Optimizing Your Rotation Experience

sepassi-on-rotation_0.jpgThe primary goal of experiential education is for students to develop the knowledge and skills required to provide optimal drug therapy for each patient. As students complete rotation assignments, they must keep in mind this primary outcome and the general goals it encompasses. Students should approach each rotation with an open mind and eagerness to learn what that rotation has to offer. Students who get the most out of a rotation are those who put the most into it. 

General Goals for All Rotations
 
  • To develop the skills necessary to actively participate in patient care
  • To prioritize the provision of pharmaceutical care when given limited time and multiple patients
  • To understand the scope of practice/expertise of other health professionals
  • To understand general types of medication-related problems and potential solutions
  • To take personal accountability for the outcome of patients, particularly outcomes related to drug therapy
  • To communicate clearly, orally and in writing
  • To display professionalism in appearance and actions
How To Engage in Rotations

Have an Open Mind to All Experiences

Your experiential schedule is designed to provide a broad range of experiences. A particular rotation may not be exactly in line with your goals/interests at this time.  However, every experience helps you learn how to care for patients.  Each rotation provides opportunities to develop communication and problem-solving skills, research clinical questions, review disease-states and the medications used to treat to them.  These things are important anywhere you end up in practice, and experience you get in every clerkship is helpful!  Even if it’s your life-long passion, don’t try to tunnel all your student rotations in one direction of interest. 

Take Initiative

Students should take initiative in finding opportunities to learn.  It is important to consider that physicians may not consider drug related problems in the same way as a pharmacist. This means you should keep asking yourself, in the context of every patient case, “Do I know everything I should about this disease, its usual therapies, and this patient’s therapy?”  “Do I know the indications, dosage, pharmacokinetic parameters, side effects of this drug?”  “Do I know the pertinent counseling points for this drug?”  “Do I know the rules/regulations that should direct my actions in this situation?”  “Do I understand how this department/organization works?”  Constantly quiz yourself, and look for the answers!  Jot down things that you do not know or fully understand and make that your own list for self-study. You should have lots of questions! Start with a textbook to give yourself a strong foundation, and ask your preceptor about important articles to read.  With all the information you learn, and the guidance of your preceptors, you will find ways to improve patient care! 

Practice communication

You can never hone your communication skills too much!  Look for opportunities to interact with all types of people – patients, patient family members or caregivers, pharmacists, other pharmacy or rotation site employees, physicians, other health care professionals.  Practice professional communication skills with all these people, adjusting the terminology and level of detail to be right for the person you are communicating with.  Seek advice from your preceptor regarding appropriate methods of communication for different types of encounters.

Practice Making Decisions

Do not act on decisions without the approval of your preceptor.  However, don’t defer the thought process to your preceptor!  Practice evaluating prescriptions/medication orders, reviewing drug profiles, counseling, fielding drug information questions, etc.  Try to decide on your own what recommendations should be made or how a question should be answered. 

Discuss your thought process with your preceptor.  Make sure you discuss both the decision you made and the alternatives you considered.  Preceptors can best teach when they understand your thought process.  It is also critical to realize that you might not know what recommendation to make.  Become comfortable with that uncertainty and tell whoever is asking a question that you do not know, but you will find out and follow-up.  You will, very soon, be the one who is expected to make decisions and recommendations, without having a preceptor to discuss it with first.

Practice Writing Notes

Whenever possible, practice writing chart notes.  Practice organizing your thoughts into the SOAP format, and clearly presenting your notes/recommendations for other providers.  Discuss rotation site policies regarding progress notes with your preceptor.  Because charts are legal documents, some institutions do not allow students to write directly in the chart, and those that do probably require that your preceptor co-sign them.  Even if you can’t write in the chart, write what you would have put in the chart and review it with your preceptor so you learn how to do it! 

Ask for Feedback

Many preceptors will provide a rotation syllabus with stated goals/objectives. Make sure you discuss these with your preceptor the first day. If there isn’t a syllabus, spend time the first day discussing rotation goals and objectives with your preceptor. Let your preceptor know what you hope to learn during the rotation. Developing your own goals is part of becoming a professional and shows preceptors that you are interested.  Feedback from a preceptor is typically brief and informal. If preceptors are not frequently giving you tips about improving for the next time you see a patient or perform a particular activity, be sure to ask for that assistance.  Ask the preceptor to complete a midpoint evaluation. Find out specifically what you can do to improve while there is still time on the rotation to address those concerns.

