After much anticipation, the day was finally here! I was equal parts nervous and excited–nervous because I wasn’t sure what to expect and I’d heard stories about how intense APPEs can get, but also excited because I love the idea of ambulatory care and have been talking about potentially pursuing it after graduation.
Before I go any further, let me define “ambulatory care”. It does not have anything to do with ambulances, contrary to what freshman me thought. It’s basically a fancy term for outpatient care. My rotation was at a primary care clinic called Rocking Horse Community Health Center that has providers who care for both pediatrics and adults in a wide range of specialties.
I know a doctor’s office isn’t the first place people think of a pharmacist working, but the set-up makes a lot of sense and gives everyone the opportunity to use their expertise. The doctors and pharmacists have what’s called a “collaborative practice agreement” that’s basically a protocol that describes what the pharmacists can do under the doctors’ name (this is necessary because pharmacists are not considered providers in Ohio, but that’s another discussion). The current agreement includes four indications that the pharmacists can treat: diabetes, hypertension, dislipidemia, and warfarin therapy. As long as we stick within those indications and practice evidence-based medicine according to the guidelines, we had the freedom to add, remove, or change medications for our patients. To be clear, the pharmacists do not diagnose. That’s not where our expertise lies. The physicians handle that and, if a patient’s diabetes remains uncontrolled, he can be referred to the pharmacists who take over managing his diabetes therapy.
A Typical Day
I got to the clinic at 8:30 every morning. Currently the pharmacists see patients in the afternoons Monday through Thursday and on Wednesday mornings. That’s probably going to change soon with their first resident starting but while I was there, I had most mornings to look at patient charts to prepare for the day’s appointments and work on projects. Most of our appointments were either diabetes or INR (for warfarin therapy) so I also focused on studying those guidelines and medications.
I had the opportunity to meet so many people throughout the month and hear about successes from some and encourage others that it is possible for them to achieve their goals. I absolutely loved getting to sit down with a patient one-on-one and ask them, “What do you want to do? What are your goals?” The whole philosophy of the pharmacists is that our grandest plan means nothing if the patient doesn’t buy into it. So the care is patient-centered. When a patient gave me a hard no on giving up his chewing tobacco, I didn’t press. Instead, we kept brainstorming and found something he was willing to change to improve his health and diabetes control.
The other piece of that philosophy that I loved was the chance to let patients have input on their medications. What?! With diabetes medications, there are so many different options and, while not every one is a good fit for every patient, there are probably a couple of good choices for each patient. That meant I got to sit down with a patient and tell him I had two options and I was going to leave it up to him. I explained the pros and cons and explained why I thought one would be a better option but, because that one was an injection and the other was a tablet, I wanted to leave it up to him. That was such an empowering experience for both of us–I got to use my full span of knowledge about diabetes and he got to have a say in his care!
As I neared my final day, I couldn’t believe the month was already over. Unexpectedly, it never became routine or boring. How could it when you’re always playing detective? You could be figuring out why someone’s INR is crazy out of range (could be smoking, pickles, kiwi, or a new medication) or why their A1c suddenly spiked (could be the chocolate milk they started drinking every day…) or how to have an open conversation with the patient with a double-digit A1c about how the cinnamon supplement isn’t doing the trick.
All in all, I had a great experience. I know direct patient care isn’t everyone’s cup of tea, but I definitely love it. I may not be making changes for the masses, but I could leave for the day having had five solid appointments where I made a positive change in each life and that’s a big win in my book!
Advice For The Month
Make a list of all of the big topics covered in your NAPLEX prep book of choice and match each of those topics to at least one rotation based on type. For example, this month I did anticoagulation, diabetes, hypertension, and dislipidemia. Commit to reading through those sections during the month. This had two purposes: it helped me prep for projects and patient case discussions and now I won’t be seeing those chapters for the first time when I sit down to study in 2019.