Shadowing an Internal Med resident

Royal Oak Beaumont pharmacy has PGY-1 and PGY-2 programs available, and I had the fortune to see a "day-in-the-life" of PGY-1 resident on their Internal Medicine rotation. 

The day started at 8:00am with us looking up patient profiles for about 10 patients, varying from those in the intensive care unit to patients awaiting discharge. Since the resident had been tracking the patients for a few days, she reviewed each profile for medication changes and lab results that were previously pending. We were able to cover a few medication profiles of the patients in depth, discussing why antibiotic changes were necessary, or what pertinent lab results would warrant a change in therapy. 

When it was time for rounds, the resident paged the resident doctors and attending physician. Rounds started with the resident doctors presenting the case to the attending physician, and with the pharmacy resident offering suggestions to change medications. With each patient visit, the pharmacy resident was able to interact with the patient directly, counseling them on proper medication use (patient questions included what the difference between rescue and maintenance inhalers, why a whole course of medication was necessary to complete, what side effects were normal to experience, and how to time taking medications in relation to food). Once a patient was counseled, the team moved to the next patient, discussing the following case while walking to the floor. This experience made me realize that it is essential to have a comprehensive work up readily available on hand for each patient, since it can often be difficult to remember all the details when on the floors.

After rounding, the pharmacy resident made a plan of action for the following day, noting which patients required closer monitoring. The rest of the day was devoted to working other residency tasks, such as making handouts for the physicians on medication dosing, creating presentations for the pharmacy department, and manuscript editing. 

Residents are certainly busy with a variety of activities to complete before they are done, but according the resident I shadowed, the experience of a residency is invaluable and truly rewarding!

In the End

Seeing that I was working in retail for the first time, and it was an internship, I took away some thoughts on retail pharmacy. The first was customer service. I learned you always have to be on your game in front of people. There is this expectation of always having a smile, quick in acknowledging the person, and speaking in simple terms. Even though pharmacy is a complex and time consuming topic, it is placed in a setting with people who have busy lives and simple medical knowledge. One time, a customer asked me about the difference between lisinopril and Dyazide. I started out describing the molecular differences then I realized this explanation is not helping her. I summed it up as they targeted two different sites in the body.

Secondly, I became experienced at being accurate and multiple tasking. At times in the pharmacy it is crazy: phones going off, customers lining up, and running out of drugs. One has to be quick, but more importantly accurate in times of stress. When counting Vicodin, we have to double count because it is a control medication. I want to quickly and accurately count the Vicodin then move onto my next task like serving the drive thru. If I am not accurate, the customer will come back saying that we shorted him. This causes more time to deal with the situation and takes away from filling today’s prescriptions. I learned to do things right the first time because it will save me time later if issues arise.

Retail taught me to be fast and to prioritize. One area I haven’t mastered just yet is drop off. I know how to work drop off but I do not have the speed for it at peak hours. One needs to prioritize when prescriptions are due then start typing them right away. And it is just not the prescriptions from walk-ins. It is ones from the drive thru, computer system, fax, and phone calls that add to the volume at drop off. One minute I am doing fine with my prescription level then five pop up on the computer, a person walks in with two and my pharmacist gives me three from phone calls. I am quick at typing but it still takes a thorough knowledge of the inventory and solving insurance problems not to be slowed down and keep up with the volume.

I realized learning and re-learning is the key to being on top of the game. Since pharmaceutics are always evolving and adding new drugs to the market, the pharmacy has to keep up with the times. Fast movers change from time to time. Brands become generics. One can get use to certain drugs and know everything about them until a customer asks you about a new drug. If I want to be great at my job, I have to look to improve myself and test my knowledge. It is easy to get in a comfort zone and think you are doing a good job when actually you can do better.

My final thought is the people I worked with this summer. They were the number one reason I enjoyed my time in the pharmacy. For being friendly, caring, and helpful, it was easy to enjoy the good and get through the crazy times in the busy retail world. I had several co-workers my age to talk about college stuff and enjoy going to the bar after a long day at work. When I leave this week for school, I won’t miss the customers, but you guys!

