Academic Day Seminar #4: Clinical Thought Process

For this ADS, Tila Pelletier went over the patient-work up, data-collection, data synthesis, and clinical thought process. I thought this was a very useful session to have, especially before starting my clinical orientation.

Some Key Points I took away from this session are:

  • Your clinical process is a systematic approach to a patient. It is the process by which you collect, interpret and apply information regarding your patient’s care pain. It is something you must continually work to improve. It must be consistent and complete!

Prior to this session, I mainly thought of clinical thought process as a process to synthesize and apply information. It was something that I would attempt to do after gathering all the needed information. As Tila mentioned later on in her session: Think about your care plan as you gather information. Don’t be in ‘gathering mode’ but in ‘thinking mode'”. For my future patient work ups, I need to be critical at every step. I think using the head-to-toe approach taught by Dr. Kanji taught us when collecting information (e.g. patient-interview) and interpreting information would help me be more systematic when applying the information to the patient. If I am struggling at a certain step, I need to ask myself if I have all the information I need to make an effective and safe plan, and assess my current knowledge on the topic (e.g. pathophysiology, therapeutic options, diagnostics, monitoring plan, current updated literature).

My current goal is to continuously build and develop my clinical process and ensure that it is consistent and complete. As I progress through residency, I will need to push myself to be more efficient with my process while keeping in mind that efficiency should not sacrifice thoroughness.

  • You must check at least these 6 places for information:
    1. Computer system (e.g. drug profile, transcriptions, labs, imaging reports, etc)
    2. Patient Chart (physician notes, nurse notes, MARs, MD orders, etc.)
    3. Vital sign documentations
    4. Current day’s MAR, glucometer readings, bowel movements, urine output, fluid status.
    5. Care connect full 14 month pharmanet (Medinet) and outpt laboratory data (eHealth Viewer)
    – see trends in labs and identify if it is a chronic or acute issue
    6. Patient interview!!! Best possible medication history
    – Interview patient on meds that were d/c in the past and reasons behind it
    ** Other souces of info: Patient’s family, Community Pharmacy, GP/other HCPs, Previous admissions, Nurses on the ward, Assisted Living Facility, HOme Cardiologist, PARIS (out pt social worker documentation which social worker has access to), Transfer charts (by fax) **

Generally, when I look for information, I generally look for it in the above order. During my clinical orientation, my preceptor told me he likes working from the back to the front when reading the patient chart. As I had more experience reading patient charts, I could see the importance of understanding the patient’s history in their current admission (e.g. understanding the med changes and why it occurred, current status of patient’s c/c). I think that I am fairly decent in collecting information in the 1st 3 areas, but need to work on #3-6 and to have a list of things I should be looking for in each patient I encounter (e.g. IV fluids (input and output), bowel movements, frequency of PRN meds).

  • “The drug and the dose are wrong until proven otherwise” AND in the systhesis, always ask:
    • Does every drug have an indication?
    • Does every indication have (the right) drug(s)?:

When I work up my patient, I need to question each drug and whether the drug, dose, duration, route, formulation is necessary, most effective and safest option for the individual patient.For elderly patients, I also need to keep pill burden in mind. Tila also mentioned the importance of knowing if you are dosing to effect or dosing to target. This is something I will have to build my knowledge on.

  • Keep a list of things to look up/read about as you are going through the report with your preceptor. Keep this list on a separate piece of paper. Check in with your preeptor every 1-2 days to make sure you review what you have looked up. Self-reflect each week.

This is definitely something I will have to improve on. During my hospital OEE rotation, I would keep notes on what to look up. However, I was very disorganized and by the end of the day, I had to sift through scribbles on different pieces of paper to ensure I had researched everything I needed to. I think I will try Tila’s advice to use a coloured piece of paper to record my list of things to read. In order to improve on my thought process, I will check in with my preceptor every few days for feedback on my thought process and self-reflect when I have missed something in my thought process and decide a course of action (e.g. modifying my monitoring form, changing my organization methods).

Academic Day Seminar #3: Patient Assessment

Day 4: Dr. Zahra Kanji’s ADS was about conducting a patient assessment with a head-to-toe approach. I found this session very useful as it gave me a better idea of what to look for under each system. Dr. Kanji also provided several examples on how to use a head-to-toe approach (e.g. to assess volume status). The examples elucidated how this approach can be useful in drawing connections between each system, and the patient’s overall picture and therapy.

Some points that I took away from this session were:

  • Being able to effectively use a head-to-toe approach requires ongoing practice!
  • The approach may differ depending on the rotation and individual patient
  • MAP = (2*DBP+SBP)/3 as the heart spends twice the time in diastole than in systole
  • For cardiac murmurs, also consider the timing within the cycle, intensity over time, location, radiation, grade, pitch and quality
  • Troponin-I can be detectable for up to 5-9 days after an acute event, making it difficult to assess the onset of the heart muscle damage
  • Important to consider what could have caused any abnormal labs, signs and symptoms (e.g. a high blood pressure –> could it be due to a small cuff? white coat syndrome? timing of medications? patient’s activity?)

