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.
Goal #1: Become more competent with history taking and information gathering from the psychiatric patient. Objectives to meet this goal:
– Know what information MUST be gathered, and distinguish it from information that is nice to have
– Further develop skills in rapidly establishing rapport with patients
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. Objectives to meet this goal:
– Achieve goal #1
– Learn how to perform an AIMS assessment in under 10 minutes
– Know other etiologies of movement disorders that are unrelated to pharmacotherapy
Goal #3: Be aware of non-psychiatric considerations for the psychiatric patient receiving pharmacotherapy, and be vigilant of those in the non-psychiatric setting. Objectives to meet this goal:
– Formulate a robust monitoring plan for each patient receiving 2nd/”3rd” generation antipsychotics
– Endeavour to obtain baseline LFTs, ECG, A1c, lipid panel, waist circumference in patients receiving these medications
– Provide patient education to those with insight and judgement into their illness
Goal #1: Hone my history-taking skills in a clinic-type environment where access to the paper chart may be limited or non-existent. Objectives to meet this goal:
– Have a robust process to obtain a relevant, focused history pertaining to atrial fibrillation
– Have therapeutic alternatives figured out beforehand to direct questioning of the patient
– Know common adverse reactions to all anti-arrhythmics used in clinic
Goal #2: Gain a better understanding of practice differences between the acute care setting and the ambulatory care setting. No real objectives, just soak it all in and ask tons of questions.
Goal #3: Be focused on providing patient-specific recommendations and alternatives, in situations where the available evidence is unclear. Objectives to meet this goal:
– For the landmark trials for A-fib rate/rhythm control and stroke prophylaxis, don’t just read the latest trial but understand the context in which the newest trials were published.
– Be able to rationalize drug therapy decision-making with both references to the literature, patient-specific factors, and permutations for various alternatives.
Goal #1: Become familiar with and be able to practically apply landmark trials in the areas of acute management of NSTE-ACS and STEMI, post-ACS management, heart failure, A-fib, and ventricular tachyarrhythmias. Objectives to meet this goal:
– Actively seek out patients to work up who possess conditions in therapeutic areas not previously encountered.
– Rationalize each CV-related drug on a patient’s profile by relating back to literature
– Become more complete in list of therapeutic alternatives in order to expand knowledge base of available literature
Goal #2: Be able to develop a complete problem list for a patient after learning about them on rounds, after report by the medical resident and RN on the team. Objectives to meet this goal:
– Preemptively determine which labs, investigations, physical findings, and medications are relevant to formulate DTPs
– Given the diagnosis provided by the medical team, be able to anticipate possible complications and think ahead to pharmacotherapeutic implications
Goal #3: By the end of the rotation, independently provide patient-centered pharmacy care to half of the CICU ward. Objectives to meet this goal:
– Fulfill goals 1 and 2
– Become more confident in my application of the literature in a patient-specific context
– Become capable of providing clear recommendations even if new information is presented on rounds
On the eve of the new year, I find myself actually apprehensive of this upcoming rotation. Having been off a clinical rotation since early November, and despite great experiences at DPIC and with the Therapeutic Initiative, I still feel out of practice with the process. The mock oral exam was also a kick in the behind for me; I hope that this upcoming rotation will allow me to further hone the tools that I have acquired and also streamline my process.
I’m also quite fond of documentaries, in any shape or form, and I often watch them to relax (my friends think I’m crazy). One such documentary I came across was Emergency Room: Life + Death at VGH, which follows the frenetic, hectic careers of the emergency physicians, nurses, and allied health in the VGH ED. Am I excited? Of course! Those folks are experienced and seasoned; hopefully I can learn a lot from them without getting in their way :D.
Goal #1: Gain a better understanding of the role of the pharmacist in the Emergency Department beyond medication reconciliation. Objectives to meet this goal:
– Complete all medication reconciliation procedure logs by the end of this rotation
– Shadow at least 2 other allied health in the ED, including EMS if possible
Goal #2: Become proficient in condensing information for patient handover from Emergency to ward pharmacist. Objectives to meet this goal:
– Continue to hone process and deliver a patient presentation to preceptor without “jumping” back too often
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. Objectives to meet this goal:
– Quality over quantity: no trying to learn all conditions at once!
– Learn by doing: by week 4 of rotation, be proficient at handling 50% of practicing ED pharmacist patient load
– Be able to distinguish based on clinical presentation and radiological findings, between conditions that may mimic one another or cause one another, such as ischemic stroke and hypoglycemia, or hyponatremia and hypoglycemia causing seizure.
It is now time to apply what I learned during EBM week, but through the lens of a pharmacist on a Therapeutics committee. I come in with preconceived notions that this is an extension of EBM week, and I hope to strengthen my critical appraisal skills and bring that to further rotations and my practice.
