IPSF-SEP at Portugal, Part 3- the Portuguese Life

So far, on top of the bacteriology lab experience, I have definitely been getting the full Portugal-experience... with the WorldCup (Mundial) craze, sweet pastries, Portuguese home-cooked meals and cakes, daily espresso's (caffe), lots of fish and potatoes, and most recently, the amazing SURF!! Friday I left lab at noon to watch the Portugal vs. Brazil game at the Student Union beer-garden with some pharmacy girls.. where I witnessed equally fervent yet friendly fans representing both countries! To the right is a picture from the 7-0 Portugal vs. N.Korea game.

Saturday I got up at the crack of dawn to take a 50min train to the nearest beach and one of the most famous-- Figueira da Foz. $30 euros includes pick-up from train station, wetsuit, surfboard, and a 2hr small group lesson. Lucky for me, the other two (a French woman and a German guy) had already been taking classes for a week through the Surf Camp and so the instructor, Felipe, was able to spend all his time with me. He was quite funny and cracked some chauvinistic jokes about me paddling like a girl.. but now I paddle "like I mean it." Felipe taught me basic rules and great technique! I was out in the ocean until my lips turned blue. After an hour and a half, I was able to paddle out, catch my own wave, and surf!!

Quite perfectly, the professor with whom I research, Gabriela, lives in Figueira da Foz. So she picked me up for wonderful steak, pasta, salad, and wine (from Alentejo region) at her beautiful hillside home. It was great chatting with her and her husband... about wine, about Portugal, and even about Google and Facebook! I was also so impressed with the mint, lemonetta (lemon-smelling herb for tea), rosemary, and sage grown in her front yard! After lunch Gabriela drove me around town-- down the coastline so I could see all the beaches, and to the other side where I could see more beaches, and then "upstairs" (as she calls it) to the forest with lush, tall trees, hidden trails, and lots of secluded picnic table areas. Unfortunately, it was very foggy and we could not see anything from the viewpoint (only fog). Then we laid out on the beach until the wind picked up in the evening. I went back to the Surf Camp hostel where I was invited for some drinks at their bar earlier. There were several English people having some beers in the courtyard, and a Canadian. The rest of the people staying at the hostel were, like most Portuguese, taking their afternoon naps. A group of English guys were on vacation for a Bachelor Party, and I chatted with a few of them and learned many interesting things. One of them is a pilot and I told him that is my dream job! They were also interested in pharmacy and the bacteriology research I was doing. One used to be a microbiologist for GSK. The Canadian had never heard of antibiotic resistance-- and I told him that Canada supposedly doesn't have that problem, perhaps because it is so cold! We all enjoyed great BBQ and I had one of the best burgers ever, and watched USA sadly lose to Ghana. If anyone travels to Portugal and loves the beach and wants to try surfing, I highly recommend doing a week-long Surf Camp at either Figueira or Baleal (just north of Lisbon) because you will master surfing, meet great people, have great food and enjoy a unique Portuguese vacation.

Ciao for now, next time I will talk more about the progress I have made in my research!
Off to watch Portugal vs. Espana!

Are you sitting here?

Are you sitting here?

This is the literal translation of a Pueblo Keresan phrase that serves the same social function as the American “hello.” It is, fittingly, my greeting to you all in my first entry about being a JRCOSTEP participant at Albuquerque Indian Health Center, a facility within the federal agency Indian Health Service (IHS). For those of you who are less familiar with JRCOSTEP and Indian Health Service, this entry serves as an introduction to my upcoming month in New Mexico.

What is JRCOSTEP?

JRCOSTEP stands for Junior Commissioned Officer Student Training and Extern Program. It offers health professional students the opportunity to work alongside the U.S. Public Health Service (PHS) Commissioned Corps officers at agencies like Indian Health Service, Food and Drug Administration, and Federal Bureau of Prisons. The PHS Commissioned Corps aim to promote the health and safety of our nation through disease prevention, emergency response, scientific research, service to disadvantaged populations, etc.

What is Indian Health Service?

IHS is an agency within the Department of Health and Human Services. It was established in 1955 to improve the quality of subsidized health care services entitled to Native Americans and Alaskan natives, many of whom were inflicted by tuberculosis and other infectious diseases. Since then, the health status of Native Americans has improved significantly. Today, IHS serves approximately 1.9 million Native Americans nationwide.

Most importantly, why would a pharmacist or pharmacy student want to work for Indian Health Service?

IHS pharmacists have established an exemplary model for pharmaceutical care. In fact, some credit IHS as the pioneer of this concept, which has helped to improve the quality of patient care as well as to raise the level of job satisfaction for pharmacists. We’ll see if I can attest to this as my month goes by.

On a more personal level, it’s great to interact with Native Americans, whose culture we hear so much about but experience so little. I had learned the greeting above from a newly-acquainted Indian coworker who speaks Keres. Keres, Tiwa, Tewa, as well as Towa are languages spoken by the Pueblo Indians in the Southwest. I look forward to being enriched professionally and culturally during my stay here.

The Diabetes Experience

In order to gain a better understanding of what it’s like to be a diabetic, I have been given the task of checking my blood glucose and giving myself “insulin” shots (which is actually just sterile water) for the next four days. The exercise is designed to increase my awareness of the difficulties and inconvenience associated with a disease like diabetes. In doing this, I will be able to counsel patients more effectively because I will be able to empathize with their situation and understand the rigidity of the different treatment regimens.

This is only my first day as a type 1 diabetic and I can already tell I’m going to have compliance issues. I have been assigned to test my blood sugar four times a day and, after going over the different insulin regimens, decided that I will be giving myself injections four times a day (Lantus at bedtime and Humalog before each meal). I decided on the four times a day regimen because I’m not very consistent with the timing of my meals so this seemed like the best plan for me. So far I’ve given myself two injections, one in the back of my upper arm and one in my abdomen. I have to say I’m very surprised with how little they hurt. I was expecting the injections to be much more painful but I’ve found that the finger pricks for glucose testing actually hurt worse.

Overall, I think this is going to be a very interesting and worthwhile experience. It will be a huge help when talking with patients about which injection sites seem to hurt the least and add some credibility to the information I’m giving since I have actually gone through some of the things they’re going through.

