Category: Reflections on Residency & Learning

C3.5 R2: Complete the UBC Online Clinical Instructor Education Program E-Tips

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.

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Reflections on Medication Use Evaluation

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!

Reflections on Toxicology

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.

Reflections on ID and Antimicrobial Stewardship

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?

Reflections on General Medicine

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!

Reflections on Oncology

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…

Reflections on Clinical Orientation

First clinical rotation complete!! The CTU was awesome, the medical team was receptive, and the St. Paul’s pharmacists were welcoming of us residents. Although the intent of the rotation was to keep it focused on developing a process and not so much delving into therapeutics, I found myself learning a lot through working up various patients. Already by the end of the rotation, I felt like I was just hitting my stride in information gathering, and have begun to crystallize a process in formulating plans. What I still need to work on overall is creating concrete and executable plans for all the medical problems that my patient has, although prioritizing them has not been a challenge as of yet. So, how did I do on my goals?

Goal #1: Holistically incorporate radiographic findings and be able to apply them to rationalize diagnoses to better develop a pharmacotherapeutic plan – I believe I have met this goal. I did look up any terms I did not understand, and used reasoning from a diagnostic test (a CXR) to rationalize that what I was seeing (in one of my patients who had CHFpEF and a query pneumonia) was more likely a pneumonia and as such should be treated based on those findings and her symptoms. This helped me better understand the medical team’s plan.

Goal #2: Become proficient at performing medication reconciliation, and proactively take action to resolve any discrepancies – During this rotation I did not get to take part in an observed medication history. However, given the characteristics of some of my patients, whether there is a language barrier, or medical literacy was low (so they did not know what they took/why they take medications/how often each medication is taken), or uncooperative patients, I became better at taking focused medication histories for the information that I most urgently needed. One example was planning a discharge for a patient who took various traditional Chinese herbal products. This patient was also on warfarin, so I had to take a quick history of her NHPs and determine if any of them interacted with it. In my future rotations, I look forward to being involved with reconciling medication histories alongside the physicians.

Goal #3: Be able to work up a relatively simple patient (<6 medical conditions) in under 3 hours – I don’t think there was a patient that I had who had <6 medical conditions during Clinical Orientation! Such is the life in CTU. However, I found that with each subsequent workup, I became more efficient in gathering pertinent data. I look forward to working on my efficiency further and being more efficient in getting up to speed on medical conditions that I may not have seen before. I did keep therapeutics notes in a notebook and wrote down things I may need to unpack later.

All in all, it was an enriching rotation and I look forward to continuing to build and refine my process.

Reflections on Evidence-based Medicine

It was really great to see the other residents, both hospital and community alike. Although by the end of a Friday afternoon it was tough to sit in one spot for 7-8 hours, there are many things to unpack and revisit throughout the residency year when it comes to appraising the literature, always having a critical lens, and (what I found to be an important talk) keeping your patient’s wishes in mind. So, how did I do on my goals?

Goal #1: Develop an efficient process for appraising a variety of literature, including RCTs, observational studies, meta-analyses, systematic reviews, and guidelines. I’d like to believe I have achieved this in that I have a good foundation and framework for approaching a variety of literature. For all the “checklists” and “scores”, I don’t think I’ll be using them for every single study I come across, but they are good for keeping in mind what elements make up a quality study.
– For observational studies, I have the STROBE checklist
– For guidelines, I have the AGREE II scoresheet
– For meta-analyses, there is the PRISMA checklist and AMSTAR score. I liked AMSTAR because it is fast, and a quick hit on what “big-picture” things to look out for in a meta-analysis.

Goal #2: Develop a process to approaching clinical dilemmas and treatment choice with patients. Achieved. Dr. Slavik provided us the 10 step workflow to doing this. The main idea I got from this was to start big when explaining medication choice, such as:
Condition (what it is) –> Drug class options –> Individual drugs –> Tangible risks (don’t give an NNT) –> Tangible benefits –> side effects, cost, other factors

Overall, the surprising thing I learned during this week was that meta-analyses are not as necessarily bulletproof as I’d like to believe. I think during undergrad, it was drilled into our heads that RCTs have a lot of areas where investigators can improve on, but I was part of a large group of my colleagues who imagined that as we were told that meta-analyses are at the “top of the evidence food chain”, they have to be of a higher quality.

Another thing that made me reflect and give me more pause was that certain research questions may be better answered by a cohort or case-control study, such as in the cases of rare adverse events, hypothesis-generating studies, or ones where larger studies may be impractical or too expensive.

