Reflecting on the two-week precepting skills rotation, I can see now how my previous DPC rotations had been preparing me for this. The process of providing direct instruction, modeling, coaching and facilitating as well as the art of recognizing the appropriate time for each have been demonstrated by my previous preceptors. Being on the other side, I could recall times were each of these methods was employed. I did my best to model this and gauge where my preceptee was at and to interpret her needs. Observing her progression was a rewarding process as she became more independent and curious when completing patient drug therapy assessments. As she became more independent, I was able to focus my attention on optimizing drug therapy for patients on the surgical ward and to practice balancing the two responsibilities. This is a valuable skill and the rotation increased my confidence as a clinical pharmacist as the two roles became easier to manage and in some ways complemented each other.
We were fortunate to be involved in the care of a patient with extreme shoulder pain, not yet diagnosed. While observing the ID physician’s assessment, infection appeared high on the differential however no organism had been isolated and there had been little response to broad-spectrum antibiotics. The purulent discharge was also new therefore infection was not necessarily the primary cause. When examining the CBC, one potentially significant finding was that the patient’s platelets where high at 600 x 10*9/L. The preceptee noticed this and was able to take concepts we had been discussing and recognize some possible causes for this including surgery and hyperproliferative disease. She hypothesized and began to investigate if this could increase her risk of VTE (a subclavian DVT was on the differential however a prior ultrasound, rated low quality, had been negative for this). Soon after this a repeat ultrasound was been ordered. The diagnosis of this patient remains unclear at present however it was extremely rewarding when my preceptee began to synthesize some concepts we had been discussing regarding laboratory values and apply these to a patient assessment.
With another successful rotation complete, on to my final project week. The main objective of this week: complete the data analysis and produce a poster to communicate my findings for the residency poster presentation.
On arrival to CCU, the knowledgeable medical resident assessed a patient at high-risk of infection post emergency bowel resection and the decision to continue a short course of antibiotics post-op was made. Unfortunately, the patient had a documented penicillin allergy and there was some debate as to which antibiotics to use. A suggestion put forward was to switch the medication order from metronidazole/cefazolin to metronidazole/ciprofloxacin. The coverage of ciprofloxacin for common skin pathogens such as the Streptococcus spp. and Staphylococcus aureus could have been suboptimal. This was true for some of the common Enterobacteriaceae ssp. associated with post procedure infection. Given the recommended alternatives form Bugs and Drugs for severe penicillin allergies (gentamicin/ metronidazole or gentamicin/clindamycin) and the patient’s eGFR of 36ml/min, some investigation was warranted. After reviewing the chart history, it was discovered the patient received:
Ceftriaxone 1g IV and metronidazole 500mg IV at 08:30 March 16, 2106
Cefazolin 1g IV and metronidazole 500mg IV at 02:00 March 17, 2016
The patient had also tolerate imipenem in hospital on a previous visit.
During the patient interview, she described the allergy as a rash to her arms, chest and abdomen that had emerged within 24hrs of penicillin use in 2006.
On exam, the patient had no signs of rash on her chest, abdomen, back or legs. Given the alternatives, if antibiotic therapy were to continue, the suggested was made that cefazolin 1g IV and metronidazole 500mg IV be continued tid as ordered with careful monitoring for signs of an allergic reaction. The probability of cross reactivity between penicillins and cephalosporins was communicated to the residents, nurses and dispensary pharmacist. Needless to say, I was diligent to monitor closely for signs of an allergic reaction!
This served as a good lesson of where reviewing the patient medication history and a careful allergy assessment was beneficial in ensuring the patient received the most effective and safe medication. It was also an opportunity to demonstrate the utility of a pharmacist as part of the patient care team. A medical resident and a pharmacy resident may have a different approaches to the same problem however by working as a team we were able to determine the most viable option for the patient.