The MCRiT Experience

Hey guys,

Summer is definitely flying by and I have been busy with life, research, and hanging out that I haven't been able to do my part in contributing to the COP blog. This summer I've been blessed to be a participant in the Multidisciplinary Clinical Researchers in Training (MCRiT) program offered by the University of Michigan for doctoral Pharmacy, Medical, Dental, and Nursing students. The program is a total of 12 weeks, in which 10 are dedicated for the summer and 2 during the fall semester. It's already the 5th week and I have lots to update!

What's really cool about MCRiT is that you get to experience how research truly is a multidisciplinary process. From the onset during orientation, the other pharmacy students and myself participating in MCRiT were alarmed to be welcomed by our own Dean Welage!!! Not only is Dean Welage awesome in the College of Pharmacy, she's also actively involved (and a big fish) at the department that oversees major research going on at UOfM. She coordinated the Basics of Clinical Research seminar ( ie what is Clinical/Translational Research, intro to IRB, Informed Consent, etc). The audience was filled to capacity with people involved in research from multiple departments at UofM for example: clinical study coordinators, research administrators, post-doc fellows, etc. To be honest, a lot of the material was over our heads because a lot dealt with research policies and protocols at Michigan that are common for research which we haven't had a lot of experience with. But it was still awesome to be there, and to enjoy the complimentary meal -- i mean network session!

Essentially, the summer MCRiT practicum is a program composed of 3 core objectives: 1. Participate in a research project under a mentor doing ongoing research. I'm working with Dr. Erickson, and we're doing a cross-sectional study on patients and their pharmacy behaviors at the General Medicine clinic at Taubman Medical Center. Above is a picture of me of what a typical day at clinic involves. Professional attire, writing utensil, and clip board on hand. Ready to engage and recruit patients into the study!

I'll end it right here, but I'll conclude by saying how much MCRiT has opened my eyes (and have made me excited) for research. I never experienced how difficult it could be to enroll patients into a study, and I now understand why there are flyers advertising cash incentives to participate in psych studies. I'll update soon about the other objectives of MCRiT and more stories, but if anyone has any questions about the program, send an e-mail to me at : cqtruong@umich.edu

The Wonderful World of IDS

If you have ever wondered how a drug goes from the lab to your bedside then wonder no longer. The Investigational Drug Service (IDS) at the University of Michigan Hospital (UMHS) provides students the opportunity to get a glimpse of the drug approval process. IDS manages over 300 different studies at UMHS. We work with the sponsor to maintain study drug and all that goes with that process. This includes managing records, staying current with all the updates to the protocol, and preparing the study drug for patient use.

This summer is my second year working at IDS. My first summer was mostly spent making capsules. In compounding lab during P1 year, I remember taking over an hour to make 6 capsules. Now I am able to use machines that allow me to make 100 at a time. Last year my record was 1600 capsules in one day. This summer we hired a new intern, Meenakshi, so she will now be making all the capsules.

This year my role has changed from capsule making to more pharmacist responsibilities. For each new study that opens we create a document called the Dispensing Guidelines. This document is a 7 to 10 page summary of a clinical protocol which is usually over 100 pages. We read through the protocol and pull out all of the information that pertains to the drug and its dispensing. So far this summer I have had the chance to write several dispensing guidelines.

When I first started here I really had no idea what IDS was about. Over the last year I have learned a great deal and I look forward to be able to share it.

Czech Republic Part III

Ahoj! Dobrý den!

I spent this past weekend in Berlin, which is about 8 hours away by bus. The city is bustling with people, many of whom are presumably tourists because they look as excited about being in the city as we do. Emily's friend coaches the men and women's USA lacrosse team and had a tournament in Berlin, so we braved the complicated subway station and went on a quest to find them. When we did, we relaxed by watching the Germany World Cup game with a bratwurst in one hand and a German pilsner in the other. All the bratwursts in the city use small baguettes instead of buns so they cover only a small midsection of the brat. Makes it difficult to pour on the ketchup.

We spent our days in Berlin sightseeing the whole city. My favorite site was the Brandenburger Tor (aka, Brandenburg Gate, shown below). This majestic gate is the last existing gate that formerly divided East and West Berlin.


The night we got back to Brno, I went to the cafeteria at the dorms to get pizza. I asked a student to translate a few kinds of pizza for me. I got the usual "cheese and ham" and "margherita pizza" but then he paused and said "cheese and fruit". I assumed he meant vegetables so I ordered the pizza ovocna, which really turned out to be mozzarella smothered on peaches, tangerines, hazelnuts, and jam. I took one look at the pizza and put back the chocolate hazelnut pudding I was planning on having for dessert. The pizza wasn't bad ... it just wasn't what I was expecting. Sweet meals aren't uncommon in the Czech Republic. In fact, there are sweet Fridays where lunch consists of fruit filled buns, which are really good.

The pharmacy where I am interning is one of the largest in the Czech Republic. They make sterile eye drops in bulk once or twice a week and sell it for a minimum profit to other pharmacies in Moravia. The "sterile"environment is less stringent in the Czech Republic, where the pharmacists making the eye drops were working in a laminar flow hood wearing their normal clothing with open-toed shoes, without gloves, and hair not pulled back. I even got to pour a few bottles but I didn't even have to wash my hands before I did it! We tested the batch of eye drops by checking for correct mass, antimicrobial activity, and concentration of boric acid using — the titration method. I never thought I would use that outside of Med-Chem lab! The eye drops turned out to be within the correct range for all three factors.


This is the room where most of the compounding takes place.

When compounding, Czech pharmacies just weigh everything directly on the electric balance in grams. At first I wondered why they didn't measure liquids in graduated cylinders but I realize that it's much easier keeping everything in grams and not having to convert to milliliters. And instead of using a water bath to heat solutions in beakers, the pharmacy here uses a shallow pot filled with paper and water and sits the beaker on top of the paper water mixture. It looks similar to the consistency of mushy oatmeal and prevents the glass from breaking while being heated.

Kristin

Success!

Today I finally presented the drug monograph I created for Vimovo (naproxen and esomeprazole). A drug monograph is a lengthy document containing all the major information you want to know on a medication- FDA indications, mechanism of action, side effects, contraindications, warnings/precautions, dosing, background of disease state being treated and clinical studies pertaining to the drug. Information is obtained through the package insert, dossier, practice guidelines...I even used the DiPiro textbook as a reference!