UMHS Patient Triage

Hello readers!

I am writing this last summer post about my experience as the pharmacy employee responsible for patient triage at the University of Michigan hospital. To start, working patient triage entails serving in one of the hospital’s inpatient unit pharmacies. The position involves completing nurse requests that originate from the pharmacy window, answering incoming phone calls into the pharmacy, responding to requests made through the University of Michigan’s medical record software called CareLink, and disseminating patient medication orders to other staff working in the unit pharmacy. These aforementioned responsibilities require good communication, team building, and leadership skills. First, fulfilling requests involves beginning, continuing, or refilling a medication in a patient’s CareLink drug regiment. This means printing out patient drug labels for compounding technicians to fill and pharmacists to check. Second, phone calls are directed to the appropriate hospital department, transferred to an available pharmacist, or are answered and provided with accurate clinical knowledge within the scope of a pharmacy technician’s role. Third, hospital staff requests through CareLink are completed in much of the same manner as phone calls are handled. Fourth, dissemination of information among unit pharmacy staff is based upon the fact that drugs are to be administered at different time periods. Since the unit pharmacy staff want to provide patients and hospital staff with medications that are new and have long hang-by and expiration timing, the technicians will usually wait until an hour before the medication is due to start compounding it or will wait for a nurse phone call to confirm if the drug is still actually needed if the medication is expensive. It is up to the employee working patient triage to accurately relay this kind of information. As always, patient triage also requires workers to pneumatically tube finished medications directly to the patient’s unit location if they are required STAT (Sooner Than Already There)!

To conclude, I want to say it has been very fun this summer. I hope that my blogs have provided you with insight on how the University of Michigan unit pharmacies inner-workings operate and the processes involved in the central pharmacy department. I hope you have enjoyed reading my blog as much as I have enjoyed writing it. I wish the rest of your summer is enjoyable and that you have success in all of your future pharmacy endeavors!

-Adam Loyson

“Watch out…here comes the term-auditor”

Being a pharmacy intern at Blue Cross has many great perks. Not only do I get to learn the meat and potato of my own team (Pharmacy Networking/Contracting), everyone always seems to be presenting me their best offers.

“Best offers” right now would surely have to be the different experiences that I’m seeing and learning everyday in the Managed Care world. And for the first time, I got to go on an auditing trip—a side of pharmacy business that I never thought I would be part of.

The way Blue Cross carries out its auditing process is different than most other insurance companies. While most insurance companies focus mainly on the expensive drugs (such as specialty drugs; ie cancer drugs) during their auditing process, Blue Cross is out to ensure that ALL drugs are billed the correct way.

Before going out to the “chosen pharmacy,” the auditor would randomly select a set number of prescriptions that have been billed to Blue Cross within the last year. Upon arriving at the pharmacy, the auditor would request few more random prescriptions to be pulled. This way, the process consists of both prepared and surprising elements that will ensure the fairness of the auditing process.

From there, the auditor will go through the hundreds of prescriptions that have been pulled, and compared them with the billing records one by one. If ANYTHING is different from the billing records—patient name, medication, quantity, missing signatures, etc, the pharmacy is subjected to a fine OR an educational lesson (aka a simple warning). If certain violations are found, the financial penalty will be EXTRAPOLATED for the entire year worth of claims filed. Such extrapolation process can be good and bad—depending how you look at it.

The actual pharmacy visit was more civil than I had imagined. We were handed the requested scripts right off the bat and were left alone to work on them for the rest of the day. Perhaps most people figured that a happy auditor can only means a happy turnout, so they all left us be. I invite whoever has been through a pharmacy auditing process to comment on this entry and let me know what it was like to be on the pharmacy side.

Overall, the trip was an experience that I will hold dearly to my heart as I progress through my career. Whichever side I end up being working for, it’s always good to know the proper rules so there’s nothing to worry about. In addition, this experience continues to amaze me just how many opportunities are out there for pharmacists.

