US Pharm. 2008;33(12)(Student suppl):5-6.

 

When I was a freshman in college, those "clinical rotation things" seemed so far away. Now, as a sixth-year pharmacy student doing those "rotation things," I cannot believe how fast the past five years have flown by. I did not realize it, but from the moment I walked into my first class as a college student, I was preparing for my advanced pharmacy practice experiences (APPEs). The reader might be thinking, "What does Art 100 have to do with sixth-year APPEs?" While analyzing the motivation behind contemporary art is not what sixth-year APPE students do on a daily basis, the fundamentals learned in classes such as this one taught me how to effectively communicate, prepare professional documents, motivate myself to strive for excellence, and think outside the box. I have completed three wonderful APPEs and can say from experience that the life skills I learned early in my college career have helped me succeed thus far. I encourage anyone who is about to select APPE sites to do so thoughtfully and to pick one or two that may be a bit outside his or her comfort zone.

Some of my experiences have been challenging, but very much worth it. My first site was a pediatrics rotation at Rainbow Babies & Children's Hospital in Cleveland, Ohio. My typical day started off with three hours of rounds. During rounds, the medical team--including physicians, nurses, pharmacists, dieticians, respiratory therapists, and social workers--discussed the patient cases from their service at each patient's bedside. The medical residents usually led the discussion under the supervision of their attending physician. Discussions included a history of the patient's present illness, current laboratory values, changes from the previous day, assessment of the patient's condition, and the plan for the current day. I chose to work in the pediatric intensive care unit (PICU) for rounds. Frequently, the PICU attending physician would quiz the residents about drug therapy. When they were uncertain, the residents always turned to me, which made me feel like a vital component of the team. During rounds I encountered many interesting cases, such as drug overdose, teen pregnancy, lithium–amiloride drug interaction, posttransplant care, sickle-cell patients, and more. During PICU rounds, I gained a tremendous respect for the people who worked there because they maintained a highly positive atmosphere, even for the children who were not expected to survive. In the afternoon, I either presented patient cases to my preceptor and the other students on rotation with me or went to the Poison Control Center located in the hospital. At the Poison Control Center, we discussed calls made to the center and explained how we would handle each call. The Poison Control Center director sometimes gave talks about really interesting cases, such as serotonin syndrome and ingestion of poisonous mushrooms. In my time at Rainbow, I had some great experiences and learned that it is important to remember that children are not the same as adults.

My second APPE was an ambulatory-care rotation at University Hospitals Family Practice Center in Cleveland. Although it was right next door to my first rotation, this rotation might as well have been in another state because it was so different from my first experience. This site was a medical clinic whose client base included the medically underserved population of Cleveland. My primary responsibility during my rotation month was to see patients and work closely with their physicians. After a patient was taken to an examination room, I would speak with him or her and take a history to find out exactly what brought the patient to the clinic that day. During this time, I would check the patient's blood pressure (if diagnosed with hypertension), counsel the patient about any medications he or she had questions about, and make my own assessment of the patient's condition. After this session, I would present the patient's case to the physician, who would then ask for my assessment and plan. Often, the physician would let me write the patient's prescription and simply sign the order when I was finished. The physician and I would then go together to see the patient to communicate our plan and perform any other physical examinations or tests that were needed. Some conditions and tests I observed during this rotation were hand-foot-and-mouth disease, acanthosis nigricans, scabies, genital warts, Pap tests, trichomonas and bacterial vaginosis under a microscope, and more. Between patient visits, one of my responsibilities was to check prothrombin time/international normalized ratio (PT/INR; a measure of a person's ability to clot blood) laboratory values faxed to the clinic by local laboratories. Almost every patient I was monitoring had had deep venous thrombosis or pulmonary embolism and required warfarin therapy to help prevent another clot from forming. If a patient's PT/INR level was too low (prone to clotting) or too high (prone to bleeding), I contacted the physician and recommended a change to the patient's warfarin therapy. After getting the physician's approval, I called the patient to make sure he or she understood the change and why it was being made. Some of my other activities were to prepare patient case presentations, which I gave to my preceptor and other pharmacy students, and to attend lectures on topics such as sleep apnea, childhood obesity, and antipsychotic therapies with the family-medicine residents.

One of the most important lessons I learned from this rotation was that the pharmacist may be the only health care provider some patients interact with. This has helped me be mindful of cultural, environmental, and socioeconomic differences that patients may face. This rotation taught me that it is important for every person to receive world-class care from his or her pharmacist regardless of education level, socioeconomic status, or ability to pay.

My third APPE was at the CVS/pharmacy corporate headquarters in Woonsocket, Rhode Island, where I completed a drug-information rotation. I worked on many projects and was able to focus on many of the areas that interest me. Every morning, I went to the office and checked the daily health news. Weekly, I reviewed the news stories with my preceptor and two students from the University of Rhode Island. This allowed us to discuss news stories our patients might see and to formulate responses to these articles in case our patients asked us about these news events. Following my daily check of the news, I worked on several projects that were expected to be completed by the end of my rotation. These projects included presenting journal clubs, in which I discussed with my preceptor the clinical impact of recently published studies; researching current trials related to specific drugs to have on hand for legal or regulatory reference; and writing a feature article for the Clinical FOCVS, a monthly clinical newsletter that is distributed to every CVS pharmacist in the country. Sometimes my preceptor forwarded to me drug-information questions from store pharmacists to research and answer. Two examples of questions I answered are: "Is there an interaction between azithromycin and warfarin?" and "Do any of the ingredients in commonly used OTC cough and cold products interact with HIV medications?" During my rotation month, I also worked on two projects for the Pharmacy Operations department that will help make compounding easier for CVS pharmacists and will allow pharmacists in selected Florida CVS/pharmacy locations to offer flu vaccinations to their customers.

My preceptor was the Community Pharmacy Practice Resident for CVS/pharmacy, and her major project was the collection of unwanted and expired medications. The goal of this project was to make sure medications were being disposed of safely, rather than being flushed down the toilet and into the water supply. With help from several volunteers, we collected more than 200 gallons of unwanted medications from more than 100 Connecticut residents. It was inspiring to be involved in an environmentally friendly service project and help a community served by CVS/pharmacy. This APPE was an excellent experience because I was able to work in the corporate atmosphere, execute projects that will reach thousands of pharmacists, perfect my professional writing skills, network with students from another college of pharmacy, and discover resources I can utilize as a pharmacist.

Through my APPEs, I have encountered many people and have learned many lessons from them that will guide me in my career as a pharmacist. APPEs may seem scary to those who have not yet embarked upon them, but I promise that they are really enjoyable if you keep an open mind and have a positive attitude.

To comment on this article, contact rdavidson@jobson.com.