(Interesting side note- one of the authors in the DiPiro textbook is a member of the P&T committee at Prime)

This morning I practiced my presentation one on one with my preceptor and was really nervous! My voice was shaking and I had no idea why I was nervous. I am familiar with all the pharmacists I was going to present to, and they are all nice. I was shocked that I was nervous!

So I practiced few more times before the real thing in one of the meeting rooms to get over my jitters...

During the actual presentation, I was speaking with confidence and was hardly looking at my cheat sheet. I was really relieved it went well and received compliments from my preceptor and other pharmacists on a job well done. I'll admit-- I am feeling pretty cool right now...I created the drug monograph from the beginning, and saw it through by presenting it at the Clinical Review Committee meeting. These tasks are exactly what the senior clinical pharmacists in Formulary Development do! My monograph will be included as one of the company's confidential files, so I like how I was given real responsibilities of a pharmacist, and not just technician duties which is typical in many internships.

I really wish I could attend a P&T meeting, but I missed the May meeting and will be missing the August meeting since I'll be back in Michigan doing P-4 rotations. All these meetings I've been attending are geared towards polishing material for P&T, so it would have been a nice experience to witness the final decisions regarding formulary decisions.

Sinai Grace Today!

So in the seemingly endless uniformity of my days at good ol' Sinai Grace, there is one thing that changes every week. Although it's not necessarily pharmacy related, there is a new "Sinai Grace Today" on the cafeteria television. This may not sound very exciting but it gives us insight into what's going on at the hospital we spend all our time at. And also, without trying, it manages to be hilarious. There is a joke every week that someone tells with a little less than comedic timing and then they show what is going on in the hospital this week. Last week they showed us about HazMat training where those lucky enough to work in an area in which they could be exposed, donned the big yellow suit and went through an obstacle course of craziness. I don't know what I would do if they did not capture this all on video for us to relive every 30 minutes at the cafeteria.

Speaking of the cafeteria, we also just instituted a new policy in which all IVs made must be put on a tray. It looks like the trays that you get from cafeteria and it makes me feel that I'm somewhere in between my middle grade self and the lunch lady that everyone was afraid of. In the IV room we have those yellow gowns and hair nets and face masks and gloves and booties, so I guess in the case of apparel we are definitely closer to lunch lady status. It makes the IV checking process safer, keeping things from getting shifted and in the wrong spot, the problem I worry about is the cleanliness of it. Ideally we would disinfect these trays after every use but because it is occasionally rushed in there this does not always happen. The odds of something transferring from one bag to the tray to another bag is probably slim to none but being a future pharmacist, of course I am somewhat meticulous (not compared to a lot of people but by my standards I am) and so this sometimes worries me.

I also learned something new this week that hopefully at least the soon-to-be P3s will appreciate. We had an extensive unit on Gastrointestinal disorders and how to treat them but I don't remember learning this (I'm pretty sure if we had learned this I would remember). Turns out for a bad C. difficile infection, a patient can receive 500g of Vancomycin in 1 L of saline through an enema (rectally). It has to sit there for an hour and then it can be removed. If that doesn't sound uncomfortable enough, it can be dosed every 8 hours at least. Yikes!! Finding that out made me more thankful for my health than I usually am.

From One Lunchlady to another... have a good week!!

There can't be two #1's...that's 11

I know how hard it is to be #1, and being the #1 Hospital in the country for the past 18 years means that Johns Hopkins deals with some of the same pressures I go through on a daily basis. The problem is that every hospital in the country paints this massive target on Hopkins in their never-ending goal of toppling the juggernaut of a hospital. Though there are dozens of parameters taken into consideration to determine hospital rankings I was very surprised at how influential the department of pharmacy was in a particular area, customer service. The patient/customer experience at the pharmacy counter is a vital component to the continued success of this hospital. There are three projects that I am working on in conjunction with other interns to monitor and improve customer service in the pharmacy.
The first project is the start of a Secret/Mystery Shopper program for the pharmacy. This project is actually let by another intern Rami, a P3 student from Harding who I work with on a regular basis. We attacked this project from several angles as we decided to not only monitor and evaluate the pharmacy via a physical shopper but also phone calls, fax's, and e-mail directed to the pharmacy. After identifying key components of customer service that we wanted to focus on we then set realistic expectations mainly composed of "Benchmark" projections. Benchmark is an actual company that sets standards in customer service along various venues from fast food to health care. We then consulted the managers of each outpatient pharmacy to their perception of how their pharmacy treats it's clientele. A private company has been contracted to conduct the evaluation and we hope to receive the results before the end of the summer.
The next project is the Wait Time Study, this is actually done by the interns each summer. I will lead the project to determine the customer perception of how long it takes to get a prescription. This is not to be confused with Lead Time which is how long it takes to actually fill a prescription and do the billing, blah blah blah. It's an observational study (nod to Welage/330) as all the interns will get their turn to visit all the pharmacies during various business hours/days to see if we are doing a good job or not. We will compile the data into a presentation that I will present to some rather important people around the end of July.
The third and probably not the last project is the implementation of new technology that should lessen wait time and lead time in the pharmacy. Ok so new technology is a really generous term, essentially is a scanner that links to the pharmacy. This new program asks that when patients check into the hospital for any reason, inpatient, specialist, clinical, or even just a normal check up, that when they take the medical card they also take the patients prescription insurance card. What then happens is that this information is transferred to the pharmacy and the pharmacy can start claims and billing before the patient gets a physical script in their hand. In theory all of the dirty work will be done before the patient makes their way down to the pharmacy. With this project I'm working with the IT department to follow the installation, learn the program, then teach it to the pharmacy staff. How hard can it be, it's really an over-priced scanner but we'll have to see if it makes me lose more hair.
I will update on these projects as more develops. It sounds crazy but I am having a great time.

My Trick

I am back at the University of Michigan Hospital for my second summer. I mostly work in Mott, which is U of M's children's hospital. I love working in Mott, because there are many different roles for technicians. Probably my favorite part of the job is compounding oral medications--which we have to do quite a bit of in Mott since not many kids can swallow pills. I love breaking out the mortar and pestle for these--it makes me really feel like a pharmacist!