Keep Thinking During Technical Tasks

At times, you may have technical tasks at a rotation site – filling prescriptions, unit dose cart fill, making IVs, etc.  Use this as an opportunity to challenge your knowledge base.  As you fill prescriptions or drug carts, ask yourself what types of patients shouldn’t receive this drug and what information this patient needs in counseling. Look at all the medications in a patient’s med drawer/profile. What are they for? What diseases could this patient have? Are they the best medications for the patient? Regarding IV’s, there are lots of questions. Do you know how quickly this drug may be infused safely? Are special infusion/storage instructions clearly stated on the label to help ensure that it is used correctly? Do you know why is this IV antibiotic is mixed in this fluid instead of that one? How was the concentration calculated? Is it a safe concentration? As you enter prescriptions/orders in the computer system, think about allergies, contraindications, drug interactions, appropriate dosing for this patient’s indication, age, organ function, etc. It is at this point in the medication use process that many prescribing errors and medication problems are found by pharmacists. Whether or not your eventual job title includes “clinical pharmacist,” it is your responsibility to ensure patients are receiving the best treatment.

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Preparation Before and During Rotations
 
  • Take a patient-centered approach to every situation. Give every patient the attention you would give a loved one.
  • Each rotation is an audition for a job interview or a professional reference.  Pharmacy is a small world.  You never know if the preceptor you are working with now is a friend of someone you will want to work with later.   Behave professionally and work hard, so that every preceptor will be a good reference for you!
  • Familiarize yourself with the reference resources available at the site and the remotely through the College of Pharmacy and the Health Sciences library.  Learn how to best utilize the different references to answer different types of questions.
  • Familiarize yourself with the common medical conditions encountered at your rotation site.  Review your therapeutics notes and read key articles. You might also want to read general and specialty textbooks to gather information.
  • Organize your patient data.  Use monitoring forms or index cards – whatever works so that you have the information you need at hand when you discuss cases with your preceptor.  Include the patient name/ID number, date of admission, age, weight, problem list, pertinent laboratory values, allergies, and a medication list (include dates started and discontinued). One simple, but meaningful, task is to line up each medical problem and all the medications and determine if you can find places where these two lists do not line up. When that occurs, you need to find out more information. If your notes include personal health information, don’t leave your facility with that information. Store it on-site in an area approved by your preceptor.
  • In most rotations, a presentation will be required.  With your preceptor, choose the audience and topic early in the rotation.  Make a timeline for completion, allowing the preceptor to preview the content.
  • Keep track of questions to ask the preceptor. Research the answers on your own first, and then review them with your preceptor. Don’t let them go unanswered.
  • Have your preceptor review content of counseling before it is done, to be sure it is accurate and complete. Observe the techniques your preceptors use for counseling as much as possible.  By watching and listening to them, you will learn several ways to state concepts present information at different levels.  Putting together what you learn from several preceptors helps you develop your own style.
  • Constantly ask yourself questions!  See below.

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Questions to Ask Yourself – With Every Patient Case
 
  • Do all drugs fit a problem/indication?
  • What is the usual therapy for the given diagnosis?  Is there any reason this patient should be treated differently (i.e. contraindications to meds, allergies, concurrent disease states)?
  • Is there any history of adverse drug reactions?
  • Have medications been stopped?  Why?  For inpatient rotations, were medications stopped on admission?  Should they be stopped?  Do they need to be restarted after the acute situation is resolved?
  • Were any new drugs started? Why? Remember to counsel!
  • Are there insurance issues with obtaining this medication?  Does it need prior authorization?  Is the drug on the hospital formulary? What alternatives can I suggest, or how do I justify use of a non-formulary drug?
  • Could other less expensive or more efficacious drugs have been chosen?
  • Are the doses, routes, schedules, or dosage forms appropriate for the condition being treated and the inidividual patient?
  • Is the optimal dosing regimen prescribed? Consider compliance.
  • Are there abnormal laboratory values (especially electrolytes and renal function)? Are the laboratory abnormalities drug-induced? Is a modification of drug dosage required?
  • What are the goals of therapy? What are the subjective and objective monitoring parameters for this goal?
  • What are the toxicities of the drugs? What are the subjective and objective monitoring parameters to detect these toxicities?
  • Are there drug interactions? What change in therapy is required, if any?
  • Are there any problems that indicate a drug should be prescribed, but it isn’t?
  • What is the projected length of therapy for each medication (especially antibiotics and Schedule II drugs)?
  • Is the therapy rational?
  • If a drug is to be stopped, does it need to be tapered or can it be stopped abruptly?
  • Are duplications in drug therapy present?
  • Does the patient clearly understand the medications they take?

Yes, this is a lot to think about.  The more you think, the more you learn!  The more you prepare and look things up, the better your case discussions with your preceptors will be.  The better prepared you are, the better your interactions with other health care providers will be when you make recommendations/interventions.  The better prepared you are, the bigger the difference you can make to your patients!  So, prepare, think, and engage in all your rotations!

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Originally posted: August 29, 2013
Last updated: October 9, 2014
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