-analyses, and going through elements of an RCT, there were a few ways that we identified where authors present data in order to make it easier to show the result they wanted to. For example, reporting events as event rates and not absolute event numbers can enable the author to not disclose how many participants were included in the final efficacy analysis (e.g. TORCH).
This rotation overall was a good reminder of caveat emptor when it comes to reading trials or meta-analyses…even in a busy clinical practice it is still possible to put on your critical appraisal hat!
Previous residents and colleagues who had undergone a Toxicology rotation told me that it was going to be a packed week. Well, we had 4 days and Dr. Kent managed to pack 5 days’ worth of material into 4! I learned how to manage a variety of toxidromes and specific poisonings (too numerous to name here), but from listening in to the poison phones, to discussing various toxicities pertaining to CNS and CV systems, I now am more confident in assessing the poisoned patient.
Goal #1: Develop an approach to evaluating the poisoned patient: We actually started with this. I will not forget the adage – stabilize always as needed, GI decontaminate if possible, antidote if available, dialyze if necessary. I also will not forget the typical tox panel to order in case of suspected ingestion: CBC, lytes, LFTs, glucose, lactate, serum acetaminophen, salicylates, and serum osmolality.
Goal #2: Become confident in providing triage, and if applicable, recommendations for ingestion a variety of toxins: It was helpful to become familiar with the various toxidromes that may accompany an acute ingestion of a toxic substance. From this and plus a well-taken history, it is possible to determine whether a patient may not be in immediate danger yet require observation (say, acute ingestion of quetiapine 2000 mg), or a patient who may suddenly seize, undergo cardiopulmonary collapse, and require aggressive medical intervention (say, ingestion of bupropion 6000 mg with suicidal intent). This rotation was also a good primer to think about acute stabilization and supportive care for critically ill patients in any care area, from ED to ICU to a general medicine ward.
I honestly had so much fun on the antimicrobial stewardship service. Apart from learning all about diagnostics, assessing fluid samples, shadowing wound care, attending microbiology rounds, and having a process to assess infection, I think where I grew the most on this rotation was communicating with the medical team. This rotation forced me to be 100% comfortable with my recommendations (at least when it came to antibiotics) and it was valuable for me to be thrown right in and defend those recommendations. Goals and objectives. Did I meet them?
Goal #1: Develop a framework and approach to assessing the patient with a suspected infection. I think I achieved this – for a variety of infections (CNS, SSTI, pulmonary source, endocarditis, GI source, cystitis and pyelonephritis, C diff) I became familiar with how a diagnosis of an infectious process is reached.
Goal #2: Begin to have a framework for correlating clinical presentation to specific microbiological etiologies. Although this is not always possible, in the case of pneumonia or cellulitis, sometimes one can have a higher pre-test probability of a suspected bug based on radiological findings or clinical presentation. See Nuggets of Knowledge for more.
Goal #3: Develop a convincing yet professional approach to communicating interventions from Antimicrobial Stewardship to physicians and other health professionals who are most responsible for the patient. Yep. Definitely feel better about this. It was helpful for me to bounce recommendations off Michelle and have her play the physician. What if the response is “my patient got better on antibiotics”, but you feel like the patient does not even have an infection? What if the response is “I’m gonna keep him on vancomycin ‘just in case'”, even though the patient has never swabbed positive for MRSA and doesn’t have any other risk factors?
Personally, I felt that being on CTU has been great for my progression through the program. Maybe it is because the conditions that I encountered were somewhat familiar since I had come across them either in undergrad or Clinical Orientation, but I felt more confident in formulating medical problem lists and prioritizing interventions than when I was in Oncology.
Goal #1: Improve my ability and confidence to provide verbal recommendations to the team: I definitely feel like I have improved in this respect. I attended both bedside and table rounds with the medical team and actively participated in them. Although there is a lot of work still to be done to refine my recommendations and rationale when it comes to verbalizing them to the team, I think I’ve made a good start.
Goal #2: Be more comprehensive with my alternatives list for resolution of DTPs: I think I have grown a bit in regards to this. I have learned to group some interventions under a “Renal Function” or “AKI” medical problem and the like.
Goal #3: Become more systematic in gathering info and reporting in regards to daily updates: Maybe this is more of an IT issue, but I felt way more comfortable keeping abreast of the new diagnostics and labs that were pending for my patients once I learned how to do that on Sunrise Clinical Manager (the computer system at SPH). However, I found out that what works best for me is to group my workflow into two parts: monitoring in the morning by body system, then interventions by medical problem.
Goal #4: Develop a strong knowledge base on the most common set of conditions that are encountered on a general medicine ward: Sometimes it got a bit too busy to actively record every little nugget of knowledge in my book, but I felt like I had a good framework by which to rapidly get up to speed on an unfamiliar condition such as warm autoimmune hemolytic anemia, and its considerations when it comes to drug therapy.
I am looking forward to applying these skills in a more focused approach during ID/Antimicrobial Stewardship!
Hey, that wasn’t so bad now, was it? First clinical rotation complete! I think I am starting to fully understand what previous residents say – as soon as you start feeling somewhat comfortable with a ward, it’s time to move on to the next rotation. However, it is all to make you a more adaptable and proficient clinician. I thoroughly enjoyed my time at BCCA, and I had so many great opportunities, such as to observe procedures such as lumbar punctures and bone marrow biopsies, and take a trip down to RadOnc to see the machines and learn more about radiation-specific adverse effects.
I also became more comfortable with formulating medical problem and DTP lists and prioritizing them. I think overall, I never expected to be an expert in oncology by the end of it, but I think I met my overarching goal which was to “become marginally closer to being a competent clinician” – yay for achieving things! How about my goals that I came up with before the rotation?
Goal #1: Develop a head to toe approach to assessing a patient for adverse drug events secondary to chemotherapy, or supportive agents for chemotherapy – yes, did this. Went back to my review of systems, and my preceptor helped me work through the laundry list of side effects that one may experience, depending on the chemotherapy agent that is being used, and at which dose.
Goal #2: Be able to provide executable recommendations upon demand for proactive nausea and vomiting management based on the BCCA protocol the patient is on – achieved this. I had a patient in my last week with a pancreas primary that was locally advanced to her GI system who had intractable nausea and vomiting, but unfortunately was non-compliant to diet restrictions recommended by the RD. It was very tricky discerning which medications or non-pharm measures were actually effective for her, but it was rewarding working with the Pain and Symptom medical team, even if it was brainstorming medication regimens that we hadn’t tried with her. My roadmap going forward will be to go back to the fundamentals – have an alternatives list to every recommendation – then you won’t miss anything.
Goal #3: Develop a process for counselling oncology patients on either a new chemotherapy regimen or supportive care medications – I did prepare a medication calendar for a couple of patients during the course of the rotation, and counselled on changes to therapy, and also symptoms of oncologic emergencies to watch out for, such as fever (heralding febrile neutropenia), or bilteral numbing in extremities (heralding spinal cord compression). Most of the patients I came across were already midway or further through their treatment regimen.
Back from the Sunshine Coast and enjoying my vacation week so far – Gen Med next…