Last summer, it seemed like all of my attention went toward learning the details of the technician roles; this summer, I'm much more comfortable with what I'm doing. I am also excited that after another year of school I've learned about a lot of the medications we are dispensing. Despite my excitement at recognizing the medications, I worry at times, that I can't recall everything I have learned about them. I don't want the seemingly endless hours that I've spent studying these drugs go to waste!

With this worry, I came up with a trick: Now, every time I see a drug that I have learned about, I try to come up with as much information as I can about it. If I feel like I'm not remembering important things that I have already learned about the medication, I write the name of the drug down. Then, if the work slows down in the pharmacy, I look up the information. Hopefully this works. I'll have to report next time how effective this memory trick is (or is not), so stay tuned... Also, in my next entry, I hope to talk a bit about some shadowing and project work that is coming up.

Emerging Drugs of Abuse

This is actually one of the first projects I worked on while here, there is some pretty interesting information available as well. So in one of my first Policy and Procedure (P&P) meetings the managers were discussing large shifts in inventory and possible methods to track this over time. Large shifts in inventory generally happen for a few reasons, either one the drugs are seasonal (like dispensing more Zytec and Claritin during the beginning of allergy season), a new drug/generic hits the market, or something fishy is going on. In this case the issue arose because there was a spike in ordering Viagra which when investigated was the result of the drug being sold illegally by certain parties (I'm not nameing names because I honestly don't know who, it was before the summer). For the outpatient pharmacy there was already a procedure in place that would track trends in Narcotic and Control medication purchases, this service was actually provided through our vendor. Nathan thought it would be interesting if I were to research Non-narcotic and non-control prescription medications that have street value.



This actually turned out to be harder than I thought as if you google drugs of abuse or drugs with street value you always get a long list of narcotic and control meds which is not what I needed to find. It would be interesting if other students would like to take on this problem and compare what they find to my conclusion. The results were actually surprising, some normal prescriptions drugs have the potential through their side effects to cause responses that people will pay good money for, crazy I know. I was actually able to produce a list of 30 emerging drugs of abuse that were neither narcotic, controlled, or otc.



The topic then changed from how do we now give this information to the 180 employees of outpatient pharmacy and nearly 200 employees in inpatient pharmacy. There are various options from an inservice meeting to newsletter. The problem then arises that even given the level of technology and accessibility to the information, alerts and information don't typically find their way to the people who need it. Now my project has taken on a life of its own as I want to evaluate the various media sources I have and decide on the best way to give this information to all parties. Quite frankly if I am going to do all this work, I want to make sure everyone is listening.

Government Programs & Pharma Drug Presentations

Last week and this week I'm spending my time within Government Programs--Medicare Part D clinical formulary management. As my first task, I was given a binder and was told to read "chapter 6." This chapter includes drugs not covered by Medicare Part D and policies and procedures regarding formulary management such as negative changes and ANOC (annual notice of change).

The project assigned to me dealt with HRM's (high risk medications). As the title implies, HRM's are medications that should not be used in the elderly or be used with caution. I was responsible for comparing utilization PMPM (per member per month) between 2009 and 2010 of HRM's. The control group are HRM's not removed from formulary, and variable group are HRM's removed from formulary. Ideally we'd like to see utilization to decrease from 09 to 10.

***
Pharma Drug Presentations
So far, I've attended 3 drug presentations presented by drug companies for Cayston (aztreonam inhalation solution), Zyclara (imiquimod 3.75% cream) and Vimovo (esomeprazole and naproxen). Each presentation was an experience in and of themselves. It's like a formal ritual-- introductions are made, business cards exchanged left and right...I'm forming quite a collection of business cards. I've noticed that the drug companies send teams of 3: medical science liasion (PharmD), expert of therapeutic topic (MD and/or PhD) and national account manager (business person concerned with money). The expert gives a presentation on the pathophysiology of disease being treated and the drug product being promoted. My preceptors and I will interject with questions, and the whole time the national account manager is writing away notes of our comments/requests in a diary-like notebook. So the flow of the presentations are pretty smooth...until we come upon the clinical studies section. Here is often where my preceptors drill and nit pick the expert and MSL (medical science liaison). I realize at that time how MSL's really really need to be on top of their game of knowing the literature AND keep their composure at the same time. I give them credit for the heat they have to take.

Today a presentation was given on Vimovo. I am fairly familiar with this drug product since I created its drug monograph. So I already had some questions prepared beforehand since some details were not exactly complete when I was doing research. There were 2 studies mentioned in the package insert (PI) saying that some result was "statistically significant." However, no p-value was referenced. I searched ClinicalTrials.gov, Medline, and Vimovo's dossier but could not find the p-value! So I asked the presenter what the p-value was, thinking that my question isn't even that complicated, and she couldn't even answer my question. She even went on to tell me the studies weren't mentioned in the PI, so then I pointed it out to her...but yea, she said she would send me some data that would contain more details on the study.

Please note: I am not dissing the pharmaceutical companies...next week I am actually going to be working alongside a medical outcomes specialist from Pfizer as part of my internship. My internship is sponsored by AMCP and Pfizer, so I get to experience managed care pharmacy and industry. I am looking forward to next week because I want to hear the perspective of a pharmacist in industry and place it within the scope of my experiences thus far. I will also be going to various sites with my Pfizer guy so looking forward to the new experience!

Side Note

Scheduling is hard. Who knew trying to get ten interns in the same place for an hour would be so hard? I kept trying to be diplomatic and letting them decide when we could all get together which then spiraled into the better half of a week trying to decide. I tried to put my foot down and decide a date and time and ended up scheduling the meeting when I should be in the middle of a presentation. There is no conlcusion to this post, just felt like ranting.

Refills

All right here's another interesting project I had the opportunity of working on -- and, yes, that's sarcasm. Recently Johns Hopkins opened a new outpatient pharmacy in the Howard County Medical Pavillion. Though this pharmacy carries the Johns Hopkins name and logo it sits in a building in a very secluded location that is not associated with the hospital . When they say location is everything, believe it. This pharmacy gets very little business and has operated at a loss since opening about a year ago. All of the outpatient pharmacy managers have made the success of this new pharmacy one of their top priorities within the last year. We literally have meetings every week concerning marketing and advertising. Okay that's the background on the Howard County pharmacy.