In my future clinical orientations, I will:

  • Work-up all my patients from a head-to-toe approach
  • Look for connections between trends in their lab values/conditions and the information I have gathered from systematically going from head-to-toe
  • When planning my monitoring parameters, systematically go from head to toe to ensure that my monitoring plan is comprehensive
  • Ask my preceptor how they conduct patient assessments and understand how it is appropriate for the field they are working in
  • Take opportunities to learn about physical assessment and diagnostic tools

Days 1+2 and Academic Day Seminars

Day 1:
Yesterday was the first day of the program and the beginning of our orientation week. It was great getting to see everybody in person and I look forward to getting to know more of my co-residents as the week progresses!

It began with Dr. Janice Yeung introducing and providing a nice overview of the program. A statement she made that really struck me was that we were all pharmacists going into this program. You would think that preparing for licensing exams the past month would have allowed this fact to sink in…but her statement reminded me of the significance of actually having a license while practicing in this program. Although I am incredibly fortunate to begin my practice under the guidance of wonderful preceptors, I need to push myself to practice as if I am the pharmacist on the ward. Initially, I would likely be absorbing a lot of information from my preceptors, but I also need to understand my preceptor’s thought process and work-flow, proactively think about how I would function in their shoes and create and work on objectives that would help me achieve competency in their role.

Some tidbits from Janice’s orientation:

  • Outcomes: Broad and not measurable – focus on results of learning experience
  • Goals: Broads and not measurable – describes what learner will gain from institution
  • Objectives: Specific and measurable – describes what the learner will be able to DO as a result of engaging in the learning activity (END RESULT, not process)
    -Tools: SMART, ABCD
  • Aim to do oral assessments by Christmas (available to do after Gen Med)
    – Read Residency Guide for Oral Assessments
    – Email Janice one month in advance before planned oral assessment

Academic Day Seminar #1: Later in the afternoon, Jason Park came to talk to us about available resources and information systems. This was definitely a very helpful session, especially for someone like me who is not tech-savvy. I found the resources we have available to keep our research project and other private data confidential useful (e.g. M Drive, encrypted USBs, password protect documents). Knowing that the information systems can be so complex, I will aim to understand the systems within the first few days depending on my exposure to it.

Academic Day Seminar #2: Dr. Peter Loewen came to talk about research and had 6 terms on his slide: Planning, Design, Approval, Conduct, Analysis, Dissemination. He talked about different things to consider when choosing a project such as: location, design, preceptor, feasibility, potential for publication. A question that Dr. Loewen left for us to ponder was whether or not it is better to be told what kind of design your project should be or be part of deciding what the design should be. Ideally, it would be good to be part of deciding what the design would be so that I have better insight into the process involved in choosing a design and rationalizing why other designs may not be as appropriate, feasible or cost-effective. Although the design has already been decided for most of the available projects, it is still imperative to inquire, understand why this design was chosen, its advantages and limitations and critically assess if this design was the most appropriate for the project.

Some tidbits from Dr. Loewen’s orientation:

  • Actively co-lead your project (create a shared document repository)
    – Have a folder for Protocol, Literature, Manuscript, Data
  • Create a skeleton protocol document
    – Write down research questions and hypothesis
    – Introduction should:
    — systematically review and have a comprehensive synopsis of current literature
    — most literature intensive and will be long…but will shorten as you edit
    — If doing a systematic review of your project = need to address what’s out there in literature…if something is done incomplete/bad/unreliable = elaborate why; if something has changed since the last SR = elaborate what…do NOT talk about the literature that you are going to systematically review in the introduction
    — Ends with goal/learning objectives
    – Sections: Objectives (can be overall goal, objectives followed by research Qs or objectives and then hypothesis, hypothesis by itself), Analysis (depends on how well you research and define your research objective), Statistics (wikipedia page), Population (define inclusion and exclusion = can change later on)
    Every objective should have an analytical plan!
    **Protocol = backbone of the project and final manuscript** (Samples provided)
  • For the first meeting, flush everything out and have a timeline for when everything should be done!
    – Consider if we need a stats consult...if you do, consult BEFORE your protocol…do not wait for the end
  • Maintain a paperless data flow
  • Medi-tech = allows you to print drug reports
  • Retrospective review = at best, you can find association (learn very little on cause and effect relationships since it’s not randomized)
  • Propensity matching: fake randomizing retrospectively
  • 6 REBs in LMPS…if anything changes significantly or changes the consent form = need to send amendment…if not significant, update in annual report

Day 2:
Today, we visited Children’s and Women’s Health Centre of British Columbia. Although I don’t have any pediatric rotations, it was enlightening to know about the different journeys some of the pharmacists took to get to their current role and that some pharmacists transitioned from an adult residency to clinical work in pediatrics. Dr. Roxanne Carr engaged us in discussions about what we wanted to gain from residency and our worries and it was comforting to know that we all shared similar goals and concerns.

In the afternoon, adult residents headed off to Burnaby Hospital. Although I don’t have any rotations in Burnaby Hospital, it was very valuable to learn about their operations, meet and hear the advice of their clinical pharmacists and get a tour of the hospital and the ICU ward.