What is it Like as a Community Pharmacy Resident?

It has been a while since I’ve made a post, but I’m back (probably because I’m at home recuperating from COVID). This post is going to describe the ins and outs of my pharmacy residency program (at least the first 6 months). Hopefully, it will answer any questions that you may have as to what my residency is like. If you still have questions, feel free to reach out to me!

My residency is an “Independent Pharmacy Ownership Residency.” It is a unique experience, but I’m really enjoying it. I work at 2 different sites, and I am able to learn as much as possible about both compounding pharmacy and independent community pharmacy while fulfilling the role of a pharmacist when necessary and completing quality improvement projects for the benefit of both pharmacies.

Compounding Pharmacy Practice

At the compounding pharmacy, I am able to put my clinical knowledge to work in a way very different than I ever intended. To be honest, I have learned more on the job about compounding pharmacy than I learned in my 4 years of pharmacy school. I have also learned a lot about veterinary pharmacy (bet ya didn’t know that was a thing). In a nutshell, most of my work at the compounding pharmacy revolves around working with my colleagues to create formulas unique to the patient that they were prescribed for (whether a human or an animal).

What exactly is pharmacy compounding, you ask? Per PCCA, a widely utilized compounding resource, “Pharmacy Compounding is the creation of a unique medical preparation or drug by a compounding pharmacist.” It is used when commercially available preparations are not suitable to the current patient (such as a patient having a gluten or lactose allergy that cannot take a commercial product because the fillers include gluten or lactose). It is used widely for veterinary medicine as well to allow for liquid or transdermal uses of medications to make administration easier.

I spend a lot of time counseling patients and pet owners on the uses of the medications and specific adverse events that they should look for.

Something I am looking forward to at this site is spending more time learning about compounding pharmacy and being able to be an asset to the team and to our patients.

Independent Community Pharmacy Practice

At our community pharmacy site, I spend most of my time vaccinating our patients (against COVID, the Flu, Shingles, etc.) as well as performing Rapid Antigen COVID tests.

On top of those tasks, I also spend quite a bit of time counseling patients, checking profiles for medication interactions, and checking prescriptions for appropriateness.

Some of my favorite things to do at this site are to perform Medication Therapy Management services and Medication Synchronization. One of our big projects for this year is to improve our MedSync program, and I am excited to be a part of this.

Something that I look forward to at this site is being able to build on our clinical services and utilizing my clinical knowledge to practice at the top of my license.

I can’t forget to mention the projects that I’m working on (what would a residency be without them). I’ve been working on several different quality improvement projects, a business plan (Creating a Diabetes course through the pharmacy), and a clinical service project (becoming certified in Spanish for Pharmacy in hopes I can better assist our Spanish-speaking population). Though I won’t go into detail about them here because I plan to make a separate blog post on them later.

Saving the best for last, one of the most important pieces of my residency is precepting students. I have had the pleasure of having students at both pharmacies. I feel like I learn as much from them as they learn from me. I absolutely love having students because it reminds me that pharmacy is a profession that will require continuous learning. It is one of the most rewarding parts of being a pharmacy resident.

Anyways, I think that’s enough for now.

Stay Golden,

Emily

So, I’m a Pharmacist Now, but What Does That Mean?

Alright, now that it’s been 2 months since I got licensed, let’s talk about how I feel to FINALLY be a pharmacist. Honestly, it feels unreal. There are days where I have major imposter syndrome and feel like I’m not qualified to be answering questions and verifying prescriptions. But the thing is, I AM qualified. I went to professional school for 4 years to become qualified. I took 2 very intense board exams to become qualified. I AM a pharmacist.

I have to constantly remind myself that pharmacy school and real practice are two very different things. I may have learned a lot during school, but there’s also a lot that they couldn’t have taught me. As of November 2020, there were over 20,000 prescription drugs on the market. On top of that, there are thousands and thousands of supplements and OTC medications. I have to remind myself that it is physically impossible for me to know every drug and every side effect.

