Reflections – Clinical Orientation

The past 2 weeks passed by so quickly! I’m really thankful that our residency program has a clinical orientation as it allowed me to focus and build on my thought process and systematic approach. I was fortunate to have Mike who was very supportive and knowledgeable. The health care team at SMH worked closely with the pharmacists and were very approachable, which helped to enrich my learning experience

For my reflections, I plan to discuss how I have accomplished my objectives, as well as, make one new objective for each of them.

  1. Use the head-to-toe approach to assess my patients and if time provided, present at least 5 full patient work-ups to my preceptor (i.e. not just reading out the information I have gathered)

    Reflection: I used the head-to-toe approach to gather information and present all of my patients. With each presentation of my patient, I felt more comfortable with the head-to-toe approach and knowing which information was relevant to point out to my preceptor. I need to work on better presenting the progress of my patient in the hospital. In my OEE, I was taught to summarize the progress in one line. While that may work for patients who are newly admitted, for patients who I am encountering part-way through their hospital stay, capturing their progress in one line is challenging. For future patient presentations, I will try to summarize their progress while going through their head-to-toe (e.g. any trends in labs, etc).

    New Objective(s):
    – When presenting my patients, use the head-to-toe approach to summarize my patients’ progress, identify any new issues and highlight relevant trends. Do this for at least 5 more patients.
    – Consistently use the head-to-toe approach when gathering information and assessing all my patients

  2. Conduct at least 1-2 patient interviews in an organized and comprehensive manner
    – Have a list of interview questions ready prior to visiting the patient
    – Prioritize my interview questions in case time with the patient is limited
    – Make sure to also inquire about adherence, community pharmacy, family support, OTCs/herbals/supplements

    Reflection: Initially, my interviews were disorganized as I would jump from one condition to the next. My preceptor taught and provided me with an interview form that allowed me to conduct a proper BPMH and patient interview in an organized manner. I was able to meet my stated objective and always prepared a list of questions prior to visiting my patients. I will definitely not forget the most important question to ask — which is what are my patient’s goals from this hospital admission and expectations of their health care team!

    New Objective(s):
    – Document relevant information from patient interviews in a concise and organized manner in the progress notes
    – Delve further into patients’ responses (e.g. use questionnaires if a patient mentions they have a low mood) and tailor interviews toward my patients’ concerns and needs.

  3. Discuss with my  preceptor and write at least 1 clinical pharmacy note. Observe how my preceptor writes his clinical pharmacy notes and collaborates with other health care professionals and implement them into my practice.

    Reflection: I was able to get more experience writing SOAP notes. My preceptor would help point out situations where pharmacists would document a clinical pharmacy note. My notes tend to be wordy and at times, I would repeat information multiple times in my notes. My preceptor helped coach me on how to write clear, concise and organized notes. Currently, I still feel more comfortable drafting my note and reviewing it with my preceptor before writing it in the chart. Some useful tips were to include information from patient interviews or gather information from the bed-side nurse for the subjective, make sure you are not repeating details, write A/P in point form and always include your monitoring plan!
    FYI — Pharmacists are able to order non-prescription meds, continue medications PTA after verifying with the patient and another resource (e.g. P’net), labs and referrals to clinics.

    New Objective(s):
    – Independently assess the patients’ DRPs and clinical situation, and determine when writing a clinical pharmacy note would be appropriate (e.g. addressing a DTP and suggesting a care plan; discharge counselling; drug level monitoring). Draft up clear, organized and concise pharmacy notes and review with my preceptor prior to documenting it in the chart.
    – Become more comfortable and confident with my documentation skills

  4. Give 1 presentation. Practice my presentation at least 3 times while paying attention to my body language, tone and flow of presentation.

    Reflection: I facilitated a journal club for the first time, which was a great opportunity to brush up on my clinical appraisal skills and review non-inferiority trials. A more detailed reflection can be found in my procedure log. Reviewing it with my preceptor ahead of time helped better prepare me for my journal club and gave me a better idea of what to consider and research further on for future journal clubs.

