It is the moment when you are fresh out of pharmacy school classes, and people around you expect you to have some idea of what you are doing. You are put to the test, and suddenly you know a lot more & less than you realized. You remember things that you did not know were even in your brain, but you are also hit with the reality of how much you need to know to be a useful member of an inpatient healthcare team.
As much as you might expect from watching Grey’s Anatomy, the reality of acute care/working in a hospital is not always about love affairs and romance. Although if it was, it might just explain Bill Clinton’s interest in the matter (yes, Bill Clinton jokes are still funny).
THE FIRST DAY
First day of acute care? Introduction and orientations were a piece of cake; I thought the rotation would be a complete joke. The following morning I arrived and met the pharmacy resident with whom I would be working (currently on the neurology floor). She told me that I had 2 hours to do a comprehensive patient assessment, and then present it and my therapeutic recommendations to her and another pharmacist working on the floor. That was the moment at which I questioned how easy this rotation would really be.
Struggling to remember the difference in treatment algorithms between the non-hemorrhagic ischemic strokes, the majority of my two hours was spent reviewing notes, current practice guidelines for atherosclerotic & cardioembolic strokes, and determining the etiology of my patient’s condition. When I realized I had 20 minutes left, I quickly threw together some non-sense for all the other patient health problems.
Do you know that moment when you are being interviewed for a job by a group of people, and they ask you the infamous “tell us about yourself”? You immediately start talking about your childhood, where you were raised, and all about your favorite pets you had growing up. Wait a second, what? Then you notice everyone in the room looking at you like a group of cows standing in the middle of the tracks looking directly at an oncoming train. Impending disaster. Clearly you did not answer the question in the way they had intended. Furthermore, you are not even sure if you are at the right interview anymore. Why are the CEO and board of directors interviewing you for a what you thought was a part-time cashier position?
That was the second moment I questioned my previous thought of how easy this rotation would be. At the table, surrounded by my superiors, I nervously presented what I thought to be interesting and relevant topics about my patient. When I finished, one of the pharmacists said to me, “that needs some work”.
That same week, I was presenting about a questionable diagnosis of seizures. I recommended that the Depakote, which was found to be sub-therapeutic, be increased from a daily dose of 1000 mg to a weight based dose of 2250 mg. While I was proud of my recommendation, the same pharmacist asked me, “What do you think their quality of life is?” It caught me off guard. The drug level is not to goal, so why not increase the dose? That was the third and final moment that I reassessed my original prediction of an easy rotation.
He again asked, “Why do you think adherence is one of the biggest problems with patients taking anti-epileptic drugs? Because they are heavily sedating and have many side effects which impair an individual’s ability to function normally and feel like themselves,” he explained. “If someone is controlled and tolerating their current regimen, why put them through worse side effects? These patients are more than laboratory values or problems in a textbook, and their quality of life is one of the most important facets you should consider when making therapeutic recommendations.” This is a key lesson I learned from this rotation.
For pharmacy students who will be embarking on rotations one day, here is a glimpse into what my daily schedule looks like:
I attempt to wake up at 5 am, go on a run, and arrive at my site by 6:30 am to begin reviewing patient charts (and down some coffee). At this point I have 3-4 patients that I am responsible for each day. This includes writing down all current medications, subjective, and objective information. I continue to complete an assessment of current health problems/appropriateness of current medications and provide a plan with recommendations for the patient’s therapy. These are presented every day to clinical pharmacists who critique my workup. Disease states seen on the neurology floor include ischemic strokes, subdural hematomas, meningitis, encephalitis, hepatic encephalopathy, seizures/epilepsy, and myasthenia gravis.
Afternoons consist of topic discussions about disease states or medication classes. I am also working on a journal club presentation about a New England Journal of Medicine article, “Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease.” I am generally at site about 8-10 hours a day followed by a few hours dedicated to searching for answers to questions brought up during the day and completing assignments due for the rotation.
As I keep practicing, I am beginning to feel a lot more comfortable with each days routine. Patient workups are going faster, and guidelines are beginning to be en-grained into my memory. Finally at the end of last week, I presented my assessment and plan for a patient, and the pharmacist who had questioned me previously stated, “You did a good job presenting today.”
During school, it is easy to think that you know everything about a topic because you can recommend a treatment for a made up patient scenario on a piece of paper. In reality, it is not that simple. People are complicated and non-textbook. It is truly humbling to make a difference in the care for someone, who is not fabricated for student learning, but real and existent.
One modern philosopher highlights the importance of this concept. In the words of Kendrick Lamar, “I’m so . . . sick and tired of the Photoshop. Show me something natural . . . sit down, be humble”