In the pursuit of answers as to where all the business for Howard County is going, Nathan (the Director of Pharmacy/my preceptor) asked me to figure out the refill retention rate for Howard County in the month of May. First I had to define refill retention rate as a prescription with valid refills remaining, to be filled in the month of May. Seems easy, right? Just find out how many possible refills could be filled in the month of May and compare it to exactly how many refills were filled in the month of May. Considering the computer system used here in the outpatient pharmacy is literally based on MS DOS the process took way too long. At first I was told I would have to manually examine, one by one, each of the scripts written in the last three months (to account for 90 day supplies), and then track their refills to see if they were filled in May. That's over 2,000 scripts! Instead of doing that I decided to be smart about the process and pass it off to somebody else ... just kidding. I did, however, use one of the IT guys here to transfer the scripts from the operating system to Excel. With this information, I was able to to produce a refill retention rate in only a few hours. We now have this rate and it's not the answer we were looking for, as this pharmacy has a very high refill retention rate (81%) when compared to the national average (47%).

Not to be defeated, I looked through the data again to determine the trend in the refills and to gather new information. We found that one of the highest rates of non-compliance came from the OB/GYN patients. This information was passed to our safety division which launched a campaign to partner our pharmacy with the OB/GYN clinic in the Medical Pavillion to promote compliance among their patients. Patients now have the option to be enrolled in automatic refills not only for their OB/GYN meds but any other meds they happen to be taking, with the option of free delivery. The pharmacy benefits with more business, the patients benefit with greater care, it's a win-win situation. The really great thing about this situation is when you see not only what corrective actions went into effect, but also the outcome of these actions. We are able to assert the role of pharmacist into pre-natal care by building a partnership with OB/GYN physicians and clinics. This partnership has the potential to drastically increase patient outcomes, not to mention increase business for the pharmacy. You have to love when a plan works out...

IPSF-SEP at Portugal, part 2

Ola!

One of my first meals in Coimbra was at a Cervejaria (beerhouse) serving seafood. In this picture, the local exchange officer, Francisca, is teaching me some useful Portuguese so I can be less lost when ordering at restaurants. Some common and fresh fish in Portugal include the Bacalhau (codfish), sardinhas, robalo (sea bass), and dourada (golden fish). The Portuguese will also indulge in gambas (prawns) and wash their food down with some beers or Vinho Verde (younger white wine).

I start work around 10 am in the lab at the College of Pharmacy. Here is the black box that I work in. It is the Faculdade de Farmacia. The professor and the post-doc I work with usually get in by 10:30am. I have been able to work by myself for most of this week: streaking a total of 100 E.coli HUC ESBL samples from patient at the university hospital, extracting bacteria DNA, running PCR to amplify the genes known to easily identify different phylogenetic groups of the bacteria (groups A, B1, B2, or D) via gel electrophoresis, and then comparing the groups with pathogenecicity factors. Other than my own project, I also help Dr. Gabriela with her antibiotic resistance study. She has conjugated different types of bacteria to observe horizontal transfer of the antibiotic resistance gene from donor to acceptor. I am learning different ways to be able to see the unseen.. quite the intrigue! Much of the lab techniques are similar to what I am used to at UCLA and The U-M College of Pharmacy Med-ChemlLab.. They are more conservative with their reagents and buffers, however, than in the States. For example, they keep the running buffer for gel electrophoresis and do not dump it out after each run, until the buffer becomes muggy! I made a joke about Americans being wasteful.. and they could not agree more ....

For lunch we go right next door to the student cantina. For $2.15 euros you can get a full meal, but with pretty much no choices on the main entree. Regardless, it is a good deal and I appreciate the simplicity. The Portuguese love to drink soup ... very simple soup.The one I am having here is extravagantly called "Green Broth".. made from a type of cabbage. It is very simple, and quite bland. I guess that is what the table salt is for.

Job description, who needs a job description?

Since my last post I have started my second internship for the summer. As I mentioned last time, I received a last minute internship offer from Washington Hospital Center and have since left Walgreens to being my new work. I was thrilled when WHC contacted me about the position. Don't get me wrong, I have enjoyed my time with Walgreens, but I haven't had any hospital experience so I jumped at the chance to get an inside look.

The initial word about the position, the interview and the job offer all came very quickly. My interview was a two-parter. The first part was with a non-clinical Manager. Then I interviewed with the Assistant Pharmacy Director. She was in between meetings and had only two minutes to answer my questions about the position. "What kinds of projects will I be working on this summer," was met with "we're not sure, you're the first intern we've had." Then she briefly described a project she thought I might work on and closed the interview with, "this position is going to require a lot of flexibility because we're not really sure what you're going to be doing, so if you're not up for that then this isn't the spot for you." I said what anyone else would say, "sign me up!"

I'm still not certain what my job entails, but I'm just going with the flow and doing my best sponge impression (soaking everything up). So far I have spent a lot of time in an area they call DDLP. No one knows what DDLP stands for, apparently it has something to do with the label printer. Basically, labels pop out of the machine, I grab them up and pull the appropriate drugs from the pharmacy shelves. After that the pharmacist checks the drug and sends it to the correct floor. When there's down time, I dust off my brain in preparation for pop quizzes - see below.

The Pharmacy Director cornered me on my first day and quizzed me on atropine. I faired well until he started in on pharmacology. Yikes! He apparently taught pharmacology at a nearby college for 30 years, so my "umm, I think..." answers did not suffice. He quickly sensed my uneasiness with the topic and instead of drilling me on it, he recapped the basics as they related to the MOA of atropine and now I will never forget its actions (or side effects). I think I will put that in the "success" column.

Now whenever I see him I know to be ready to answer medication questions. I have quickly learned that if I touch a drug, or even look at it, I should know its brand/generic name, what it's used for and at least one major side effect. I think this summer is going to be a good warm-up for rotations.

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In other news, our sand volleyball team is undefeated. I have managed to bring home enough sand in my shorts to create a small beach in the front yard (kidding). This weekend will be another big sports weekend. We have a kickball tourney on the National Mall on Saturday, followed by football playoffs on Sunday. I hope to be able to walk on Monday, this getting older thing is for the birds! Oh, and for you baseball fans, I got to see Stephen Stasburg pitch (and win) his first Major League game last Friday. Woohoo! City life is not too bad, except for the water - my hair is not pleased, too much chlorine.