Reflections on Drug Distribution

It certainly feels good to have the 1st rotation under my belt…although it seems like the calm before the storm. All in all, I feel that I got more out of my drug distribution rotation than I had preconceived. Apart from doing the various drug distribution-y things such as “prepare and dispense medications safely and accurately according to institutional policies and procedures” and “accurately transcribe orders onto the patient’s medical record”, I had the opportunity to branch out a bit too. So one does not have to go back to the original post, here were my goals:

1. Develop an efficient process to processing and verifying drug orders – I think I have developed a flow for doing this. Name, 2nd identifier, allergies… then the rest is clinical. Screen the order – and NESA each order.
2. Become familiar with preparation and distribution procedures for parenteral medications in the hospital setting – which ones come premade from PDDC? Which ones need to be mixed? IVP, MED, or MEDM? Doesn’t only apply to parenterals…but I’ve been told it comes from experience.
3. Appreciate the role of pharmacy technicians and the impact of their scope of practice in the hospital pharmacy dispensary – see below.
4. Become familiar with reporting medication incidents from the hospital pharmacy dispensary – see procedure log. Reporting a PSLS was an interesting exercise.

And here were my objectives to meet those goals. Were they met?
– Prepare and dispense 3 medications safely and accurately according to institutional policies and procedures: ACHIEVED. See procedure logs. I got to be with a technician in various steps of preparing medications.
– Accurately transcribe 3 medication orders onto the medication profile of an inpatient: ACHIEVED. See procedure logs. Reflecting on my experiences, I think one week of order entry is way too short to have a working competency given the various idiosyncrasies of individual hospitals, but I can safely say that I have achieved this.
– Clarify 3 orders with physicians and other prescribers: I did not fully achieve this objective but it highlighted the difficulty in making completely informed clinical decisions from the dispensary. At least it encouraged me to be mindful of what I should find out in order to make a decision!
– Demonstrate the safe preparation of 1 IV medication: ACHIEVED (sort of?). I observed the preparation of various IV medications, including a few chemotherapy agents during my visitation to Burnaby Hospital. I do have some tissue culture (asceptic) technique experience in the past, but my muscle memory must be terrible and the technicians do it so quickly…that dexterity! Everything was very protocol based, and all your calculations, prep work, etc was done OUTSIDE of the hood. HOWEVER, if for some reason I was the only pharmacist on call who could do it and it was 2am…I think I could plug through it.
– Name 3 logistical barriers to providing clinical pharmacy care when pertaining to drug distribution: Only 3?? ACHIEVED. Not to say that it isn’t an efficient system. The hospital dispensary is like a well-oiled machine. However, things do happen. Unclear orders, porter delivery times, pass medications and the requirement for 24 hours notice, patient’s own medication ambiguities, incomplete/incorrectly filled out MedRecs… there are many things to keep in mind.
– Name 3 unique roles that the hospital pharmacy technician assumes to expedite safe and effective drug distribution: ACHIEVED. More like, “name a role the hospital pharmacy technician does NOT assume in the dispensary”. Ward stock, inventory, IV prep, you name it, they do it. My preceptor was mentioning that Fraser Health was moving towards centralized order entry. Not sure how that would work out, as it comes with the advantage of standardized order entry procedures, but some drawbacks as well. The techs or pharmacists who would be entering orders would not be following the patient, would not be screening for more subtle DTPs given the Hx of the patient, etc. However, the technicians basically run the show. They do the product check, preparation, most of the order entry (at least at ERH)…the pharmacists mainly deal with order verification in the dispensary, and most pharmacists are on the ward.

Project week (with an interesting ADS coming up on one of my interests… infectious diseases!)…then UBC summer didactic week…then clinical orientation.

Vancomycin tapering for C. difficile

I found this one to be interesting, and involved some digging into EMR. The patient was in for C. difficile associated diarrhea (CDAD), and was the first instance that I could see on Meditech (since 2010 at least), and was on vancomycin 125 mg PO QID since the 28th (closing in on one week). The order read as follows:

vancomycin 125 mg PO TID x 2 days (starting Jul 5th) then
vancomycin 125 mg PO BID x 3 days then
vancomycin 125 mg PO daily x 2 days then stop.

Immediately I thought that I better look into it as I was unfamiliar with taper regimens for PO vancomycin. What I found was that there really is not that much evidence to support taper regimens despite it appearing on UpToDate and some clinical guidelines, and taper regimens are only recommended under guidelines for the 2nd recurrence. In addition, it was the patient’s first bout with C. difficile as far as we knew; in that case what is recommended is either metronidazole 500 mg PO TID or vancomycin 125 mg PO QID x 14 days, if severe (see the paper above for more details). I decided to write it in the clinical book that the pharmacy had, describing my concerns so that the clinical pharmacist could reassess and follow up. It was a good opportunity to delve a bit deeper into an order and try and make an intervention from the dispensary.