Goal #1: Develop a robust process for evaluating the quality of an RCT and whether to proceed with further critical appraisal. Objectives to meet this goal:
– Have a flow of 1st aspects to evaluate when approaching an RCT
– Practice: evaluate a ton of RCTs during the two weeks
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. Objectives to meet this goal:
– Be able to list sources of bias outlined in the Cochrane handbook
– Be able to explain 2 common methods for statistical analysis for RCTs and the shortcomings with each analysis
Goal #1: Develop an approach to evaluating the poisoned patient. Objectives to meet this goal:
– For each toxidrome, have a framework for which abnormal lab findings, signs and symptoms I would expect to see, head to toe
– Work on obtaining collateral for which substance was ingested and timeline from ingestion
– Become familiar with various laboratory and radiologic findings for ingestion of certain toxins
Goal #2: Become confident in providing triage, and if applicable, recommendations for ingestion of a variety of toxins. Objectives to meet this goal:
– Come in with prior knowledge of how to navigate the DPIC Poison Management Manual efficiently
– For common poisoning agents (acetaminophen, TCAs, ethanol, polyethylene glycol, etc), be able to describe the toxidrome and severity of each agent.
– Be able to address the elements of supportive care (i.e. https://lifeinthefastlane.com/fast-hugs-in-bed-please/ – FAST HUGS IN BED PLEASE) in the poisoned patient
Goal #1: Develop a framework and approach to assessing the patient with a suspected infection. Objectives to meet this goal:
– Develop a head to toe approach to evaluating whether the patient actually has an infection or not
– Know the common clinical and radiographical presentations for pneumonia, cellulitis, infective endocarditis, sepsis, UTI, septic arthritis, and osteomyelitis.
– Develop a monitoring plan to assess drug therapy for each intervention made during my time on the AMS service.
Goal #2: Begin to have a framework for correlating clinical presentation to specific microbiological etiologies. Objectives to meet this goal:
– For each infectious syndrome, where it is possible, acquire knowledge on distinguishing factors on radiography or clinical presentation that would differentiate between different causative pathogens.
– Attempt to interpret dictations from 1-2 X-rays or CT scans, i.e. “pulmonary infiltrates”, “ground glass lesions”, per day.
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.
– Practice, practice, practice. Become involved in that aspect of the service.
– Incorporate pharmaceutical teaching into interventions.
A bit late posting this…first couple days on CTU Pink at St. Paul’s has been busy! It’s certainly interesting what rolls in through the door and the different issues that come up. Here are the goals I set for myself prior to starting the rotation..mostly borne out of the feedback I received from BCCA in regards to my process:
Goal #1: Improve my ability and confidence to provide verbal recommendations to the team. Objectives to meet this goal:
- Attend team bedside rounds and have my recommendations ran by my preceptor and ready to go by then
- Structure my rationale in terms of efficacy and safety
- Have a plan B recommendation prepared in case my first one is not accepted with a good rationale
Goal #2: Be more comprehensive with my alternatives list for resolution of DTPs. Objectives to meet this goal:
- Include and consider continuing current management, or different doses or dosing forms of medications in my alternatives
- Do not leave a DTP without a medical issue attached to it, e.g. adjust the bowel protocol for renal dysfunction, attached to AKI as a problem
Goal #3: Become more systematic in gathering info and reporting in regards to daily updates. Objectives to meet this goal:
- Utilize the same format and process in updates as in the initial workup, e.g. ROS, vitals, labs, new problems, DTPs, alternatives, plan
- Consistently solicit feedback from preceptor on how to streamline thought process to be more comprehensive
Goal #4: Develop a strong knowledge base on the most common set of conditions that are encountered on a general medicine ward. Objectives to meet this goal:
- Seek out new opportunities to fill in gaps in knowledge; personally, substance abuse disorders and acute conditions not well covered in the undergrad curriculum, e.g. CHFE, DKA, sepsis, hepatitis C
- Perform personal mini didactics on unfamiliar conditions, structured similarly to how conditions were learned in pharmacy school, e.g. pathophys, lab and physical, treatment alternatives, landmark trials/evidence, monitoring
- Continue to record nuggets of knowledge in notebook to reconcile with previous knowledge of conditions, and reflect how one would treat the condition with differing circumstances
I look forward to further developing my thought process and being more confident in formulating plans.
I’m anticipating a big jump from Clinical Orientation right into Oncology, and I hope that the previous very very basic knowledge I gained from the oncology elective in undergrad will be activated so I can build upon it and apply it in a meaningful way!
Goal #1: Develop a head to toe approach to assessing a patient for adverse drug events secondary to chemotherapy, or supportive agents for chemotherapy.
Objectives to meet this goal:
– Assess 3 patients per week, head to toe, for ADRs as practice.
– Develop a “hit list” for treating various ADRs from chemo, such as neuropathy, nausea and vomiting, and hand-foot syndrome
– Document in the chart my findings based on this assessment for at least 2 patients per week.
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.
Objectives to meet this goal:
– Know 10 chemotherapy agents that automatically qualify a regimen to be “highly” emetogenic as per BCCA protocols and the Hesketh algorithm
– Be able to rationalize changes to nausea and vomiting prophylaxis and treatment based on patient response from previous cycle of chemotherapy
– Provide recommendations to the team for nausea and vomiting management for at least 2 patients per week
Goal #3: Develop a process for counselling oncology patients on either a new chemotherapy regimen or supportive care medications.
Objectives to meet this goal:
– Counsel at least 1 patient per week on supportive care medications that they will bring to a community pharmacy
– Counsel at least 2 patients per week on a new chemotherapy regimen as per BCCA protocols
– Ask for feedback on counselling skills in the oncology clinic setting from preceptor after each session.