The clinical teaching unit (CTU) really is an ideal learning environment for medical residents, students and in this case a pharmacy resident! CTU was fast paced learning environment. With the help of my preceptors I was able to adapt and transition into a more independent practice as expected during my final rotation in the practice residency. During this rotation it felt like each of my experiences in the residency had led up to this and each day I felt more prepared to contribute and to help optimize patient care. Although the learning will continue throughout my career this experience in CTU helped to build my confidence in independent practice. I learned when to reach out to colleagues (and in this case my preceptor) and when I felt I had enough information and knowledge to make a recommendation to the team. The volume and turn over challenged me to refine my process and each day was an opportunity to improve. I feel that this rotation enhanced my ability to contribute meaningfully to direct patient care as part of an interdisciplinary team.
This is the final chapter of this journey, thank you for accompanying me along the way. I do not yet know what the future has in store. I do know one thing for sure: I am ready.
Beginning my adult ICU rotation, I have outlined the following goals and objectives that I have identified for the next 4 weeks:
1) Goal: Demonstrate necessary skill to provide direct patient care
a) Consistently, identify, justify and prioritize patient-
specific drug therapy problems.
b) Complete patient work up in 2 hrs including interview and
resolution of top DTP.
c) Increase efficiency of care through increasing patient care
These are quite fundamental and areas where I will continue to strive to improve to increase my proficiency in providing effective, timely and safe patient care and recommendations.
Specific to ICU, my learning objectives are to:
1) Understand the different types of shock and various shock treatments depending on etiology.
2) Improve ability in interpreting ABGs.
3) Electrolyte replacement, including magnesium and phosphate, to achieve normal
As part of my cardiovascular rotation, I prepared an inservice for the nurses in the out-patient anticoagulant clinic outlining the treatment of acute VTE and extended therapy options. This was in line with one of my rotation goals to provide inter-professional teaching. The team in the anticoagulation clinic is extremely knowledgable and I wanted to demystify any lingering questions. In many cases, these questions revolved around patient inquiries regarding the duration of therapy and the necessity of warfarin bridging (5days total warfarin treatment and 2 consecutive INRs within therapeutic range). The use of fondaparinux in heparin induced thrombocytopenia (HIT) was another hot interest of discussion and I had to exercise caution when explaining how it was the synthetic pentasaccharide sequence of heparin and safer to use in instances of HIT…I have learned that unnecessary jargon is the fastest way to loose an audience especially when interacting with a different health care professional team with a different knowledge base. This inservice gave me a better appreciation for the knowledge relevant to nurses and allowed me to tailor the presentation to the nursing staff on the cardiovascular intensive care unit (CCU).
Unfractionated heparin and some of the IV administered anticoagulants were not agents employed in the outpatient anticoagulant clinic however these were used in various contexts in the CCU setting. These were not addressed in this presentation as it focused on VTE treatment in the out-patient anticoagulant however this presented a learning opportunity which will likely be important in my ICU rotation.
Below are my prepared table for VTE treatment as well as a simplified presentation which allowed me to work through each drug and drug target in hopes the the coagulation cascade would appear less overwhelming.
Acute Treatment of VTE_ Anticoagulant Clinic Therapy Table in the Outpatient ATC_ Clinic Nursing Inservice
Clotting Cascade Supplemental to Anticoagulant Nursing Inservice
One of aspect that I did touch on during the nursing in-services was a little off topic but an issue that I personally feel strongly about. Each of us is responsible for medication safety and I believe the nursing places a key role in preventing medication errors and so more eduction can never hurt. Currently there is a debate between the nomenclature between NOACs (new oral anticoagulants) and DOACs (direct oral anticoagulants) because they are not “new” any more blah, blah…to me these arguments are semantic in nature and I honestly should care more about this, but I don’t (sorry to all my preceptors and mentors that feel differently). To me it gained importance when it became a matter of patient safety. Read the following physician note, quickly jotted down with the best of intentions:
“Stop warfarin, NOAC”
What does this say to you when you read it? 9/10 healthcare practitioners read the same thing. “Stop warfarin, no ac (anticoagulation)” rather that the intended “stop warfarin and begin a NOAC.” I was not directly involved in this patient’s care however I was sad to learn he died shortly in hospital from an embolic stroke. For this reason, I urge others to refer to this class of medications as DOACs if the abbreviation must be made.
Following 2 project weeks that had me at several different locations on the Island, it is now the beginning of my Cardiology rotation. I anticipate it will be challenging and a steep learning curve but one I feel ready for. After meeting with my preceptors, I have developed some specific goals and objectives for this rotation:
Goal 1: To develop and apply knowledge and clinical skills specific to cardiology.