    New Objective(s):
    – Prepare a cleaner and shorter journal club form
    – Have more questions prepared to facilitate discussion during future journal clubs

  5. Take opportunities to ensure continuity of care (e.g. with discharge counselling, communicating with the community pharmacy)

    Reflection: I was able to do a discharge counselling for a patient who was leaving nicotine replacement patches and a few medication changes. Although I was not able to do much discharge planning as most of my patients were still in the hospital when my clinical orientation ended, my preceptor and I helped prepare patients for discharge in other ways (e.g. asking what patients’ goals upon discharge, writing referrals, contact community pharmacies, medication reconciliations).

    New Objective(s):
    – Perform and document at least 5 discharge counselling during my general medicine rotation. Provide medication calendars and any useful counselling material.
    – Liase with community pharmacists and other appropriate health care professionals, in order to ensure a seamless continuity of care
    – Educate and connect patients with any necessary health resources during discharge (e.g. blister packing, special authority, insurance cards (e.g. Pfizer Strive))


On a random side-note…I recently watched Piper, a Pixar short about an unbelievably adorable little sandpiper bird (squee!) who leaves its nest to find food. I won’t spoil the story, but I found the beginning of Piper’s story to be similar to my start in residency where I’m starting to develop the skills and knowledge to be a clinical pharmacist. So, I’ll end my reflection with a picture of Piper in the beginning of its discovery of the world outside its nest:

13569772_10157160427930650_83957525_o

C3.1 R4(e): Perform & document a vancomycin or aminoglycoside pharmacokinetic interpretation

Patient’s Vancomycin Doses:

Dose # of Doses Prior to Level Level
1g IV Q12H 5 24.3 (High)
750mg IV Q24H 2 15.3
  • Aspirate from L shoulder: MRSA +
  • Challenging to obtain information from patient (e.g. wasn’t able to ask about side effects like sxs of ototoxicity). Patient is mostly in bed, but appears to be improving.

————————————————————————–

Clinical Pharmacy Note: Re: Vancomycin

s/0 77 yo male with MRSA septic arthritis L shoulder. Target vanco should be: 15-20mg/L.

vanco to 750mg Q24H since Jun 19. Vanco level at 2147 on Jun 21: 15.3 mg/L

eGFR~ 89, stable for last few days.
Jun 21 – WBC: 10.3, CRPH 57.7 ↑
Jun 22 – 36.8oC T, BP 130/87, HR 87

Pain was worse last night (pt crying), as per nurse. Settled with PRN hydromorphone dose. No complaints of pain today. Swelling same as yesterday, as per nurse.

A

  1. Septic arthritis appropriately treated with vancomycin for MRSA.
  2. Level is drawn appropriately at steady state and is within target.
  3. Renal function stable
  4. All doses charted as given.

P

  1. Continue vancomycin 750mg IV Q24H
  2. Awaiting ID consult to determine duration of tx.
  3. If prolonged duration, weekly vanco level
  4. Monitor renal function 3 times a week.
  5. Monitor s/s of septic arthritis (pain, swelling, mobility), WBC, CRPH, vital signs. If clinically worsening, increase vanco monitoring and R/A.

Order:

  • Continue vancomycin IV with no stop date. Awaiting ID consult RE: duration of treatment.

C3.5 R3(d): Prepare and FACILITATE a journal club to pharmacists

My first journal club is on the following article: Liraglutide and CV outcomes in T2DM.

My preceptor kindly reviewed my journal club prior to the presentation. He brought up questions and points to consider to better prepare me for my presentation which was very helpful! During the presentation, he also asked questions to help guide and prompt discussion. We had about ~8 pharmacists attend which seemed like a good number as it allowed us to have a good discussion. I was very fortunate to have a very supportive audience for my first journal club – a lot of thought-provoking questions were also asked by the group which made for very good discussion. ☺

What went well:

  • Started prep work early (~1 week prior) for the journal club
  • Increased familiarity with basic principles of different trials (e.g. non-inferiority)
  • Had two different versions of the journal club template: 1 with my notes and things to bring up, and 1 which was a much cleaner version that was easier for my audience to follow
  • Had an opportunity to practice and review my journal club with my preceptor