Czech Republic Part II

Dobry den (good afternoon/good morning/good day/hello...basically an all encompassing greeting),

I've been in Brno almost a week and am feeling increasingly more acquainted with Czech Republic's second largest city and the culture that surrounds it.

Czech has this soda called Kofola that was introduced while it was a communist country and did not import Coke or Pepsi. Kofola looks like Coke but takes more sour and has hints of lemon/lime. I was excited to try it when a few people told me that they prefer it to Coke, but I think I'm good after trying it once. Another thing, they have multivitamin flavored soda here, but multivitamin just means mixed fruit. It threw me off when I first read it on a menu.

Emily and I have been making ourselves useful at work by putting away the daily medication order from the distributor. That's our main contribution, I would say. We also do a lot of observing...observing the compounding process, observing interactions with patients.

Other major differences between pharmacy here and pharmacy in the US are that here, upon receiving large stock bottles from the distributor, they must open and smell each one to make sure it the label matches what is in the bottle. All orders from the distributor are rubber banded together which makes it much easier to find the same medication. Inventory is done once or twice a year while CIIs are checked every month. Two copies of the CII prescription are made. The original copy is sent to insurance, one copy goes to the doctor, and one stays in the pharmacy. All medication labels (pills, ready made creams and ointments, anything compounded) are hand-written except if they are special order allergen vaccines directly from the distributor - those have the labels pre-typed. I didn't even know allergen vaccines existed before yesterday. So far I've seen dog/cat hair and grass allergen vaccines.

Emily and I have been watching the World Cup, although being in Europe you would think that any European city would partake in fotbal festivities, but Brno is big on ice hockey so it's been a challenge to find bars to watch the games and to encounter people that are excited. You would think I was in the US with the soccer apathy I've encountered. (In case you haven't been watching, the US tied England!)

Emily, our coworker Basia, and I took a day trip to Vienna (or Wien as the Austrians call it). It took an hour and 45 minutes by bus to get there. The city looked pretty desolate when we arrived because it was before 8 am on a Sunday morning. We visited the Natural History Museum in its entirety before making it to the Schonbrunn Palace, home to the rulers of the Austro-Hungarian Empire. We took an informative guided tour which was actually really interesting but confusing with all the inbreeding and who's related to who. We spent the rest of the day walking around, sitting at cafes (we also went to Starbucks because Basia had never been there and insisted that we go) and tourist watching. Vienna is chock full of tourists from all over the place. Vienna is known for its coffee, chocolate, churning out of classical composers (Mozart, Schubert, Haydn, Strauss, etc.), and of course wiener schnitzel. Wiener schnitzel is nothing like the American fast food chain. It's usually pork or veal that's been pounded into a thin slab of meat, fried, and served with a lemon wedge. It doesn't sound very appetizing, but it's surprisingly good.

Emily and I took a trip to the laundromat today. The laundromats here are also bars. I didn't understand why til I saw it for myself. It took 3 hours to do one load of laundry so it would make sense to give customers the option of getting drinks while they waited.

Till next time,
Kristin

Off label uses for some common meds

Over the past couple of weeks, I have learned about a lot of very strange and unusual uses for some common medications so I thought I’d share a few of them with you here because they are pretty interesting.

Premarin for recurrent epistaxis (nose bleeds)

The topical estrogen cream is applied to the nasal mucosa and improves the stability of the nasal blood vessels. This occurs by changing the weak epithelium into a thicker layer of stratified, squamous epithelium that is more resistant to trauma.

N-Acetylcysteine for altitude sickness

Dr. Regal may have told us about NAC’s use in acetaminophen toxicity but I think he forgot to mention its use in altitude sickness. This over the counter amino acid can easily cross cell membranes before being converted to cysteine and then to glutathione, a powerful antioxidant. NAC’s ability to regenerate glutathione levels is what’s thought to help with the symptoms of altitude sickness.

Everclear for antifreeze poisoning

Antifreeze (ethylene glycol) poisoning may not be a very common occurrence seen by us as pharmacists but it can happen. Fomepizole is the first line treatment; however, this is a very expensive medication that may not be readily accessible. In these cases, intravenous ethanol is used to treat ethylene glycol poisoning because the ethanol prevents ethylene glycol from being converted to toxic chemicals in the body.

These are a few new uses that I wasn't aware of before. It just goes to show that when asking the "What did your doctor tell you this was for?" question, you may be surprised by the answer but that doesn't mean it isn't true.

IPSF-SEP at Portugal, part 1

Bon Dia!

I was warmly welcomed to the University of Coimbra in Portugal with a kiss on each cheek by Miss Francisca, the local exchange officer for IPSF-SEP program. My first day, Francisca showed me around campus, including the Old University area which is one of the oldest Universities in Europe, dating back 500 years! This University used to be the home and school for the Kings of Portugal. It remains as one of the major academic institutes in Portugal and has become a major site for culturally-inspired tourists. In fact, I have never been at a university where tour buses and groups are here everyday snapping photos of the campus and its gorgeous views as it sits on top of the hill, surrounded by a river. Just in the one week I have been here, I saw tour groups from Italy, Portugal, England, and even Japan and China.

In addition to the strong culture and history that is embedded in this "Land of Love" (Coimbra), the best part about my time here, so far, is the research project I am working on. The pharmacy faculty I have been paired with is Dr. Gabriela Jorge da Silva. She is extremely cute and hip... and very knowledgeable about her area of expertise: microbiology, bacteriology, antibiotics, and antibiotic resistance.

Because of my previous laboratory research experience at UCLA and interest to continue translational research, I chose and was placed at this University. As a P1 I have not yet learned about antibiotics and Abx resistance.. so in order to do the lab research, I started desperately reading for a basic understanding of different antibiotics, criteria for resistance and mechianisms, Class 1 Integrons, and pathogenicity groups.

More about the Portuguese. They love their cafes (espressos). Actually, espressos are enjoyed all over Europe! And I can say that because I have been to 5 European countries in the past month and sipped on aromatic espressos with the French, Germans, Italians, Spanish, and the Portuguese... and the coffees get better and better (and cheaper and cheaper!).