In school, they taught me one of the best skills to utilize as a pharmacist, and that’s to investigate AND to do it quickly. How long does it take me to pull up MicroMedex or Lexicomp or the Natural Products Database and search for a specific drug or supplement? Less than 5 minutes. How long does it take me to dig a little deeper and look for primary literature? A little longer, but not too long. That’s the thing about pharmacists. We know how to dig.

So yeah, I may feel like sometimes I don’t know anything. I may feel like I’m not qualified, but between my ability to research and several more years in practice, I’ll know a heck of a lot more. I mean hey, even I can cut myself some slack. It’s only been 2 months.

I absolutely love everything about being a pharmacist. Getting to counsel patients on how to take their medications and see the impact that I’ve already had in 2 months, I know I chose the right field.

I’m learning so much, and I know I’ll continue to learn over the course of my career as a pharmacist. I’m slowly gaining confidence in myself. I’ve given countless COVID vaccines and COVID tests, I’ve counseled over a dozen patients, and I’ve had great conversations with others. I’m getting more comfortable in the shoes that I’ve stepped into when I took the Oath of a Pharmacist, passed my boards, and signed on to a residency program to grow as the pharmacy professional I know I can be.

So here’s to the rest of my life, to continuously learning, but most importantly, to helping my patients.

Stay Golden,

Emily

Study Tips: NAPLEX

Hi all! It’s about that time. I graduated with my PharmD ~1 week ago. Now, it’s time to really crack down on studying for the NAPLEX/MPJE. However, if any of you know me, you know I’ve been slowly studying all throughout P4 year. Also, my school provided a required 1-month NAPLEX review course prior to graduation. With all of these things coming together, I feel very prepared for the NAPLEX. Here’s a few important tips and tricks for those of you trying to figure out how to study for this BEAST of an exam.

Which Program?

Personally, I absolutely LOVE RxPrep! I feel like they really highlight the important information and really had everything down in a reader-friendly book. However, I’m aware that it is a pretty pricey program (my school provided it for us).

There are a ton of other programs out there, that could be more suited to your price range. I would do more research to determine which program would be the most beneficial for you.

Timeline

Most people feel that it is adequate to take 1 month to study for the NAPLEX, however, if you have the time, I feel like it is important to review the material as you go through P4 APPE rotations in order to ensure that you are as prepared as possible.

If you’re running low on time, you can take 2-4 weeks to go over the information that is most difficult for you, and go from there. I am currently in this stage of studying, and I plan to spend 3-4 hours a day on NAPLEX preparation (knowing I’ve already had a lot of preparation). For you, it may be 2-4 weeks of 8 hours study days. That is up to you.

Calculations

It is SO important to be constantly doing the calculations chapters. I would suggest at least 1 hour a day of calculations. It is so easy for us to forget the formulas, and we want to be fresh with the math so we make sure we don’t miss any of the more simple math questions on the exam.

Brand/Generic

It is also SO important to know brand and generic. The exam will expect you to know both. If you know what amlodipine is and that it can cause gingival hyperplasia, but have no idea what Norvasc is, how do you expect to get the question right?

Other things to focus on:

Biostatistics, Compounding, Narrow Therapeutic Index drugs (and their therapeutic drug levels), Infectious Disease, Vaccines, Oncology, and any other topics more difficult for you.

It is also important to take all practice questions that you can, and try to think through why every other answer is wrong. It is important to understand the concepts, not just memorize the questions (newsflash, it won’t be the same questions on the NAPLEX).

Weaknesses

Go through and determine your weaknesses on the first day of studying. Focus on these weaknesses. Make sure you’re comfortable with the information, then move on to brush up on the more familiar topics.

Exercise and Sleep!

Don’t neglect your self care. It is so important to get at least 6-8 hours of sleep and at least 30 minutes of exercise a day. Keep your physical and mental self healthy, and you’ll do just fine!