Rx on TV

Hey all,

Even though last week was my last day in the office, I want to post one last time and provide some closure on the internship. In my previous post, I promised a session on TV advertisements, and (because I hate breaking promises) you will find it somewhere in the blog post.

PRESCRIPTION DRUG TELEVISION ADVERTISEMENTS
Have you ever turned on the telly and accidentally ended up on Good Morning America or CNN (HA…“accidentally”)? If so, you may have noticed a commercial featuring a woman doing yoga and the drug, HUMIRA® [adalimumab].

Yup, I spent a good part of my internship discussing this commercial with the rheumatology team, and I will be available next week for autographs [/brag]. But seriously, the amount of work and compromise that goes into making one television commercial is mind-boggling. Not only that, but companies have to follow the FDA Drug Guidance on Consumer-Directed Broadcast Advertisements and the Draft Guidance on Presenting Risk Information in Prescription Drug and Medical Device Promotion.

I shall break those down into three easy payments*: Adequate Provision, Major Statement, and Other Nuggets. *Not all-inclusive of requirements

Adequate Provision
Along with the broadcast itself, the ad must make “adequate provision” for disseminating approved package labeling (read: drug information). There are no official right or wrong ways to ensure this provision, but companies typically (and should) provide the following four:

1. Toll-free number: provides drug information and an option to get labeling mailed to the patient
2. Referral to print material: “Please see our ad in blah blah magazine”
3. Referral to healthcare providers: “Ask your doctor or pharmacist for more information”
4. Website: "www.saynotodrugs.com"

For visual examples of the above, I randomly chose a Plavix television ad.

Toll-free number and referral to healthcare providers


Referral to Print Material


Website

Major Statement
As mentioned in my earlier posts, print advertisements include a printed Brief Summary of side effects, contraindications, and effectiveness. TV ads, on the other hand, present this information using what is known as a Major Statement—an audio or audio/visual alternative in layman’s terms to presenting risk information.

Example of Major Statement: “This drug is indicated for moderate to severe fractures of the clavicle. When taking this drug, you may experience side effects of nausea, vomiting, diarrhea, and loss of dignity. Don’t take this drug if you desire to play an integral role in society.”

Other Nuggets
The above two requirements cover a majority of the risk information, but there are other nuances that go into TV ads. I’ll just bullet them because they are easier to read.

• Superimposed text should be easy to read and contrast well with the background
• Superimposed text should be onscreen long enough to read and understand
• Background music should be comparable in volume and should not be distracting
• Avoid distracting graphics: busy scenes, frequent cuts, vivid visuals, moving camera angles

That’s about the gist of the TV ad requirements. As always, there are more regulations to cover, but I just wanted to go over the main topics. If you’re like me, watching these ads on TV will never be the same.

THE ABBOTT INTERNSHIP
This internship exceeded all expectations. I urge everyone thinking about a future in the pharmaceutical industry to apply and check it out. Even if you’re not interested in the industry, apply and check it out—you may be pleasantly surprised. There are a lot more pharmacists in the industry than you think, especially in medical information, medical review, and regulatory affairs. In these departments, you are surrounded by very intelligent people (shout out to my managers, fellow interns, and the regulatory affairs department) who put their medical background to use on a daily basis to, ultimately, ensure patient safety. Five stars: *****.

Eric Zhao

PS Be sure to check out my new posts at: On Rotation: Life as a Fourth-Year University of Michigan PharmD Student.

I am currently was a summer intern in the Regulatory Affairs Department, and the opinions and positions expressed are my own and don’t necessarily reflect those of Abbott Laboratories.

Shots, Shots, Shots!

One of the new and cool skills pharmacist can perform now is immunizations. Every state except one allows in some form for pharmacists to immunize their community. Michigan allows trained and certified pharmacists to give vaccine shots just like physicians and nurses. I trained this week to be certified to give immunizations. It is not required for pharmacists to be certified immunizers, but it is extra skill I have wherever I end up in the medical field. I had a week to read 100 pages packed with information on vaccines and the basics for immunization, take a pre-test, attend a hour long conference call, and six hours of classroom training. Add in work and chores around the house, I kept pretty busy.