Francisca told me immediately that the Portuguese always have coffee after a meal, and usually at a different location for a change of scenery. So I had lunch with several research professors followed by a helping from their Pharmacy faculty Coffee Heaven cabinet. The top shelf has chocolates; the next shelf holds each person's own espresso cup; the third shelf the red NEspresso machine ( famous for the series of commercials featuring the suave George Clooney); and, on the bottom shelf, as you might be able to spot, several bottles of port wine. Maybe we will have some one day if I am able to characterize some virulence factors and pathogenecicity island groups to the Portuguese E.coli I am studying!

420/330

My summer has boiled down to two courses, 420 and 330. (Makes me wish I actually paid attention in those classes, j/k...) Working with Nathan is like a whirlwind of everything I learned in the last year condensed into 9-10 hours a day. My first major assignment combined all we learned in 420 and 330, John Clark would be so proud Dean Welage not so much.

Johns Hopkins owns their own Managed Care Organization. This hospital also services a disproportionate share of low-income and patients without insurance. Which means the Hopkins Medical Center is authorized to purchase drugs under the 340B pricing guidelines. The hospital is also involved with a high level of charity care in which the hospital takes on all costs of treating a patient without coverage or assists patients with their medical bills. This all seems simple but there is a lot more to it that I don't care to explain at the moment, by the end of my first day I think I had 340B somewhere in all of my sentences. Moving on, the managed care organization wanted to increase their charity work for the Fiscal Year 2011 (which for Hopkins begins in July 2010) and therefore needed to decrease their spending on drugs. Here is where I come in...

In order to save money on prescription drugs I was tasked with reviewing their drug formulary and looking for cost saving options. The only bit of advice I was given by Nathan was to review five classes of drugs: PPI, Statins, Diabetes, ARB's, and Pain Management. The first thing I do is identify each drug for each class, for each class there was at least 6 meds regularly used in their formulary. Next I had to find the price per pill for each drug under the 340B pricing. A side note, 340B pricing is a minimum of 49% discount some brand names were so cheap I couldn't believe it, $0.01 for a bottle of 100 Prevacid 30mg??? So now I have multiple drugs under each category of varying strengths and I have their price per pill under 340B purchasing. Here's where the 330 comes into play, now I need to research the comparative efficacy of each of the drugs in the class. This was a serious headache and I found myself channeling all of my EBM knowledge into this tasks, I had to not only research the task on sites like PubMed, Micromedex and UpToDate, but also appraise the articles for their validity.

Long story short for the five classes: PPI to Omeprazole, Statin's to Simvastatin/Lipitor 80mg, Diabetes to Actos, ARB's to Cozaar, and Pain Management was inconclusive. With the following changes I then had to apply my formulary adjustments to the total spend of the pharmacy for the first three quarters, then annualized for a full year of spending. With this I could show the managed care organization how much money they would have saved this year if they used my proposed formulary. The formulary adjustment equated an 6.5% savings per year which doesn't seem like much, but when compared to an annual spend of $200k in drugs, the costs savings add up.

I then prepared a presentation of my project to be presented today for the Johns Hopkins Charity Committee. The proposed formulary adjustment will be discussed and voted on and could see integration for the second quarter of the 2011 fiscal year. In the last three weeks I have accomplished something of significance that I could not have prior to my first year in pharmacy school. The funny thing is that this is one of 6 projects that I have taken on in the last 3 weeks with more to come. I plan to keep showing the other interns here why they call us the "Leaders and the Best"

Different Perspectives

I really like how my internship is very cohesive. For example, at the next CRC meeting I will be presenting the monograph I authored for Vimovo and also defend the CTL (clinical threshold level) I rate for this new product. In a few weeks AstraZeneca will be doing a presentation on Vimovo that I will be attending, and during my time with the UM (utilization management) team, I had to do drug comparisons between Vimovo and Celebrex. Another example: I did a limited review for a cream to treat actinic keratosis, and am now working on the criteria for its UM program and in a few weeks the manufacturer will visit to do a presentation on their product. (I can't give the specific drug name due to confidentiality).

What criteria am I talking about? Maybe first I should explain UM. Please note at my internship UM stands for many things, BESIDES its true meaning of University of Michigan ;-). U of M can mean University of Minnesota, and can also mean Utilization Management. The UM (utilization management) team is responsible for programs surrounding various medications, such as Prior Authorization, Quantity Limit or Step Therapy. They write and manage the "obstacles" that community pharmacists deal with on a daily basis. The UM team collaborates with the Formulary Development team to come up with ideas of how a medication's program should be set up.

Today I actually finished writing up criteria for a drug to treat heavy menstrual bleeding. When thinking of the criteria, I had to put the contraindications, FDA indications, and patient populations studied in clinical trials into account to guarantee the program ensures appropriate prescribing patterns. I find it really fun!

Czech Republic Part I

Ahoj! (Ajoi is pronounced “ahoy” and it means hi)

I arrived in Brno, Czech Republic after a few delayed flights and finally made it back to my Brno University of Technology dorm room. The University of Veterinary and Pharmaceutical Sciences is a small university, so we were given dorms elsewhere.

I went to my first day of work this morning. The Czech word for pharmacy is "lekarna". Work begins at 8 am and ends around noon (for me at least: everyone else works the full day). The pharmacy is much larger than it appears from the outside. It consists of three floors, not including storage space. The basement contains a laminar flow hood and other equipment to make sterile ophthalmic solutions, which the pharmacy sells to smaller pharmacies. The main floor is where all OTC products and prescription medications are stored and where interactions with patients occur. Instead of the standard white shelves we have in the US, this pharmacy contains beautiful dark wooden cabinets, drawers, and counters. The second floor of the pharmacy has a break room for employees, two compounding rooms, a locker room, and offices.

There are so many differences between pharmacies in the US and pharmacies here. For one, Czech pharmacies do not count pills because everything is prepackaged from the manufacturer. Pharmacies here are primarily compounding pharmacies. Secondly, controlled drugs are rarely dealt with in community pharmacies because they are mainly provided in hospitals. Thirdly, OTC products are not available for patients to peruse because they are kept behind the counter. The patient must state what he or she needs and is then handed the product to purchase. These are just a few of the differences I have seen thus far.