Example Study Schedule (2 week)

Good luck and Stay Golden,

Emily

Update: I passed the NAPLEX on the first try!

APPE Reflection- Surgery

Wow. I’m finally done with my APPE rotations. All that stands between me and my PharmD is a 1-month NAPLEX review course. This rotation was a really good experience. I feel like I learned a lot and was able to help improve patient outcomes.

You might be wondering what in the world a pharmacist or pharmacy student would be doing during a surgery rotation, so let me give you a little insight into what I was doing.

My preceptor and I sat on the surgical floor (near the nurses) and worked through our patients. We dealt with any pre or post-op medication issues or issues relating to a patient’s home medications. We made sure the patients got their antibiotics on time and didn’t get them if they were not needed. We also worked directly with the nursing staff to make sure the patient’s pain was well controlled. The main reason we sit with the nurses and not down in the main pharmacy is so that we can hear everything that goes on and can act fast when something happens.

Every day this month, I looked at about 7-10 patients, went through their medical chart, and completed a whole workup on them. A “whole workup” includes their background, the reason that they were in the hospital, any pertinent lab values, drug allergies, home medication list, current inpatient medication list, etc.

Along with working the patient up, I went to speak with them after their surgeries to make sure that their medication list that we have was correct (i.e. a medication reconciliation) or ask them any questions that we had about their medications.

I also spent a lot of time talking to the nursing staff and the providers to try and get antibiotics corrected or stopped on time or change doses of a patient’s medications.

Overall, this month I have become more confident making recommendations to the providers and talking to patients. I was able to get patients sent home on appropriate antibiotics and stop antibiotics when they were no longer necessary. I feel like I was truly able to make an impact on the care of the patients that I interacted with.

Over the course of the month, I also had 4 topic discussions with my preceptor (Post-operative Nausea and Vomiting, TPN management, Appendicitis, and Septic Joint Infections) and a presentation to the pharmacy staff on Post-Operative Ileus Prevention and Management.

Of course I also helped in several COVID vaccine clinics as well.

I cannot believe that it has already been a year since I started this journey.

I cannot believe that I’m almost a pharmacist. If you know me, you know that I’ve wanted this for as long as I can remember and now its ~6 weeks away (well.. I guess a few months until I’m licensed to practice).

I hope you’ve enjoyed walking through this journey with me.

I’ll keep you all updated on my post-graduate plans, and I’ll continue to blog as a practicing pharmacist.

Once I pass the board exams, be on the lookout for a blog post on helpful study tips!

Stay Golden,

Emily

APPE Reflection: Internal Medicine

Wow… I cannot believe I only have 1 rotation left! This month went by so quickly. This month was a whirlwind in terms of everything happening all at once. I had several post-grad job interviews, and I had a lot going on personally otherwise. However, I feel like I was really able to make a difference for my patients during my Internal Medicine rotation.

I made countless recommendations to providers (primarily changing up insulin regimens and adjusting antibiotics), but one in particular stands out. We had a patient that was in for possible infective colitis (inflammation of the colon caused by bacteria) who subsequently got a new diagnosis of Non-Alcoholic Steatohepatitis (NASH), which is a type of liver disease. He had ascites (fluid buildup in his abdomen due to the liver disease), which increased his risk of a bacterial infection of the inner abdomen called spontaneous bacterial peritonitis, or SBP.

Why this is important is that I have had experience with patients with liver disease and ascites who do develop SBP and actually did a case presentation on a similar patient a few months back. I noticed that his white blood cell count (WBCs) had been trending up and he was on appropriate treatment for colitis. I mentioned to the provider that the patient could now have SBP and that we should consider getting a paracentesis (sample of the ascitic fluid) and possibly switching antibiotics. Once we got the results of the paracentesis, it was noted that the patient did have SBP, so the recommendation to switch antibiotics was accepted. This provider was extremely thankful for my input and this recommendation, which I made during the first week of my rotation, helped me to build a great professional relationship with that provider.