What I could work on:

  • I think having a good pace is something I still have to work on. When I know I have a lot of information to cover, I tend to go fast and trip on my words. I think slowing down and perhaps turning it to the group every once in a while will help keep the interest and discussion going.
  • Analyzing whether the duration of trial is a limitation and for assessing what outcomes it might a limitation for
    • e.g. retinopathy normally takes 10-15 years to develop…for patients with diabetes for an average of ~12 years, is tx of 3 years enough to assess the efficacy in preventing retinopathy?
  • Answering questions – I think I definitely struggled to answer some of the questions and didn’t answer a lot of them as comprehensively and clearly as I could.
    • Having a clearer idea of the application into practice…specifically into the “timeline”/”steps” of guidelines
  • Need to become more familiar with critical appraisal, statistics, trial designs, etc.

Feedback on reviewing draft:

  • For inclusion/exclusion criteria: don’t only consider whether the patient characteristics are appropriate, but also if such patients would be treated according to current guidelines
    • E.g. Inclusion criteria of T2DM patients with HbA1c > 7% for liraglutide
      –>  If patient’s HbA1c is 7.1%, will you consider liraglutide?
  • What is pre-specified and not?
    • If not pre-specified, may be “looking for” differences
  • When going through template, consider advantages and disadvantages of the trial design?
    • E.g. pros and cons of: multi-centered, international, randomised
  • Be able to identify “specific” bias
  • Consider: How do the results seen compromise blinding?
    • If known SE is weight loss, how will that affect the trial?
  • For withdrawals (before randomization, during trials), know why they withdrew?
    • How does this affect your results
  • Be able to answer: If your family member needed a ___ medication, what would you give? Does the trial change your decision?
    • Be familiar with trials and outcomes of other medications.
  • Think of where you can pose a question to the audience and guide discussion. Provide time for the audience to answer.
  • Put relevant tables/figures in the table

To do for next journal club presentation:

  • Use the NERD-CAT tool
  • Have more questions to guide and prompt discussion
    • Perhaps have someone else answer about background? E.g. what do we know currently about this drug?…and start it off in a more interactive way
    • Don’t just ask “what your thoughts are on the inclusion criteria”…be more specific e.g. what are your thoughts on them including patients with HbA1c > 7%
    • Whenever a pharmacist asked me a question, it might be good to answer but also turn it back to the group at the end so that others have a chance to add in.
  • Have checkpoints throughout the journal club to ask if anyone had any questions
  • Create a more concise and hopefully shorter journal article page
  • Think about what questions could come up and better prepare myself for them
  • *KNOW IF THE DRUG IS ON FORMULARY*
  • *What would you consider clinically signiifcant? Does this agree with the article? Do you agree with the article and their MCID? Be able to justify your answers*
  • Print out about 10 copies of journal club template
  • Print out about 10 copies of journal club article

My journal club review: JC Summary – Liraglutide (Audience)

To end this post off, I’ll leave it with an image that I personally find very relatable:

C3.2 R5: Reconcile a patient’s medications on ADMISSION

With the help and guidance of my preceptor, I completed a medication reconciliation on admission. Generally, medication reconciliation is done in Emerg. However, this patient had a MVA and was transferred from another hospital directly to our ward with the goal of repatriation.

In Saanich, patient was taking:

  • Citalopram 10mg once daily, as per P’net
  • Gliclazide 60mg MR twice daily with food, as per P’net
  • Metformin 1000mg BID with food, as per P’net
  • Linagliptin 2.5mg BID with food, as per P’net
  • Pantoprazole Mg 40mg once daily 1/2 hour before food, as per P’net
  • Timolol 0.5% 1 drop in both eyes BID (different from P’net)
  • Zopiclone 5mg HS PRN (not on P’net)

On P’net but not on transfer:

  • Ferrous fumarate 300mg capsule twice a week (Mon and Thurs)

Medication Reconciliation:

