A little help

I have a small dilemma. At the end of the internship each intern is required to make a presentation to the directors, managers, residents and remaining interns. Mine is of course the last one...because you save the best for last. Unfortunately I have no idea which of my dozens of projects I should actually present on that will also engage the crowd. One of my favorite projects happen to be my simplest project in which I know I could bring it to life and have tons of fun with it. On the other hand it borders on un-professionalism, but should I really worry about that?
I have about 15 different projects that I am involved with out of those 15 none of them are actually completed. This is due to no fault of my own here a simple project can span into a year-long headache. I knew this before coming and accepted that things I started would most likely be finished by someone else and maybe within a year I will see the fruits of my labor. The biggest project that I will try to get updates on during the school year is the Creative Alternatives packaging. I found alternative packaging for this program through a product called DisPill. It's actually really innovative and all signs point to them moving forward with the packaging in the coming months. More than just finding it through a google search I had to work with our IT department to ensure that the programing would integrate with our current computer system. Discussing the operational impact of packaging change and the costs per patient associated with the new packaging. I also had the opportunity to work with producers of DisPill to change their software to benefit our target population. I have a problem presenting this as my final presentation as it only has application here at Johns Hopkins. I want to present something that no matter where their career takes them they can think back and remember the presentation. It looks as though I will have to search through my projects and find the one...

It's all about the people

I just wanted to spotlight some of the great people I have had the opportunity to work with as this will be the last week we are all together. This year there were 24 interns accepted into the Johns Hopkins Internship program and I am grateful for the opportunity to meet each and every one of them. I won't go through all of them but I did want to talk about a few people who have made my experience incredible.
The preceptors are the people that make it possible for us to have this program. My preceptor is Nathan Thompson the Director of Outpatient Pharmacy. Other notable preceptors include: Yvonne LeBlanc (Clinical Applications Manager), Jim DiPaula (Operations Manager), Bridgette Thomas (PharmIS Manager), Krista Decker (Quality & Safety Manager), Brendan Reichert (PharmIS Director), Brian Pinto (Drug Use and Policy Director), and Edina Avdic (Pharmacoeconomics Manager). I was able to spend at least one full day with each of these preceptors and want to thank them for their time. A lot of other people have acted as a reference and guide this summer and hopefully mentors as my career progress these people include; John Hopkins (that's his real name, no relation) and Jim Van Daniker who both serve as the business managers for the outpatient pharmacy and Dan Ashby (Director of Pharmacy) I have to send a special thanks to Luis Simbala who is not a pharmacist but taught me so much the summer about Microsoft programs that Bill Gates himself should write this guy a check.
The interns helped me keep my sanity and made me laugh every day. First up is Abbie Shallop who we all know since she goes to school with us. It was great to get to know Abbie more of the summer we had some great laughs together and I want to wish the best of luck on her marriage and hopes that she enjoys it before classes begin again. Then there is Rami Beiram who is like the big brother I always wanted. He is a third-year student at Harding University by way of Atlanta, Georgia, he and I share the same humor and make quite the comedic duo. Then there's Tamara Fawall, the little sister I never wanted. Actually she's great her and I have the same exact birthday so you can imagine what a female version of me is like to deal with. Tamara is also a third-year student at Rutger's University, I finally found my Jersey girl. Without the three of them I would not have enjoyed myself nearly as much and I will keep in contact with all of them as we go forward, Abbie has no choice since I'll sit right next to her in class but the other two I will bother them through other media. This Monday will be our last day together as Rami heads back to Atlanta before heading back to school at Harding University. I swear... I'm not going to cry...

You never know what they've been through...

Recently, my fellow interns and I went to a state-of-the-art simulation center on the Mayo medical campus. The facility was created to help doctors, nurses, and pharmacists practice real life situations in a controlled environment. There are rooms where surgeons can practice surgeries, nurses can practice suturing, and rooms like the one we used where individuals can work on patient counseling.

The exercise we participated in involved speaking with a “patient” who is actually an actor trained to portray certain personality characteristics. This exercise was similar to those done in many of our PCare courses and was a great way for me to improve on the patient counseling skills I have gained through the extensive amount of counseling I’ve done this summer, in addition to what I’ve already learned in school.

The prescriptions I had to counsel on during the simulation were ciprofloxacin and albuterol (thankfully, not too tough). My patient wasn’t as difficult as I expected. She was in a hurry because she was going on a cruise so I had to make sure to relay the important points of her medications in a timely manner to ensure both of us were satisfied with the amount of information shared and the time it took for this interaction to occur.

Although this was a simulation, I can attest to the fact that this is just one of many types of patients that come into the pharmacy every day. In the 8 weeks I’ve spent as an intern this summer, I’ve dealt with yelling patients, crying patients, and MANY who are in a hurry. Realizing that they are probably going through a difficult time and not to take anything personally has helped me deal with the most difficult of patients, although, it’s not all bad. In contrast to the difficult patients, I’ve had individuals who were extremely grateful that I took the time to explain their medications, potential interactions, and possible side effects. Many patients are unaware of the side effects with their medications and have developed symptoms that are actually due to a new medication. They are confused as to why they are experiencing these new symptoms and have a feeling of uneasiness surrounding this. Now when I counsel, I try to point out at least three side effects with each medication. This may seem like a lot but I feel like it’s better for them to know about it and then not get it versus not knowing and then wondering why they’re experiencing sun sensitivity, increased effects of caffeine, or tendonitis (all of which are effects associated with ciprofloxacin).

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"

Working in a pharmacy with no medications...

This summer I am interning at the Mayo Clinic in Rochester, MN. I am an outpatient pharmacy intern and will be rotating through six different outpatient pharmacies during the duration of my program. As a Minnesota native, I have grown up hearing about the Mayo Clinic practically every day but for some of you who aren’t as familiar with this hospital system, here are a few basic facts. The Mayo Clinic is the largest integrated medical center in the world and serves more than 350,000 patients per year. More specifically, the outpatient pharmacies see about 1,000 patients per day and process approximately 4,000 prescriptions daily.

Because of the huge volume of patients seen at the various outpatient pharmacies, the Mayo Clinic utilizes a separate medication filling center, allowing for two of its six outpatient pharmacies to focus their efforts on patient counseling and worry less about the actual counting of prescriptions because there isn’t actually any filling of medications at these two locations.

Let me explain a little bit more about how this process works. Basically, a patient brings a new or refill prescription to our pharmacy where a technician enters it into the computer system. While the prescription is being entered, the pharmacist counsels the patient on their medications and answers any questions they may have. All of the pharmacists I have worked with so far utilize the three question approach we learned in PCare (What did the doctor tell you this medication was for? How did the doctor tell you to take this medication? What side effects did the doctor tell you to expect with this medication?). After the prescription is entered into the computer, it is scanned, verified by a pharmacist, and sent off to the filling center. There, the prescription is filled, checked by a pharmacist, and sent back to our pharmacy through a tube system where the patient can pick it up roughly 30 minutes after dropping it off.

I was very surprised when I first learned that they did not have any medications in the pharmacy but so far the process seems to run very smoothly. It’s great to see the pharmacists spending the majority of their time counseling patients on their medications and less time counting pills and checking orders. It was also very encouraging to see some of the exact same patient counseling techniques we learned in PCare put into practice in the real world and how effective they can be when communicating with patients. Looks like we really will use some of the things we learn in school!