I took part in another mass COVID vaccination event at the beginning of the month.

A lot of this rotation was focused on learning antibiotics, which I really needed. I have always had a hard time keeping antibiotics straight, but now I feel like I understand them a lot better. I also gave a case presentation on bacterial meningitis at the end of the rotation.

Overall, this rotation was a great experience for me, and I am so glad that I got the opportunity to experience it.

Stay Golden,

Emily

APPE Reflection: Oncology

Let’s start this post on a high note… I absolutely loved this rotation! One of my favorites, but honestly, all of my experiences have been amazing. Also, I received both doses of the Pfizer-BioNTech COVID-19 vaccine during this month, so I will briefly be going over that experience.

On this rotation, I spent the month in the Oncology Clinic Pharmacy, where I assisted the pharmacist as well as nurse navigators and providers to ensure exceptional care for our patients. Oncology, if you don’t know, is a fancy word for cancer… or rather oncology is the study of cancer.

I spent some time helping the nurse navigator with educating patients about their new chemotherapy regimen.

On the very first one, I met a patient who I was able to help more than I knew that I could. She was a patient with newly diagnosed breast cancer and had already received surgical intervention and radiation. Through our conversation, I was able to get to know her better and learned that she was really interested in meeting the president of my university, Nido Qubein. She kept mentioning it, and at the end of our discussion, she mentioned it one more time stating “tell Nido I’m here.” After contemplating whether or not it was appropriate to contact him on her behalf and discussing it with my preceptor as well as the nurse navigator that was in the room when the conversation took place, I decided to email him. After he put me in touch with the appropriate person, we were able to get flowers sent to her on his behalf when she was there for her first treatment the next week.

She told me that she was so thankful and that it really made her day.

That is the first time that I felt like I had the opportunity to go above and beyond what is asked of a GOOD pharmacist or pharmacy student and give her something that she would likely not forget.

Some other things that I was able to do is sit in on some of one of the provider’s new patient visits. I got to learn a lot about ways to break bad news to a patient in a way that shows how compassionate you are and how you are truly there to help them the whole way.

I also researched and got answers for questions that providers had for me. I was able to teach them something new. This was a very rewarding process for me.

I spent a lot of my time in the clinic’s pharmacy assisting the pharmacist in being a part of a 2-check verification system. This was a way for the pharmacist to have someone check their calculations, requirements of diluting/mixing the product, and other pertinent patient information to insure that the patient was safe to get their medication that day and that it was made properly.

Another important aspect of my rotation was going through the concise treatment plans of all new patients to insure the therapy was both appropriate and safe and verifying those things with resources available to us.

Also, I participated in a mass COVID-19 vaccination clinic where we vaccinated >1000 patients. Along with that, I occasionally helped the hospital provide vaccinations at their smaller clinics (Here’s an article detailing the mass vaccination clinic).

Overall, I feel like I learned a lot over the course of the month, and I feel much more confident in my ability to understand oncology and various chemotherapeutic regimens.

Moving on, I’d like to talk a bit about my experience with the Pfizer-BioNTech COVID-19 vaccine. I received the 1st dose on January 5th. I didn’t have any side effects from that one. The injection site was a little sore, but it was less than I typically get with my annual influenza vaccine, so it really didn’t bother me at all. I got my 2nd dose on January 22nd (I know that was only 17 days after the first one, but it’s the only day I was able to get it). It is recommended to get the 2nd dose 21 days after the first. Anyways, the side effects that I had with the 2nd dose were severe pain at the injection site and swollen and severely painful axillary/armpit lymph nodes (on the same side) for ~3 days. I also had a mild headache and felt a little nauseous. I understand that my experience was a lot milder than some people, but I just figured I would explain what happened to me.