- To develop an understanding of the pathophysiology, risk factors, pharmacological and non-pharmacological treatment of VTE, Afib and valvular heart disease through therapeutic discussions with my preceptor.
- To improve my patient presentation approach to preceptor (ID, HPI, medications and past medical history, etc).
Goal 2: To demonstrate the skills necessary to provide effective direct patient care.
- To develop a system for identifying patients most likely to benefit from a comprehensive pharmaceutical assessment through practice and discussion with my preceptor.
- To clearly identify and prioritize DTPs.
- To practice presenting the treatment alternatives and justifying my recommendations.
- To refine monitoring parameters to include time to expected change, patient specific thresholds to changes in therapy (in terms of efficacy and safety) and frequency of monitoring.
- To gather relevant information in a consistent, systematic fashion using a condensed data collection sheet (20mins).
- To improve my interpretation of diagnostics and imaging by creating a list of unfamiliar terms.
Goal 3: To develop and integrate knowledge to provide direct patient care and medication- and practice-related education.
- To provide pharmaceutical education to patients and non-pharmacy health care professionals through formal teaching sessions to as per rotation schedule.
- To provide pharmaceutical education to patients health care professionals through a nursing inservice.
This is slightly more structured than previous rotations however I believe these are quite attainable during my DPC rotation #4 with two great preceptors to coach, model and facilitate.
Project Management 101: So I may not have mentioned this but my residency research project is going to require digging through hundreds of paper charts to locate BPMHs for data collection. In order to make this feasible, I interviewed several pharmacy students with the help of the UBC TMP-SMX mentorship program. Each of the students was exceptional however I did need to make a decision. Then, on Thursday night, while working on additional residency requirements, the selected student informed me she would be unavailable to assist do to circumstances out of her control. The data collection processes was to begin the following Monday. Okay Gina, don’t panic, you can handle this it is all part of being a project manager (I am a bit reluctant to admit that this thought is madness to pre-residency Gina). So I promptly contacted the other students and was able to quickly connect with a highly motivated 4th year pharmacy student who was excited to start Monday morning. The situation worked out wonderfully and even better, it gave me a tangible experience of the challenges faced when managing a project where other people are involved and things do not always go as planned. It also provided me with some clear evidence that I have evolved throughout the residency program, as I was able to adapt and adjust to this change in a more systematic and productive fashion that I would have anticipated.
The Internal Medicine rotation allowed me several opportunities to formally and thoroughly present patients to my preceptor in a head-to-toe format. Improving my DTP identification and presentation skills were identified as goals for this rotation and these exercises were a fundamental portion in striving towards this. These were important practice opportunities and my goal moving forward in my upcoming ID and Antimicrobial Stewardship rotation will be to concisely and consistently present patients to my preceptor including DTPs and alternatives (within 20mins).
With the process of patient assessment and work-up coming into place, I would like to focus on maintaining a greater number of patients in my care. My goal will be 4 new patients in the first week (keeping in mind the short week with my BC Case-Wide Presentation on the Friday) and 7-10 new patients in week 2. During my second acute care rotation, I would like to maintain at least 15 patients at any given time. My goal for this rotation is to speed up my time to patient work up while continuing to follow my current patient assessment form. I would like to shorten this form where possible and my goal is to decrease my current patient work-up form by one half by the end of my up coming ID and Antimicrobial Stewardship rotation. I would love your suggestions regarding these goals or tips on how you set and achieved your own residency goals…seriously, the floor is open.
I have made some progress in my patient work-up skills and I would like to focus on maintaining the quality of the process while decreasing the time it takes. One thing I learned about myself in the past month is my own need to maintain focus and mental discipline when so many potential questions exist. Someone once said, “If I had an hour to solve a problem and my life depended on it, I would spend the first 55 minutes determining the proper questions to ask.” I think that may be a simple but key statement when faced with seemingly endless information. Focus on the right questions to solve the challenge at hand. This is true in information gathering, patient interviewing and DTP identification and alternatives…Lucky for me a duo called Hepler and Strand may have been thinking the same thing!
Reflecting back on a fabulous 4 weeks of clinical orientation, I hardly believe how far I have come! During this rotation I have begun to develop many foundational skills allowing me to build a ‘patient database’. These include navigating through charts, systematically collecting lab data and relevant information from resources I previously did not realize were available. I had the opportunity to conduct patient interviews, to practice a review of systems (ROS) and write targeted SOAP notes. I have to admit that filtering all of the available information and completing a patient work-up in a 2-hour time frame remains a challenge for me but I am optimistic that this will improve over the course of my residency year.
Clinical orientation allowed me to identify targeted areas for improvement. I am hopeful that practice during my upcoming ambulatory rotation will sharpen my DTP identification skills and improve my ability to rationalize specific recommendations.