I have been doing a lot of walking through Brno, getting to know my way around the city while visiting historical landmarks and places of interest such as the Cabbage Market, a farmer's market that has been here since the 13th century.

Brno's namesti Sovbody, or Sovbody Square, is filled with people walking the cobble-stoned streets with an ice cream cone in hand (ice cream is zmrzlina in czech...check out those consonants). The architecture is old and intricate and the city is filled with history like the Augustinian Monastery, where Gregor Mendel formulated his theory of genetics.

Cau (pronounced chau)!

Somewhere between tech and pharmacist...

This summer I am continuing my internship at Sinai Grace Hospital part of the Detroit Medical Center. For those who don't know I would say it's located in inner city Detroit. It's not a huge hospital but because it is mid sized there are opportunities to work in different areas that are separate in big hospitals and non existent in smaller hospitals. We have our own technicians for the neonatal intensive care unit, the operating room, narcotics as well as the Emergency Department. We also have the regular IV room and delivery (which Margo says she likes, but I do not).

On the weekends I usually work in the OR and that is probably my favorite area. There is a satellite pharmacy up there and while there is a lot of running around you move at your own pace and it's a different experience than the other areas. I also like the NICU mostly because it's similar to the OR and sometimes it's really nice to see that the babies are progressing and it's nice to see them with their parents or siblings occasionally. Basically in the OR and NICU, it's more visible that you are in your own little way helping people.

Since I've been trained in all the areas, right now there is not a lot to learn. Right now I am basically functioning as a technician doing what they will do but I am hoping to get shadowing and project experience later in the summer. Basically I don't have too much to share right now but hopefully I continue my learning experience and have more to post later this summer!

Leukotriene Modifiers & Zetia?

Earlier this week, I was attending one of the Clinical Review Committee (CRC) meetings and 2 main topics were of discussion: (1) antibiotics- therapeutics rankings within the different antibiotic classes on Prime's formulary and (2) criteria for the Zetia utilization management program, aka criteria patients must meet in order to receive coverage from their insurance.

Up to this point in my internship, I haven't been called out among a group of pharmacists to answer a question. So the meeting goes along and we started discussing clindamycin. It flashed through my head how I did a limited review on clindamycin 2 1/2 weeks ago. (Limited review involves researching the literature to see if there's any updates on therapy regarding a medication within the past year). At that time, my preceptor hadn't told me that I would be expected to talk about it at a future meeting....until the CRC meeting this past week....on the spot during the meeting. I didn't see it coming (I probably should have), but yeah, my preceptor turned the meeting over to me to discuss updates on clindamycin. The last time I had looked at my work was 2 1/2 weeks ago...needless to say I wasn't 100% prepared so that was kind of embarrassing.

However, I totally redeemed myself later in the meeting. We were going over the utilization management program of Zetia and I identified a HUGE mistake in the document. I spoke up and said, "On page 4, what does leukotriene modifiers have to do with Zetia?" And the pharmacist I directed my question to goes, "It does not have anything to do with it..." This document was being reviewed by 13 pharmacists, and me, the intern, found this mistake! All the pharmacists in the room were laughing how it was me out of all them that identified the error.

(In case you don't know, Zetia is a medication for high cholesterol and leukotriene modifiers are involved in treatment of allergies). It turns out the pharmacist was also working on criteria for leukotriene modifiers so that's why it was accidentally in the Zetia criteria.

But yeah, I will be more prepared from now on. For instance, I created the monograph for Vimovo (combination esomeprazole and naproxen product) and people from AstraZeneca will be visiting Prime to talk about their product. I will be prepared for that presentation since I will be the "expert."

Oh yeah, that changed too...

When starting my second year as an intern at the University of Michigan inpatient pharmacies I figured everything would come back quickly and I wouldn't have any problems. Well I remembered how to do everything, but the old way. The phrase "Oh yeah, that changed," has been a common one since starting back.


At the hospital I work in the inpatient satellite pharmacies as a technician with benefits. The benefits being once weekly intern meetings where I get to interact with my supervisors and learn more about the hospital. My work includes making IVs and filling unit dose orders to be sent out to each of the nursing units every hour on the hour. This was the same work that I did all last summer except now there are some new procedures to get used to. For example, UMHS changed their narcotic protocol so that we have a better idea of where all of our narcotics go and who has them in their possession each step of way. This isn't very difficult but takes time to get used to. The delivery is my favorite part because the hospital is so large it takes 15 minutes sometimes to complete a run so it's like killing two birds with one stone because I get to exercise while working.


Overall, the position has not been too exciting thus far. Without the H1N1 patients, things have been a little slow. I suppose this is good so I have the time to get use to the changes made while I was at school. Soon I will be shadowing some pharmacists and starting on some projects. Once those come up I'll keep you updated on the fun facts I learn.

My First Three Weeks: A Recap

I spent a few days in my hometown after finishing exams, then packed up the car and headed down to our nation's capital to start my second summer with Walgreens in the DC area. Walgreens is relatively new to the DC/Northern VA/MD area, so they have lots of new stores opening in the district. They have seven pharmacies opening in the next two months alone! So it's not surprising that my first week of work entailed stocking the shelves and vacuuming the floors of one of these brand new pharmacies. The store's pharmacy manager, a technician and I stocked the pharmacy and whipped it into opening shape in just two days, leaving me three free days.

I spent those days preparing for another big move as my fiancé and I purchased our first new home in an up and coming area in southeast DC. After that, free time was spent enjoying sports around town. We had a kickball game by the Washington Monument and a Volleyball game in the shade of the Lincoln Memorial.

Week two and three at Walgreens have been a little slow prescription-wise. We've averaged about seven scripts a day. That has left plenty of time for counseling patients and special projects. I spent a few afternoons running a blood pressure screening table. I enjoyed having an opportunity to interact with patients and practice taking BPs.

My adventures at Walgreens are coming to an end for the summer. In a last minute turn of events, I will be changing jobs. Wendy Perry, a UofM COP alumnus helped me secure an intern position at the hospital she works at, Washington Hospital Center. The details of the position have not been ironed out yet, but I am sure it will be a great learning experience.