Anyways… I only have 2 more months of APPE clinical rotations and then I’ll be in my NAPLEX review class for 1 month and then graduation!

Also, I got a job offer!! I’m still waiting for a community residency to get back to me so I haven’t accepted yet, but it really seems like a great opportunity!

I’ll keep you all updated on that process.

Stay Golden,

Emily

APPE Reflection: Entrepreneurship

Originally, my November rotation was supposed to be a medical mission trip to Jamaica. However, because of COVID, the whole thing got cancelled. While I was disappointed at first that I was not able to go on that trip, this rotation was amazing, and I really learned a lot about myself.

This rotation was designed for us to be as independent as possible. We were tasked with creating a new pharmacy product or service. Throughout the whole rotation, we worked on this project and presented it on the last day of rotation. I’d give you my idea, but then you may steal it, and I actually might act on it in the future.

We were also tasked with choosing a book on innovation to read throughout the rotation and come together weekly to discuss what we learned from the book with the other students and our preceptor. I chose “The Innovation Stack” by Jim McKelvey (co-founder of Square credit card readers). This book was a great read and made me think a lot about what it means to be truly innovative in a world where we are trained to copy.

We also each watched an episode of Shark Tank and summarized it to the group. I think this was critical to the process in that we could see how people were really able to sell their products just based on their pitches and how some flopped for the same reason.

Overall, this experience was great and something that I definitely needed since I would like to own my own independent pharmacy in the future. It opened my eyes to the possibilities of creating a new product, business, or service and rolling it out.

I’m excited to finally have a month off of rotations, and I know I’ll be well rested and ready for my Oncology rotation that starts in January.

Stay Safe and Stay Golden,

Emily

APPE Reflection: Ambulatory Care

The rotation that I had over the month of October was my Ambulatory Care rotation. I completed this one at the Naval Medical Center at Camp Lejeune in the Family Medicine Clinic. I spent a lot of time with patients in the clinic, but I would consider this rotation a “blended” Ambulatory Care rotation.

In the mornings for most of the month, I was on the inpatient Family Medicine team doing rounds. During these rounds, I would work with the pharmacist to answer any questions that the medical interns/residents/students had for us about the different patients and their medication regimen. We also pre-rounded on the patients so that we had suggestions of regimen changes ready to go when we met with the team.

For the rest of the day, I was working in the Family Medicine Clinic with my preceptor or another clinical pharmacist to take care of patients. We saw a variety of patients for different chronic conditions such as diabetes, hyperlipidemia, hypertension, and anticoagulation (with Warfarin, for INR checks and regimen changes).

I didn’t really start writing up patient encounters in the electronic medical record (EMR) until the last week and a half. At that point, I wrote up pretty much all of our encounters and had them sent to my preceptor for review before he signed them.

Because I was at a military location, the clinical pharmacists were able to change medication regimens without a collaborative practice agreement. It was really a great experience being able to see the impact of pharmacists on a clinic. It reinforced for me the true value of pharmacists in the clinic environment.

Over the month, I was able to watch 2 eye surgeries and was also able to shadow a variety of different practitioners (NPs, PAs, and Physicians) and see how they interacted with patients.

I’m so thankful for the opportunity, and although the military environment isn’t really for me, I’m confident in the care that they are receiving.

Stay Golden,

Emily

APPE Reflection: Advanced Community & Enhanced Clinical Services

As with any new rotation, I was very nervous going into this one. However, I had an amazing experience. I got to do things during my community rotation that I feel like a lot of people don’t get the chance to do.

What were those things? Lots of clinical services! I worked with several of our Chronic Care Management (CCM) patients and was able to call and check in on them and see how they were doing with their chronic conditions and how they were dealing with COVID. This is a task that I feel not many people relate to pharmacists, but we are in the perfect position to do these types of services! It’s important to check in on these patients and make sure that they do not have  any pressing issues with regards to their medications or their health in general. Pharmacists partner with physicians to provide these services to their patients. Another important clinical service that I was a part of was Medication Therapy Management (MTM). This involves calling patients and making sure their medication regimen is up to date, they are adherent to their medications, and they are not having any unwanted side effects. It’s important to make sure patients are taking the medications as they are prescribed to them. 