I am happy to report that today was my first day teaching at the warfarin information session in my Cardiology rotation (Tuesdays and Thursdays at 10:00 if you are interested). At this session, one woman diagnosed with atrial fibrillation and her daughter, were my two audience members. This actually turned out quite well as I could tailor the presentation to her specifically. They both had many questions, which I could easily answer. The part that surprised me most was how much I had actually learned from them. They had intelligent, legitimate questions about this new medication and I had answers that they could understand. I have never doubted the key role of a pharmacist in providing medication related education but it reminded me that concepts considered common knowledge in the health care profession and in a busy hospital can often be a black box to patients. So my key reminder here today was to educate, educate, educate. If necessary, educate until the patient cannot even stand the thought of Googling it anymore (Disclaimer: I do not dislike Google at all but accessing accurate information is a rant discussion for a different time and place). As an added bonus, becoming an effective pharmacy educator is one of my residency learning objectives and this was a great opportunity to exercise this. Overall, it was a good experience and I am once again sincerely grateful to the patients for helping me become a better clinician.
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.
As an assignment in the academic detailing rotation with PAD, I was tasked with appraising and presenting the results of the FDA Advisory Committee’s assessment of the IMPROVE-IT trial. The pharmaceutical company’s request to make the broad claim that the addition of ezetimibe to a moderate dose statin lowered cardiovascular events was carefully scrutinized by an advisory panel including cardiologists, statisticians and consumer representatives. Of particular interest were not only the advisory’s decision but also their individual reasoning behind the vote. It was a great exercise in critical appraisal, which is in line with my residency learning objective 5) “I will demonstrate the ability to critically appraise literature in a systematic fashion and determine the applicability of the study to a specific patient” and my revised post-midpoint learning objective 3) “I will become a more effective presenter and pharmacy educator.” Although this was not patient specific, it did provide me with resources to access data not otherwise provided by researchers (such as the effect on missing data). This assignment was in line with my residency learning goals to improve my critical appraisal skills and to become an effective pharmacy educator. I also had the opportunity to closely assess the clinical relevance of composite end points. Even in a seemingly positive result, a careful assessment of the parameters used to measure the out come (such as “non fatal MI”) revealed the fragility of an already questionable endpoint. For more information, my slides are available and I would love any questions you might have!
IMPROVE IT- What did the FDA Say?
I had a very informative 4 days with the ladies responsible for local Provincial Academic Detailing (PAD). For those who are unfamiliar with PAD, it was developed to provide practitioners with evidence based, objective data regarding both the safety and the efficacy of medications. It serves to bridge a knowledge gap too often “filled” by drug company representatives. Topics such as oral diabetes medications, anticoagulation in atrial fibrillation and proton pump inhibitors were selected based on need and interest. It was incredible to learn that the team spends up to a year developing the material to discuss with healthcare practioners and judging by the detail I can understand why. I had a great learning experience on the academic detailing rotation and appreciated the opportunity to attend appointments with the team members. I was impressed by the detailed, professional work conducted by the group in both preparation and delivery of the information. It was obvious the clinicians highly valued the academic detailing sessions and the physicians even started their day early to attend. For myself, the salient learning point from this rotation was the need for pharmacists to remain active in the role of pharmaceutical educators both within the pharmacy department and within our interprofessional teams.
I was extremely fortunate in my ID rotation and some of the rare infections on my list of “would like to see” manifested in hospital during my ID rotation. This included fungal lung infections. The culture was +1 for aspergillus of a lung biopsy and it provided me an opportunity to clarify a burning therapeutic question and that was how to assess these culture results? In a patient with respiratory disease, one of two things could be happening. Firstly, aspergillus is an environmental mold and isolation from sputum or lung tissue biopsy does not necessarily indicate invasive disease of the lung parenchyma. This may be a commensal with no implication in the current clinical status of the patient. Although the sequelae of an untreated invasive or chronic aspergillosis may be serious, the antifungals to treat aspergillus have potentially toxic side effects, serious drug interactions and long durations of treatment. So understanding when and when not to treat is an important part of medication management. I recalled a case early in my residency where a deep sputum culture grew +1 aspergillus however unlike this patient no treatment was recommended. In the end, it came down to careful consideration of the patient specific factors including history, risks and comorbidities.