Patient was able to confirm that he was taking all his oral medications as per P’net, as well as, strength and regimen. For non-prescriptions, he was taking calcium and vitamin D, vitamin B12 and a multi-vitamin for over 50 years old. No samples. He uses blister packs. However, he had difficulty in identifying the eye drops and their regimens. I had to look at MediTech –> EMR –> Patient’s Summary and click next of kin. I called the daughter who was able to bring in the eye drops and his old blister pack. Along with my preceptor, we confirmed the following:

  • Travoprost (Travatan Z) 0.004% Instil 1 drop in right eye HS
  • Brimonidine Tartrate (Alphagan P) 0.15% Instil 1 drop in right eye BID
  • Brinzolamide (Azopt) 1% Instil 1 drop in right eye BID
  • Timolol (Timoptic-Xe) 0.5% Sol-gel Instil 1 drop in left eye QAM (as per pt – P’net said both eyes –> some confusion but patient later thought likely both eyes)
  • Prednisolone 1% Instil 1 drop in left eye TID (but pt usually does it twice)
  • NOT taking fluorometholone 0.1% drops
  • Medications taken in blister pack was as confirmed with patient previously

Recommendations:

  1. Decrease metformin to 500mg BID d/t risk of lactic acidosis while having chronic renal dysfunction (eGFR ~low 40s)
  2. Change Timolol 0.5% to 1 drop in both eyes QAM
  3. Start Prednisolone 1% 1 drop in left eye TID
  4. Start Travoprost 0.004% 1 drop in right eye HS
  5. Start Brimonidine Tartrate 0.15% 1 drop in right eye BID
  6. Start Brinzolamide 1% 1 drop in right eye BID

Reflections:

  • I should have had a closer look at the Pharmanet to clarify any differences between P’net and what the patient was telling me. I noticed later on that timolol was written for both eyes QAM on the P’net and went back to re-clarify with the patient. There was some confusion but both daughter and him decided it was best to follow the P’net and patient seemed to think that he might have been using it for both eyes. The unit clerk and pharmacy staff probably didn’t appreciate the extra order I wrote only one hour later.
  • My preceptor helped confirm the eye-drops with the patient in a very efficient way. He showed the eye drops to him as he asked how many drops and how many times he was taking it. He re-confirmed and summarized the regimens at the end. For my future medication reconciliations, I will read out the final list of medications at the end to the patient and confirm its accuracy.
  • When asking for non-prescription medications, I forgot to list out non-prescription formulations – e.g. creams, ointments, etc. Some people may not consider topical medications a medication, so it would be good to list them out for the patient.

Objectives: Clinical Orientation

I can’t believe that I will be starting my clinical orientation at Surrey Memorial Hospital this coming Monday! Although I am incredibly nervous, I am also excited to be moving from unconscious incompetence to conscious incompetence.

  1. Use the head-to-toe approach to assess my patients and if time provided, present at least 5 full patient work-ups to my preceptor (i.e. not just reading out the information I have gathered)
  2. Conduct at least 1-2 patient interviews in an organized and comprehensive manner
    – Have a list of interview questions ready prior to visiting the patient
    – Prioritize my interview questions in case time with the patient is limited
    – Make sure to also inquire about adherence, community pharmacy, family support, OTCs/herbals/supplements
  3. Discuss with my  preceptor and write at least 1 clinical pharmacy note. Observe how my preceptor writes his clinical pharmacy notes and collaborates with other health care professionals and implement them into my practice.
  4. Give 1 presentation. Practice my presentation at least 3 times while paying attention to my body language, tone and flow of presentation.
  5. Take opportunities to ensure continuity of care (e.g. with discharge counselling, communicating with the community pharmacy)

How to achieve:

  • Take the initiative to ask my preceptor for any feedback at the end of each day
  • Reflect on my progress and check in with my preceptor on what he feels I should work on and whether or not  at the end of each week
    – Reflect on my patient work up and if I am missing things, reflect on why and how I can ensure I don’t miss them during my next work-up
  • Use GoogleKeep to record a list of things I should work on. Prioritize the items and complete them either end of day, end of week or end of rotation based on urgency and importance to my ability to provide patient care
  • Ask my preceptor if a mock oral assessment would be possible at the end of my orientation
  • Make one(or two..or three)-pagers of medical conditions