I also participated in 4 flu shot clinic days where I was able to give ~200 flu shots to teachers and other government employees. 

Aside from the clinics, I also gave flu shots, shingles shots, pneumonia shots, and tetanus/diphtheria shots in the pharmacy. 

I also did a lot of blister packaging. For those of you who may not know what that is, it’s where the pharmacy packs all of a patients medications in a weekly or monthly pack with the foil backing to so that the patient can see that they did or did not take their medications on a certain day. Not only did I pack them, I was able to check a few that my preceptor packed (to get experience actually acting as the pharmacist) and looked through patient charts to make sure that their medication regimen made sense. I was able to find some areas where the packs could be improved and was able to prevent some medication errors.

I was able to also check a few prescriptions (with my preceptor) to make sure I understand what it’s like to actually be the pharmacist.

Here’s a couple pie charts that show some of the things that I was able to do over this rotation!

August Patient Care Tasks
September Patient Care Tasks

I really, really enjoyed my time at this rotation site, and I’m so excited for my Ambulatory Care rotation next month! 

Stay Golden,

Emily

APPE Reflection: Critical Care

I was very intimidated going into this rotation because it is only my 2nd APPE experience and the CCU is such a fast-paced environment. However, I have learned a lot over this rotation, and I had the best experience I could have imagined. My confidence in making recommendations to providers has increased significantly, and I was able to do a lot of independent learning.

During the first week, I had my first counseling experience of the month. I was able to counsel a patient on a new prescription for warfarin. It was a great experience because there are so many different things to consider when counseling on warfarin (diet, bleed risk, goal INR, etc).

I also had my first ED shift of the month this week and was able to complete several medication histories as well as make calls to pharmacies to gather information/cancel prescriptions that were sent to them by mistake. It is the job of the ED pharmacist to make calls for patients who tested negative for COVID and make sure that they no longer had a fever. I was able to practice with this on week 1.

I witnessed my first rapid sequence intubation during week 1 and was able to assist the pharmacist in drawing up medications to make sure it ran as smoothly as possible.

Week 1 was also where I began rounding every day on the CCU. Every day, I spent half of my shift sitting on the unit by myself and assisting with any medication related questions that the nurses/providers may have. Of course, being a student, I had to report to my preceptor with all of the recommendations that I had to make sure they were appropriate before recommending them to the provider.

Moving on to week 2, I was able to dose a new start vancomycin in a patient and adjust a heparin drip based on the patient’s aPTT level.

Week 2 was also where I had my weekend ED shifts. I completed 7 medication histories, 16 negative COVID callbacks, and another intubation.

The rest of the month was pretty chaotic. I attended 4 rapid responses, 2 codes, rounded on a total of 35 patients, dosed and prepared TPA, and made daily recommendations to providers. I pretty much handled the CCU patients on my own, with verification with my preceptor.

My big projects for the month were to present a case presentation on a COVID patient that had been in the CCU for most of my month long rotation and create a reference sheet on how to treat hypertensive crises.

I also had 1-2 topic discussions a week on critical care topics such as FASTHUGS, Sepsis, the ABCDEF bundle, RSI/NMBA, PADIS, and ACLS.

The hardest part of this rotation was experiencing codes and seeing how intense and emotionally draining they can be.

I have nothing but good experiences to report for this rotation, and I’m so sad to be leaving this hospital until January. I have really connected with the pharmacy staff here and really have started to feel like family. I hope to have as good of an experience during my Ambulatory Care and Community rotations that I have over the next few months.

I will continue to keep you all updated with all of my rotations!

Stay golden,

Emily