May: Ambulatory Care

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.

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366 days to PharmD

Another school year has ended and, with it, the inevitable slew of well-meaning “aren’t you graduating?” questions is sure to follow.  No, my dear friends, I am not.  Yes, I have been in school for six years but I am (still) not finished.  I am close, though!  Here’s a breakdown of what my pharmacy journey has looked like thus far and what is in store for me:

UNDERGRAD: fall 2012 – spring 2015

These years included gen chem, organic chem, cell biology, and anatomy & physiology.  Those classes ruled my life, stretched me, and taught me how to keep going after failing.  They were hard and the source of many tears and I wouldn’t trade them for anything.  Freshman year I thought there was no way I’d make it through pharmacy school with how much I was struggling with gen chem.  I wanted to switch majors.  I started making plans and finding out what paperwork I’d need to fill out.  That’s when I told my adviser what I was thinking and he encouraged me to finish out the year then do some shadowing before I made any changes.  He had me talk to another faculty member who connected me with a pharmacist at Nationwide Children’s hospital and that’s where it finally clicked for me.  She let me spend two days there shadowing a bunch of pharmacists in all kinds of jobs.  I finally saw and began to understand what a pharmacist actually is.  I was so excited to continue pursuing this profession!

That fall I got a job as a pharmacy technician which was one of the best decisions I’ve ever made.  Going in, I had no clue what the job actually was.  All I knew was that I needed to experience pharmacy for myself.  And I am so glad I did!

GRAD SCHOOL: fall 2015 – spring 2019

Year 1 (’15-’16):  The idea is to kind of get your feet wet this year.  To be exposed to a little bit of everything with the caveat that, over the next two years, we’ll go into more detail.  The reality is that you’re drinking from a firehose that’s somehow in another language (?? my metaphor really broke down there).  Everything is new, drug names are weird and hard to say, and what do you mean I have to do a 3 year research project??  It’s intense but I’m proof it’s possible.

Year 2 (’16-’17):  I started to get the hang of things and really enjoyed diving into different topics, learning all about disease states and how to treat them (spoiler alter: a good pharmacist will not say drugs are always the answer).  While this year was still intense, I felt like I finally had a handle on things.  Mental breakdowns were quite possibly at an all-time low (at least during first semester) and I managed to also train for and run my first marathon!

Year 3 (’17-’18):  The first semester was spent finishing off our exploration of different topics.  Hello neuropsych and oncology, goodbye sanity and social life.  I also somehow found my way into 3 leadership positions this year (compared to 1 each year during the previous two years).  Oh, and I ran my second marathon after promising myself I wouldn’t attempt marathon training during school a second time.  *facepalm*  Second semester was different.  Our major class was Capstone, a class devoted to reviewing everything we’ve learned thus far.  Yeah, the amount of material you think we’re covering?  Go ahead and triple it.  We also wrapped up that research project I mentioned, praying like we never have before that the statistics program will spit out numbers that mean all the work was worth something (then crying literal tears of joy when it does).

CU SOP Class of 2019

Class of 2019: the fun ones

Year 4 (’18-’19):  On May 1st, I left the classroom and headed out into the real world to learn how to apply everything we’ve learned to real patients.  Over the course of this year, I will complete 9 different 1-month-long rotations in various practice settings.  We had the opportunity to rank the sites in our region so, as faculty created our schedules, they could try to give us rotations we were hoping to experience.  When I ranked my sites, I knew this would be my one chance to test out a bunch of different areas of pharmacy.  With that in mind, I made a schedule that was as varied as possible, with in-patient, out-patient, general, and specialized rotations.  I may not love every one of my rotations, but I won’t live with the regret of never trying it.  Here’s what my schedule looks like:

  • May: Ambulatory Care at Rocking Horse Community Health Center
  • June: Managed Care at CareSource
  • July: Community Pharmacy at Target
  • August: Psychiatric Pharmacy at Haven Behavioral Hospital
  • September: off: celebrate my 25th birthday!
  • October: General Hospital at Atrium Medical Center
  • November: Neuro Critical Care at Miami Valley Hospital
  • December: off
  • January: Critical Care at Kettering Medical Center
  • February: off
  • March: Oncology Ambulatory Care at Kettering Medical Center
  • April: Internal Medicine at Miami Valley Hospital
  • May: graduate and take the NAPLEX!

I’ll be writing reflections each month for school and I’m planning on using those to share my experiences at each site on here.  As I go, I’ll try to remember to come back here and link the corresponding post in the list above.  Fellow final-year pharmacy students, I’d love to hear about your rotations!  And pharmacy students looking ahead to future rotations, tell me what you’d like to know about rotations and I’ll include it in my posts!

Here’s to beginning the final chapter.  Let’s get that PharmD!

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why pharmacy part 1: get excited

Confession: when I chose to major in pharmacy I didn’t have a good reason for choosing it.  Sure, I had an answer for everyone who asked why I wanted to spend seven years taking some of the hardest science classes offered.  I told them that it fit with my talents in math and science and my goals for the future.  In reality, though, I picked pharmacy because I couldn’t find anything else that fit better.  It was my Plan B and I didn’t have a Plan A.  I didn’t even come up with it myself–a few other people suggested it and I agreed to look into it.

After I decided that pharmacy was going to be my declared major, I began telling people.  After receiving my rather lackluster answer to their “why did you pick pharmacy?”, their response was almost always, “Well, you’ll be making good money.”  Honestly, at that point, I didn’t care about the money.  I didn’t even realize how nice of a salary pharmacists can get.  I just knew I needed to pick something and that worked.  It was a pretty good Plan B.

As time went on and I worked through my freshman year, I grew unsure of my decision.  Is this really what I want to do?  I’m hating Gen Chem and everyone makes it seem like that’s a pretty important thing for pharmacy.  I considered switching my major–even had a meeting with an advisor in the education department about which classes would transfer over and how far I would be behind.  After a lot of stress I decided to stick it out through the end of the year and shadow some pharmacists.  I figured if I hated that, I could look at switching again.  I didn’t hate it.  I went to Nationwide Children’s Hospital and fell in love with the idea of pediatric pharmacy.  I got excited about my major for the first time.

Then, partway through last semester, I was talking with my friend about what we are going to do when we get out of college.  I told him I think I want to do pediatric pharmacy and maybe own my own pharmacy someday.  His response was a simple question: “And that makes you excited?”  It took me by surprise and I gave a halfhearted “yeah” as I began to think about his question.  In fact, it’s been running around in my head ever since.  Most people give me a skeptical look when I tell them I’m excited to be a pharmacist and in pharmacy school so I’m used to that but, for some reason, his question was different.

I won’t go into what the next several months contributed to my thought process because that’ll make this way too long.  I will say that there were a lot of different factors that went into it.  One of the critical factors is my job as a pharmacy technician.  I figure that, since I love this job, I should love my future job.  One other big factor is my classes.  I made it through the annoying introductory science classes and am in the ones that have something to do with pharmacy.  Turns out Gen Chem isn’t that important.  The fact that my favorite class this semester is Immunology is a confirmation that I’m on the right path.  As I said, a lot of other things have gone into this thought process but now I can confidently say, “Yes, it does make me excited to be a pharmacist.”  Now, when people ask me “why pharmacy?” I have a real answer to give them.

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