Bright and early on a Saturday morning I had to travel to Bloomfield Township for my immunization class. I wasn’t sure exactly where I was going and ended up a couple minutes late because Bloomfield Township doesn’t know how to logically order street address but that it is another story. It didn’t really matter because the teacher was still trying to figure out how to connect his computer to the overhead screen. Once he got it to work, we spent the next five and a half hours on the different immunizations we could perform. It is not just the influenza shot. He taught us about pneumococcal, hepatitis A and B, measles, mumps, and rubella, diphtheria, tetanus, pertussis, meningococcal, polio, and the human papilloma virus.

There is a lot of information to keep track of in terms of ages, contradictions, and how to administer the shot. It wasn’t until the last half an hour that we had to poke our classmates with two intramuscular (I.M.) and one subcutaneous (S.Q.) shot filled with saline solution. There were several pharmacists in my class learning to be immunizers for the first time too. One lady was so nervous giving her first shot that her hand was shaking though she was perfectly fine after doing the first one. I was a little nervous myself but performed well when it was my turn. I enjoy doing intramuscular shots more than subcutaneous because I.M. shots are at ninety degree angles while S.Q. shots are angled at forty-five degrees.

The biggest concern about giving shots is not how to poke the person or drawing up the solution but getting a needle stick once one removes the syringe from the skin. Many syringes today have safety devices where the needle retracts once the shot is given. Now these devices only work 50% of the times meaning technique and positioning of the immunizer needs to be appropriate. One’s legs needs to be on the opposite side of the body from the hand that has the syringe, and the sharps container needs to be next to the immunizer. If done correctly, it will be one fluid motion of poking the skin, injecting the vaccine, activating the safety device, removing the syringe, and placing the syringe into the sharps container. It can be all done in five seconds. At the moment, I am not giving out shots at my pharmacy, but I will have the skill if called upon in the future.

*Special Edition Post* - Pharmacy Advocacy

Greetings! I would like to tell you about my experience advancing the pharmacy profession at the nation's capital in Washington D.C.! This past weekend, I chose to attend a conference held by the American Pharmacists Association-Academy of Student Pharmacists (APhA-ASP) that ended up being a blast. During the conference, I was presented with the opportunity to visit Capital Hill and talk with multiple senators and state representatives about the current pressing issues facing student pharmacists and the pharmacy profession. The first topic that I brought up in discussion was the development of Medication Therapy Management (MTM) programs and how the inclusion of pharmacists could make a great impact by providing MTM in transitional/integrated care models (Bill H.R.891/S.274). The second topic that I discussed was the Student Pharmacist Loan Repayment Plan under the National Health Service Corps. While the NHSC performs admirable work in under-served areas of our nation, the pharmacy profession is currently not listed as one of the professions qualifying for school loan repayment. In conversation, I discussed that pharmacists serve an integral role in interdisciplinary health care teams with physicians and are the medication experts in handling patient's drug regimens. Placing a greater emphasis on the pharmacy profession could possibly save the nation $177 billion in medication errors each year (Bill S.48). My interactions with all congressmen were very pleasant with many of them becoming interested in supporting both bills or possibly co-sponsoring!
The remaining time in DC was spent at APhA-ASP's Summer Leadership Institute (SLI) where I had the great opportunity of developing my leadership skills in professional-speaker workshops, discussing pharmacy advocacy with student pharmacists from other schools, and touring the capital to see all of the national monuments. This is not even mentioning the great opportunity of networking that I had with the student pharmacists present from all 50 states! APhA-ASP's SLI conference is only one of the great things that I have been able to take apart of while being a member of the organization as a student. With additional conferences this year in Indianapolis, IN and New Orleans, LA; local chapter committees to choose from and perform patient care activities; and being able to hang out with my pharmacy friends at social events; there is almost certainly something in this organization that could be of interest to you! Feel free to check out UofM APhA-ASP's website at http://pharmacy.campusgroups.com/apha-asp/home/. I look forward seeing you at their meetings next year!